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What you need to know about Question 1

Question 1 would limit the number of patients assigned to hospital nurses at one time. The Massachusetts Nurses Association, a labor union, backs the ballot measure.Jonathan Wiggs/Globe Staff/File

The Globe’s 2018 election guide takes a look at the candidates and issues on the Nov. 6th ballot.

More from the 2018 election guide:

Question 1, a ballot initiative to regulate nurse staffing in hospitals, may be the most controversial issue on the ballot this year.

The “yes” and “no” camps are bitterly divided on this complex health care question, and both sides have spent millions of dollars trying to persuade voters, including with TV ads.

Question 1 would have implications for health care costs and the care that patients receive at hospitals across the state.

Question 1, a ballot initiative to regulate nurse staffing in hospitals, may be the most controversial issue on the ballot this year.
Question 1, a ballot initiative to regulate nurse staffing in hospitals, may be the most controversial issue on the ballot this year.

Here’s what you need to know:


What would this ballot question do?

Question 1 would set strict limits on the numbers of patients assigned to hospital nurses. The limits would vary, depending on how sick patients are. Nurses taking care of medical and surgical patients would be limited to four patients. In emergency rooms, the limit would range from one to five patients per nurse. The limit for psychiatric patients would be five to a nurse.

The ballot question requires these limits to be in place at all times — day and night — and it would charge fines of up to $25,000 per violation, per day, to hospitals that don’t comply.

A “yes” vote would enact the ballot law, which has an effective date of Jan. 1.

A “no” vote would make no change in the current laws. (Currently, hospitals can staff their units as they see fit.)

Who supports it?

The ballot question was written by the Massachusetts Nurses Association, a labor union that has been pushing for nurse staffing laws for about two decades.

Four years ago, as a compromise between the nurses union and hospitals, Massachusetts legislators approved a law to regulate nurse staffing in intensive care units. Nurses working in ICUs are limited to one or two patients at a time. But union officials say ICU limits aren’t enough, and they submitted Question 1.


Many labor groups and Democratic officials also support the ballot question.

Who is against it?

The Massachusetts Health & Hospital Association, a lobbying group that represents hospitals, is leading the campaign to defeat Question 1. Hospitals have contributed almost every dollar spent on the campaign.

But several other health care groups — including some professional organizations that represent nurses — also oppose Question 1.

Nurses appear to be split on the measure, according to a WBUR poll and reporting by the Globe. Governor Charlie Baker has said he plans to vote “no.”

What does the research say?

Many studies show a link between nursing care and patient outcomes — but the studies don’t say specific ratios of patients-to-nurses actually cause better outcomes.

Studies about the impact of the nurse staffing law in California — the only state to have a similar law to what is proposed in Massachusetts — had mixed results. The Massachusetts Health Policy Commission concluded in a report in October that there was no systematic improvement in patient outcomes in California after that state’s nurse staffing law was implemented. The limits proposed for Massachusetts and the penalties of not complying are more strict.

What would this cost?

Estimates from the “yes” and “no” camps vary widely: The nurses union put the cost at about $47 million a year, while the hospitals estimated more than $900 million in annual costs.

The Health Policy Commission’s analysis largely backed up the hospital industry’s cost estimates. The commission said hospitals would have to hire as many as 3,101 additional full-time nurses to comply with Question 1, and that the total costs of compliance could reach $949 million per year.


Hospitals could demand higher reimbursements to cover these costs, the commission said, and the costs could be passed on to consumers in the form of higher insurance premiums.

What are the potential benefits of the law?

The union argues that nurses working in Massachusetts hospitals are often overburdened. If they’re assigned too many patients, care can suffer. The union argues that the strict limits set in Question 1 would ensure that patients are getting the safest care.

The Health Policy Commission found a potential for some cost savings if the question passes, because greater numbers of nurses working in hospitals could help reduce the length of stay for patients, and reduce adverse events.

What are the potential negatives?

Hospitals say that Question 1 would have many dire consequences. The costs of complying with the measure would be so high, they say, that instead of hiring more nurses, hospitals would have to close beds. Hospital leaders say they would be forced to cut important services such as mental health care. Struggling community hospitals could close entirely, they warn. In addition, wait times for emergency departments could soar because emergency nurses would not be able to take on more than five patients at a time.

The Health Policy Commission’s analysis largely backed up these concerns.

RELATED: Read full Globe coverage of Question 1


Informed voters make the best decisions. Sign-up to receive the Globe’s midterm election guide, with breakdowns of key local and national races, profiles of the candidates, and endorsements from our editorial board. And come back on election night, Tuesday, Nov. 6, for live results on the races and analysis from our expert political team.

Priyanka Dayal McCluskey can be reached at Follow her on Twitter @priyanka_dayal.