The Experts and Question One

Posted on by Jerold Duquette

Economists and healthcare policy experts have weighed in on both sides of the debate over Question One. There are clearly compelling expert arguments on both sides. My analysis on this question to date (which can be reviewed here, here, here, and here) has been about how average voters ought to consider this and every other ballot question, especially those that involve issues not in their personal wheelhouses. Here I will lay out a political argument for voting YES on Question One. I am not, to be clear, claiming that a political argument for voting NO does not exist, rather that in my view the political dynamics of this ballot measure fight provide strong support for a yes vote.

Average voters are willing and able to make POLITICAL decisions. They are neither willing nor able to make complex public policy decisions. Ballot questions are often related to complex public policy questions, which leads many to suggest that ballot questions are a bad idea and therefore smart voters should always vote down ballot initiatives. Since the wisdom of ballot questions themselves is not on the ballot and actual ballot questions are, the larger process debate can reasonably be put aside here.

Ballot initiatives are the result of POLITICAL disputes between interested parties that were not resolved in the more conventional public policy making process. In the case of Question One on this year’s Massachusetts ballot the dispute is a labor-management dispute between hospital administrations and bedside nurses who have been arguing over nurse staffing ratios for decades. The fate of Question One will impact the ongoing relationship between healthcare workers and management in the state. Voters will liberal sensibilities and a belief in the importance of organized labor cannot pretend that this ballot question is merely a vote about a specific policy. In fact, it is also a vote about the ability of healthcare workers to compel employers to do the right thing by workers. In other words, it’s a POLITICAL question.

If Question One is defeated, bedside nurses’ leverage in negotiations with hospital management will be greatly reduced. Having successfully defeated the bedside nurses’ best play, the well-financed anti-labor interest groups who have to date prevented legislators from enacting the proposed nurse staffing ratios will have no reason to compromise with the Nurses union.  If Question One is passed, however, both sides will have strong incentives to work together to solve whatever complications are created by mandated nurse staffing ratios. Effectively, all the dire predictions by opponents of Question One, even if entirely accurate, can be mitigated or eliminated by the legislature subsequent to the passage of Question One. Because the Massachusetts Hospital Association and its allies continue to have great sway over legislators, the political incentives to correct problems with enacted nurse staffing ratios are far better than would be the political incentives to find a pre-enactment compromise on this issue. Bedside nurses have been trying to do that unsuccessfully for decades. Only the leverage created by the threat of a ballot question has produced progress on this issue. In 2014, with the threat of a ballot question looming, a legislative deal was struck with the governor and state legislature to enact nurse staffing ratios in the state’s Intensive Care Units. Once such a ballot question is defeated, however, the balance of political power between healthcare workers and management groups tips decisively toward the already more powerful management groups.

The POLITICAL bottom line is this: If Question One passes, negotiations on this very important issue to bedside nurses will be energized and the ballot measure itself will have served one of the primary purposes of ballot measures in the first place, which is not to allow average voters to make complex policy decisions, but rather to allow the general public to exert POLITICAL influence on behalf of interests that would otherwise be at a severe disadvantage in getting their issues addressed by politicians who depend on the financial support of wealthy special interest groups. When proponents and opponents of ballot measures treat average voters like policy experts they are really manipulating them, which is why both sides on every ballot question supplement their “expert” arguments and endorsements with appeals to voters’ in-group loyalties, or as in the case of the opponents of Question One this year, to average voters’ irrational fears. Voters can and will happily choose sides in a political dispute and ballot questions, like any statute, are NOT set in stone. They can be amended or even repealed by elected policy makers, which means that despite the hype, voters will not have the final say on Nurse Staffing Ratios when they vote next month. Pretending that they will and that a “mistake” by voters will bring on the apocalypse is at best naive.

A YES vote will force hospital lobbyists, nurse’s union representatives, and the state’s elected policy makers back to the bargaining table. A yes vote will force all three groups to accept meaningful responsibility for dealing effectively with this issue. A NO vote will further empower and embolden the wealthy special interests whose outsized political influence has prevented the legislature from taking up the nurses’ cause, further weakening the ability of healthcare workers to resist exploitation by hospital administrators.

I am a political scientist and this is my expert opinion on Question One.

 

39 thoughts on “The Experts and Question One”

  1. Clear, concise and powerful. Thank you for a thought provoking article that makes voting yes on question 1 a “no-brainer”

  2. Who are the wealthy special interests? Please be specific. I dont think the straw man argument is an effective one. .

  3. I notice you never mention patient safety. This is a political labor issue couched in patient safety terms and that it is why it rubs many of us, including liberals, the wrong way. There is no evidence that it will help patients in Massachusetts, and to the extent that Medicare money is distributed in fee for service lumps, it may hurt other workers: Social workers, MAs, mental health counselors, etc.

  4. Well stated. I support your argument and add that patient safety is everyone’s business. It should be everyone’s concern when they make their decision at the ballot box.
    I am an RN and I support this measure.

  5. Seems obvious to me. I have been a bedside RN for 31 years. This is about safe patient limits vs. corporate greed. Unless you are a rich hospital executive, voting YES IS A NO BRAINER.

  6. > which leads many to suggest that ballot questions are a bad idea and therefore smart voters should always vote down ballot initiatives

    I know it’s not the point of this piece, but note that this perception itself can be manipulated. Hence Prop 3 being phrased so a “yes” vote keeps the status quo and a “no” vote overturns it.

    1. Actually, ballot questions are, perhaps, the last barrier between being ruled by a few according to their will no matter what popular opinion or demand is. Look at this on the federal level where there are no ballot measures and 80 + % of people thought we needed some changes in how we issue gun licenses five years ago, but we made no changes. The
      ballot questions come about usually after a problem has developed, persisted, and the legislature needs a hard nudge for a change. As much as this question is about nurses, it’s about patients and what standard of care we ought to get for the huge expense we pay for medical care. Ballot questions absolutely can be manipulative in their wording, but they are a last vestige of a true democratic process.

  7. Nurses have been voted the most trusted group in the country, voters should trust what the nurses are proposing. The motivation for this question to be on the ballot has been disgusted for 30 years to my knowledge. Voting YES will improve patient care and that has been documented by research and action already in place in California. I ask the public to trust the bedside nurses in this action and vote YES.

  9. The writer says this is a POLITICAL question and not a policy question, but I do not understand the basis of that statement.
    Surely this question has policy implications that will have significant financial consequences for hospitals across the Commonwealth. How is this not a policy Question?
    I absolutely support nurses and want them to feel supported in the workplace. If I could vote to say “Do something about understaffing!”, I would. But even proponents of Question 1 say it is flawed in its thinking and will need to be negotiated after passage. So how can I find my way clear to voting for something that isn’t what it says it is?

    1. So you will not be voting on this question. We can live with that, I suppose. You are not a No voter in sheep’s clothing, right?

  10. So if the union represents 25 percent of nurses in Massachusetts and they have a problem with management at their unionized hospitals- the other 75 percent of nurses and hospitals have to have mandated inflexible staffing plans. Doesn’t seem reasonable. Another argument used is to compare daycare staffing to hospital staffing. Daycare is a controlled/ planned environment you allow x number of children and have x number of staff. Hospitals cannot control the number of patients that arrive and need care in most cases. Emergency rooms, labor and delivery, mental health issues- can’t plan ahead for that. Conversely day cares can say- sorry we have no openings- we will put you on the waiting list. If the daycare wants to meet the demand they can choose to upsize or not. Healthcare in a hospital doesn’t work that way. That’s why bedside nurses are compensated at a higher rate of pay than nurses in other environments. They use their critical thinking and assessment skills to juggle influxes of patients.
    I don’t want to be having a heart attack and be put on a waiting list.
    And I have a voice at the non unionized facilty that I choose to work at.

    2. The point for Susan is ratios place patients safety first. I am not sure what you mean about having a voice now unless you are an administrator and then of course your response makes sense as it is all about dollars and cents to you. Vote yes support bedside RN and most importantly PATIENT Care.

      1. Absolutely Anne!!! A nurse does not equal a nurse in this scenario!! Bedside nurses, nurses who actually take care of patients, are looking out for PATIENT SAFETY FIRST. Nurse executives are looking out for their bottom line, THE ALMIGHTY DOLLAR. It’s very clear and very sad.

      2. Wow- as a nurse regardless of my role on the healthcare team, my obligation is to the patient. We have never met and you both are accusing me of violating the code of ethics for nurses.

        1. Susan, I have not accused you of anything. If you truly believe I have accused you of something, then you have shown yourself to have poor judgement. The fact that you are a nurse manager is very relevant to this question. You are management in a non-union maternity ward. As such, your opinion on this matter is not at all surprising. This is a fact, not an accusation. I have no clue what you mean when you reference your code of ethics. I can tell you that I have received a number of comments from nurse managers pretending to be something they are not in order to give themselves greater credibility in opposing Q1. I did not accuse you of misrepresenting yourself.

          1. I have been a nurse for over 50 years including management. The political argument that this will give nurses unions leverage is flawed. A political ballot question should not be a requirement for poor managerial skills in the unions…. what is missing is embolding nurses unions is taking precedents over patient safety! Unions are not decisively advocating for their membership and their patients….DSM have greatly cut into billing and care and unions have worked a lot with management .

    3. The CEOs and higher administrators. They might have to give up their bonuses or maybe God forbid take a pay cut. Even worse, loose face or some power.

    4. Only if you are Voting in their favor! Look at So. Shore Hospital, can only speak if you are voting NO. It’s against the law to intimidate employees yet it goes on! This question is about providing better staffing so nurses can actually better serve all patients. Hospitals are promoting Crisis Nursing staffing everyday to make a dollar. Not okay for patients or nurses. Enough is enough! YES on 1

    5. A nurse manager is what you are? Then you naturally want whats best to keep the profit margin high.. I think this measure is a no-brainer and it wont pass, only because the unsurpassed amount of money spent on negative, dishonest ads in favor of “no”.. ITs really disgusting to me that people who supposedly care about patents, such as yourself, can even think about saying No to this.. As stated in the article, at least it is a start in the right direction, and only initiates negotiation, its not the “absolute” end product.. You guys make it sound like its “do or die”, and god only knows how you call a “no” vote, being in favor of patient safety… Its a no-brainer to want this kind of measure.. You dont need tons of data to prove something so obvious… And the thing about making people wait at the ER has NOTHING to do with this measure, one way or another.. All providers are protected by samaritan laws, including even the hospital. AND there have been ZERO fines imposed by California since its been going on for the past few years…… This is disgusting.. I work in health care and firmly believe, esp after this DOESNT pass.. the likely outcome,,,, that medicine should be 100% socialized as profit and patient care do not mix.. All the over rated, over salaried medical managers should get real jobs n stop milking the medical business.
      …

    6. It is a false talking point for the executives running the No campaign to say the MNA represents 25%. More tha. 70% of the hospitals’ bedside RNs in Mass are part of the MNA, and Q1 is about care in -hospitals- .

  12. This is a brainy political analysis that frames the debate in terms of bedside labor/management, and greedy hospital profiteers. Unfortunately, it’s incomplete. The author and his panel are well credentialed–but in fields outside of healthcare. Nursing is no longer simply “labor” but a developed profession which includes highly educated specialists, advanced practice clinicians, academics, sophisticated researchers, and its own experts who understand the complexities of healthcare from public policy perspective. Its leaders know that high quality bedside patient care is not simply a matter of numbers; many variables are crucial. For starters, nurse experience vary greatly, thus is a huge factor; also, hospitals vary greatly in the amount of flexible support they give to the bedside nurse, and also vary with regard to complexities of patient problems. This proposed “one size fits all” bill ignores these and other components. It’s rigid, draconian, and may well result in unintended consequences.

  13. Excellent commentary Jerold! I have been wobbling even though my wife is a (retired) RN and MNA activist. I agree it’s as much about economic and political power as healthcare. Hospital administration has become bloated and overpaid. Nurses (and other staff) are often exploited, especially when they don’t have collective bargaining rights.
    So I will vote YES and allow management, labor, and the state to regulate the details.

  14. Aren’t the unions spending tons of money on this question too? My guess would be they are funding the Yes on 1

  15. When I was a young nurse, things were different; we were in fact instructed (by the very well educated & practiced older army nurse, that any time we saw ourselves (and the situation in which we were currently working), we were to call our supervisor, insist on support, and leave the floor after informing the powers that be, till the situation was rectified.
    Can you imagine that today?! (It was in the early ’60s). Since then the hospitals have heaped onto qualified RNs huge amount of added financial management duties for their units, in addition to the hands on nursing responsibilities. They’ve been absorbed into the “business aspect” of running health care. I worked in pedes and neonatal units as well as geriatrics and on med-surg.wards, both in California and Massachusetts.
    When you are a professional, and will be held responsible for your professional decisions, you must be able to control your work choices, ESPECIALLY those pertaining to SAFETY.
    NURSES ARE PROFESSIONALS , and must be given a say in the safety of their work. Please VOTE YES on Question #1 on the ballot. Thank you,
    Kate K. Webster, Retired RN.

  16. I’m a Physical Therapist who does home care. For 20 years. Maybe 10 years ago the hospitals cried poverty and the hospital where most of my patients come from got rid of the aides who provided the less skilled care. There was essentially a decrease in care for the patients which the nurses had to deal with.
    Our patients are also sicker and are in the hospital for less time. What I see when they come home is patients are getting less education, many report waiting long times to go to the bathroom, being left wet, and I’ve even had patients fall in the hospital because they tried to get to the bathroom on their own. Pts never used to come out of the hospital with new decubitus ulcers but it happens now.
    A other thing that has happened is the acuity in hospitals has gone up overall. I read an account recently on the MNA website of a medical floor nurse from Worcester who stated she often had patients who were sick enough to be in ICU. She talked about feeling exhausted and sad, overwhelmed. And as if she was unable to give all her patients her best care.
    In Franklin County the nurses went on strike for better working conditions, not more money. They had routine understaffing and nurses often could not go home at the end of their shifts.
    I believe that we all need question 1 to pass for both patient and nurse safety! And of course it’s also political. Help the MNA in their work to support every nurse even tnose who are not unionized.
    AND SHAME ON THE LYING SCARE TACTICS OF THE HOSPITALS AND THEIR SUPPPORTERS. Every week I have an elderly patient who is worried about what will happen if they have to go to the hospital.
    Please choose patient care over greed and support Question 1

    1. You say hospitals ddid away with nurse aids because they cried about the extra cost.
      That doesn’t sound true. Everyone can reason that an aid would be less expensive than a nurse so would be a more economic choice for the hospital. I suspect doing away wwith aids was pushed by nurses. That they will use scare tactics, much like the republican party, to twist the truth. I don’t believe tthe MNA. I believe tthey are pushing for this for there own benefit.
      Vote No on question 1

      1. Your logic doesn’t make sense here. You suspect? If you could know, you would know it’s the same for teachers. We need our paraprofessionals; our jobs are not doable for all students without them. We stand up to fight against losing the right fit for personnel with the populations we serve. Nurses take an oath to work for the healing of patients – their obligation, their oath is to people who need them. Hospital CFO’s have an obligation to share holders. It’s a business. There are hospitals that already have the staffing ratio sought in this question who are doing just fine according to nurses I know. MGH may be one of them. David, no disrespect, but you have not followed the money in this scenario and you seem to harbor some negative biases about nurses. Those who benefit from this ballot question are the patients!

      2. You’ve got to be kidding me? The only way I could get through my day was with an nurses aide helping me with patient care. There is NO WAY any bedside RN is going to demand we get rid of help. They are an extension of our eyes and ears. We can’t be in every room at once, we can’t answer every call bell, every phone call, we can’t transport patients off the floor for testing …who do you think does that? …. David have you ever had a job where you don’t get lunch or get to go to the bathroom? I have had days where I am so busy, that I can’t even take care of my own basic needs. I have been so tired at the end of my shift that I don’t remember driving home. I have been so stressed by the work load, I will call in sick because I can’t face it again the next day.
        We have been begging for ratios for years and it has fallen on deaf ears.

        Would you want the nurse above caring for one of your loved ones???

        I want to be able to go home at night knowing I made a patients life better, not lose sleep because I was too busy to give good care.

        Cara RN, Nurse 25 years.

        1. This is no exaggeration! I know because it’s the same for me as a teacher. My hours go from 60 – 70 a week during the school year, and those “vacations” in between are spent catching up or getting ready or just plain repairing myself from the abuse I must endure – including not being able to go to the bathroom or eat in a healthy way during the day. I love the job – the kids – their growth – the fact that I’m helping to create thinking, empathetic citizens. They will make the decisions about my old age, when I can’t, so I better! And then – I have to provide evidence that I actually do my job – add another week of work for that. I’m with you sister.

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