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OAKLAND, Calif. — Both sides of a contentious ballot question to regulate nurse staffing levels in Massachusetts are stoking fears of a doomsday scenario, either if the measure passes or if it fails.

But in California, where a more lenient version of the law has been in effect for almost 15 years, the results seem to undercut the panic on both sides, proving to be neither a panacea for improving patient care nor a fatal blow to hospitals’ finances.

Officials at the Massachusetts Nurses Association, a labor union, point to California as an example of success, and they’re asking Massachusetts voters Tuesday to approve a measure that is similar, but stricter. Hospitals are fighting the ballot referendum, arguing that it would threaten the state’s high-performing health care system, costing nearly $1 billion a year and forcing care providers to delay care, cut services — or perhaps close altogether.


The bitter debate about patient limits — also called nurse-to-patient ratios — echoes the one that played out in California, and the experience of that state offers some lessons for Massachusetts.

California hospitals hired thousands of additional nurses to comply with the staffing law, initially relying on temporary nurses from other states. While many hospitals reported struggling with the costs of the law, those higher costs did not cause a wave of hospital closures.

The research on whether nurse-to-patient ratios improved the quality of care at California hospitals is also mixed. Some studies found improvement in patient outcomes, while others did not.

Gaylee Cox (left) and Linda Hedlund, who both worked as pediatric nurses at the City of Hope Hospital in Los Angeles, huddled together to stay warm during a nurses rally in 2004.
Gaylee Cox (left) and Linda Hedlund, who both worked as pediatric nurses at the City of Hope Hospital in Los Angeles, huddled together to stay warm during a nurses rally in 2004.Rich Pedroncelli/ASSOCIATED PRESS/File

And while supporters of the ratios hold up California as a model, key differences between the California law and the measure proposed for Massachusetts make direct comparisons difficult.

In addition, Massachusetts hospitals already have higher levels of nurse staffing than California hospitals, according to a report from a Massachusetts health care watchdog agency.


Zenei Cortez, a nurse at a Kaiser Permanente hospital in South San Francisco, well remembers the years before California’s staffing law. Cortez said she was responsible for so many patients each day that she used to leave her shifts worrying that she might have missed something.

In 2004, when the California law went into effect, “life got a little better,” Cortez recalled in an interview at the headquarters of the California Nurses Association, a labor union where she is a co-president. The California union is backing the Massachusetts ballot effort.

“Nurses were so used to running around. All of a sudden, they had time to sit with the patient, spend time with the family,” Cortez said.

California’s law was approved in 1999 but did not take effect until about five years later. The specific nurse-to-patient ratios were developed over time by state health officials, with input from different stakeholders.

The Massachusetts ballot question, though, includes specific ratios for different units of the hospital. And if approved, it is supposed to take effect just eight weeks after Election Day, even though state regulators have indicated they may need more time to write regulations and set up an enforcement structure.

The Massachusetts proposal calls for stricter limits than the California law. For medical and surgical patients, for example, California set a limit of five patients per nurse, but in Massachusetts the limit would be four patients per nurse.

Question 1 also would require Massachusetts hospitals to pay penalties of up to $25,000 per violation per day if they break ratios, regardless of whether the violation caused a problem with the delivery of care. The California law didn’t specify such penalties, but hospitals can be fined for incidents that put patients at risk.


Charlene Arrington, a registered nurse at Doctors Medical Center in San Pablo, joined more than 200 other nurses and supporters in a march in 2004.
Charlene Arrington, a registered nurse at Doctors Medical Center in San Pablo, joined more than 200 other nurses and supporters in a march in 2004.Rich Pedroncelli/ASSOCIATED PRESS/File

Both measures call for the staffing mandates to be in place at all times, including during overnight hours and when nurses go on meal breaks.

As in Massachusetts, unionized nurses in California pushed for a nurse staffing law for years. There were failed attempts — including a 1996 ballot referendum that voters rejected — before the Legislature and Democratic Governor Gray Davis approved a law in 1999.

The unpopular Davis was recalled in 2003. The next governor, Republican Arnold Schwarzenegger, clashed with the nurses union and tried to block the staffing ratios from going into effect, but he ultimately withdrew his legal challenge.

Jane Sandoval, an emergency nurse at Sutter Health’s California Pacific Medical Center in San Francisco, said she and other union nurses remind their supervisors to stay in compliance with the law when hospitals get busy.

“You have to really know how to advocate and say, ‘This is not safe right now,’ ” Sandoval said.

Research from Linda H. Aiken, a professor at University of Pennsylvania, has shown links between California’s nurse staffing law and better patient outcomes. Among her most cited work is a 2010 paper that compared the workload of nurses in California to nurses in Pennsylvania and New Jersey, which don’t set nurse-to-patient ratios. The study found that ratios in California were associated with lower mortality rates.


“There’s plenty of evidence that improvements in nursing are driving quality improvements,” Aiken said. “Hospitals are doing a lot of things [to improve quality], but still nursing is the driver.”

But that 2010 study also cautioned: “We cannot establish causality in the associations we observe.”

Joanne Spetz, a professor at University of California, San Francisco, was a coauthor of that paper. Spetz said subsequent studies, which include data from before and after the California law went into effect, show no systematic improvement in patient outcomes.

“A few outcomes got a little better. One or two got a little worse,” she said. “It’s kind of a wash.”

Spetz, who worked on the Massachusetts Health Policy Commission’s report on Question 1, agrees that there’s a link between nurse staffing and quality of care. “The difficulty,” she said, “is that is not the same thing as ‘If I force a hospital to change its staffing, I will force better outcomes.’ ”

Hospitals in California initially were challenged by the requirement to hire more nurses, but they stayed afloat. All these years later, California hospital executives still aren’t fans of the law, but they’ve learned to live with it.

“It would be difficult to say that any hospital in California closed solely because of nurse staffing ratios,” said Jan Emerson-Shea, spokeswoman for the California Hospital Association, a lobbying group representing hospitals.

“Has it come with some challenges? Yes. Has it come with increased cost of business? Absolutely. It’s regulations like this that add to that cost of care,” Emerson-Shea said.


The hospital association never studied the total costs of the law, nor did the California Department of Public Health.

In Massachusetts, the Health Policy Commission estimated the costs of Question 1 could total $949 million a year. This includes the cost of hiring up to 3,101 additional nurses, wage increases for existing nurses, and other implementation costs.

Those costs could be passed on to consumers in the form of higher insurance premiums, the commission said.

The commission’s Oct. 3 report compared the California law and the Massachusetts proposal, and chairman Stuart Altman, a health care economist, told reporters at the time: “I think we can learn some things from California but . . . this legislation in some pretty fundamental ways is very different.”

Polls show that support for the Massachusetts ballot measure is slipping, with most voters now leaning toward “No.” Even nurses are split on the issue.

Massachusetts hospitals already outperform California on a number of national rankings. That’s a case for why Massachusetts should reject the nurse staffing ballot question, according to Steve Walsh, president of the Massachusetts Health & Hospital Association.

“While California’s been focused on trying to meet rigid ratios, we’ve been trying to improve patient care,” he said.

He stressed that the Massachusetts proposal is more rigid than the California law: “Because the law [here] is so much more strict, the results would be more severe,” he said.

Union representatives maintain there’s enough evidence that the California law works and argue that Massachusetts needs patient limits that are even more stringent.

“California didn’t fall into the ocean,” said Kate Norton, a spokeswoman for the union’s ballot campaign. “There was not a catastrophe that happened because of safe patient limits, and there will not be in Massachusetts.”

Priyanka Dayal McCluskey can be reached at priyanka.mccluskey@globe.com. Follow her on Twitter @priyanka_dayal.