Issue 1 has me in knots. Not because it is confusing as hell (and it is). No, for me, Issue 1 is a woeful reminder of how our legislative institutions fail regular citizens and how even the promise of direct democracy does not save us.
On the “yes” side of Issue 1, as my colleague Professor Duquette clarified last week, there are bedside nurses represented in substantial force by the Massachusetts Nurses Association (MNA) – a union with close to 23,000 members – who have long pushed for lower nurse to patient ratios. Their efforts have largely been met with legislative silence in Massachusetts.
So they went to the initiative process. Direct democracy! If Beacon Hill won’t listen, then take it to the people! It is actually fairly cumbersome to get an initiative on the ballot but the Committee to Ensure Safe Patient Care, largely directed by the MNA, did it. We are now voting in November on Issue 1 which “would place a limit on the number of patients a single nurse can be assigned at a time and impose a $25,000 fine on hospitals that violate those ratios.”
Proponents of the initiative process see the ability of citizens to take their concerns directly to other citizens as a good thing in an era of state legislatures and the US Congress being largely beholden to corporate interests. These interests, and their corrupting money, are increasingly difficult to trace after the Supreme Court’s Citizens United decision. Legislative outcomes are also skewed as our representatives are wildly unrepresentative in terms of their social class backgrounds. Monied interest groups have long had deeply effective lobbying machines but, in the modern era, they play on a gameboard largely uncluttered by countervailing citizen influence.
The initiative process aims to provide citizens a way to circumvent the game so tilted against them. If the hospitals, healthcare executives, and American Hospital Association have the ear of Beacon Hill (at least their willingness not to act) then direct democracy seemingly provides a tool for the people. And, really, who wants an overworked nurse administering their care?
Here is the thing though: there are some plausible arguments against Issue 1. The cost would be too much for small hospitals, ERs and floors that are at ratio could delay or turn away those who need care, staffing is a concern given the nursing shortage. Personally, I find most of these wanting as they miss basic supply-and-demand economics: if you pay more, more nurses will come. Similarly, if administrators increase the number of nurses on each shift then the wait/turn away problem becomes far less likely.
Most of all, however, the concerns of the anti-Issue 1 crowd are about cost. Costs accrued to healthcare providers and maybe passed on to you. By some industry-backed estimates, 1.3 billion the first year if implemented and 900 million in each subsequent year. It is no surprise then that hospital associations would lobby hard against bringing down nurse to patient ratios.
And they are indeed lobbying hard – some 12.2 million spent by early September alone. And their advertising is compelling. …because it muddies waters. Nearly everyone wants nurses afforded the time to spend on their case. Enter the nurses featured in the “no on Issue 1” ads. They are against 1?! So nurses must be split on the Issue?! Nope. Missing from these 30 second spots are the facts that (a) nurses in the anti-1 ads are those who have largely moved into administration, and (b) while the nurse managers are front-and-center in the political advertisements, they are nearly absent from organizations paying the bills in the anti-1 camp.
If Issue 1 had gone through the normal legislative process most of the concerns, and the misleading advertising frame of equally pitted “battling nurses,” could have been seriously mitigated. The resulting legislation would have likely had higher ratios than the Massachusetts Nurses Association advocates for but would have been an improvement over current norms. And some, not all, of the concerns expressed by management would have been addressed. In short, the law would have been better for all involved and, most importantly, better for the health of MA residents and their pocketbooks.
That’s not what happened. Direct democracy is great on paper, particularly when the interests of regular citizens are so outmatched in the legislative arena – especially in healthcare. But on Issue 1 direct democracy has meant that the nuanced policy deserving of something as complicated as nurse staffing has not emerged. It can’t. Ballot initiatives require clean, clear, and short language readily absorbed by voters. Healthcare in Massachusetts requires complicated, nuanced policy the initiative process largely can’t deliver. It isn’t designed to.
It’s a woeful irony then that in the current political environment the policy best for democracy cannot emerge from a captured legislative branch nor the initiative tool of direct democracy. Issue 1 thus demonstrates much of what is really sick in our democracy.