Bidwell Advisors
October 18, 2018
To neighbors and friends, Ward 2 and elsewhere,

With the arrival of shorter days and colder nights comes an increase in the pace of things in City government. We're in the middle of a very busy fall for the City Council. I again extend an encouragement to any and all to attend our regular Council meetings, on the first and third Thursdays of every month, at 7:00 pm, in City Council Chambers (in the Puchalski building, behind City Hall.)
In another newsletter in the next few weeks I'll be reviewing many of the matters we're taking up as a Council this fall.

But I want to devote this newsletter to the ballot questions that will appear on the November 6 ballot. ( Sample ballot here.)

Of the five questions on our November ballot (three of them binding, two of them non-binding), Question One - the Nurse Staffing Ratio ballot initiative - is the one that has generated by far the most confusion and has prompted the most questions to me. I have taken time to study the Yes arguments and the No arguments. I have concluded that we do indeed have a problem with insufficient nursing levels in some of our hospitals, but that this one-size-fits-all blunt instrument is not the right solution.

I am urging a No vote on Question One, for the reasons I detail below.

Question Two proposes to create a citizens commission to consider and recommend potential amendments to the US Constitution to establish that corporations do not have the same Constitutional rights as human beings and that campaign contributions and expenditures may be regulated. One aim would be to undo the harm caused by the Citizens United decision. I am urging a Yes vote on Question Two.

Question Three asks voters to either affirm or repeal an existing law that adds gender identity to the list of prohibited grounds for discrimination in places of public accommodation, resort, or amusement. (Such grounds also include race, color, religious creed, national origin, sex, disability, and ancestry.) A Yes vote keeps this important law on the books, and a No vote would overturn it. I am urging a Yes vote on Question Three.

Question Four is a non-binding question that instructs our state representative "to vote for legislation to create a single-payer system of universal health care that would provide all Massachusetts residents with comprehensive health care coverage including the freedom to choose doctors and other health care professionals, facilities and services, and that would eliminate the role of insurance companies in health care by creating a publicly administered insurance trust fund." I think a Yes vote would send the right message.

Question Five is a non-binding question that instructs our state representative to "introduce and vote in favor of legislation adopting a system for all state and local primaries and elections in which voters rank candidates in order of preference." I think a Yes vote for rank-choice voting (or instant runoff voting) would also send an important message.

Please be in touch if you have questions or suggestions. And stay tuned for future newsletters that will cover a variety of upcoming community conversations and forums, a welcome to three non-profits that have recently located in Ward Two, and Council resolutions dealing with the proposed expansion (yet again) of the Pioneer Valley Chinese Immersion Charter School in Hadley and with the proposed Columbia Gas pipeline expansions.
Dennis Bidwell 
Question One: I am urging a NO voteone
Of the three binding questions on the November 6 ballot, Question One - the Nurse Staffing Ratio ballot initiative - is the one that has generated by far the most confusion and has prompted the most questions to me.

My initial reaction was that surely this is a good idea, and surely we should be supporting our hard-working and under-appreciated nurses. After all, as a progressive, I should be supporting a measure backed by the Massachusetts Nurses Association (MNA), right?

Then, as I learned a little more about the specifics of the ballot initiative, I realized that this is more complicated than I thought, and that it deserves more than a knee-jerk Yes impulse. I decided I needed to learn a lot more.

Having read many studies, listened to the arguments pro and con, attended briefings and forums, I am now convinced that passage of Question One would be very harmful to  health care in the Commonwealth, especially to Cooley Dickinson Hospital and the rest of the network of health care organizations that we rely on here in Northampton, and particularly for the neediest among us seeking care. These mandated nursing ratios would limit the use of discretion and judgment by nursing professionals and the care teams they work with, who now have wide latitude to shift personnel based on the ever-changing situations facing them.

If enacted into law, the initiative would mandate specific registered nurse-to-patient staffing ratios that would apply equally to every hospital in the state, whether a teaching or a community hospital, whether large or small, at every shift regardless of time of day or night, and regardless of whether a nurse has one month or 25 years of experience.

The initiative provides for penalties of up to $25,000 per violation, per day. As written, all of this would go into effect January 1, 2019, only 56 days (38 business days) after the election.

I have concluded that we do indeed have a problem with insufficient nursing levels in some of our hospitals, but that this one-size-fits-all blunt instrument is not the right solution.

Proponents of the initiative, and its opponents, have offered enormously different projections of the impacts of the initiative if passed. Quite helpfully, on October 3, 2018, the Massachusetts Health Policy Commission, an independent state commission with a mandate to analyze health care costs in the Commonwealth, issued an objective and data-driven cost impact analysis of the proposed initiative.

This carefully researched report largely supports the analysis and conclusions of those opposed to Question One. Here is a link to the report.

Let's look at some of the key assertions made by the proponents of Question One.

Assertion: 86% of Nurses Support Question One.

There are approximately 100,000 nurses registered with the Massachusetts Board of Registration in Nursing. In April of this year, the MNA conducted phone interviews of 302 nurses selected randomly from these nurses. (This was a sample of about 0.1% of RNs in the Commonwealth.) When the MNA claims that "86% of Massachusetts nurses" support Question One, that is based on these April interviews of 302 nurses.

A poll conducted just this week by WBUR of 500 registered nurses indicated that nurses are basically evenly divided on this initiative: 48% were in support, 45% were opposed, while 7% didn't know. The 3 percentage point difference falls within the poll's 4.4% margin of error.

This WBUR poll fits with my own experience - the nurses I have spoken with appear quite divided on this issue. One thing that is certainly not the case is the assertion that a large majority of nurses support the initiative.

Some have attempted to cast this issue as a clear labor vs management issue, with labor supporting Question One and management opposing it. This is clearly not how the lines are drawn.

Some of the groups opposing Question One include: the Massachusetts Chapter of the American Nurses Association, the Organization of Nurse Leaders, the Massachusetts Association of Colleges of Nursing, the Emergency Nurses Association, and the Western Massachusetts Nursing Collaborative.

I have great respect for the good that has come from the work of the Massachusetts Nurses Association, but we should remember that they represent just 20% of the state's nurses. And we should remember that even organizations we respect can occasionally be wrong.

Assertion: The hospitals have plenty of money to implement this. It would only cost $47 million for the whole state.

Proponents have claimed that implementation of Question One would cost the hospitals in Massachusetts no more than $47 million, representing a negligible financial burden for the hospitals. Opponents of the measure have argued that it could cost as much as $1 billion to implement the mandated nurse patient staffing limits, with potentially crippling impacts.

On this matter the HPC study is particularly helpful. Their conservative estimate of the annual costs of implementing the ballot initiative is from $676 million to $949 million. This represents 2.4% to 3.5% of total hospital spending. And these estimates don't even include the added expenses in emergency departments, where there was insufficient data to estimate incremental costs.

Cooley Dickinson Hospital, which currently operates at a financial breakeven, would be faced with $9 million of additional annual expenses if the initiative were enacted. The hospital projects that this would mean drastic cuts throughout the system, including the restriction of admissions, increased waiting times in the Emergency Department, and reductions in a range of community programs.

Assertion: There is no nursing shortage. The nurses could easily be recruited to fill the positions required by this initiative

The HPC study estimates that implementation of the initiative would require hiring of an additional 2286 to 3101 registered nurses in the state, with community hospitals (like Cooley Dickinson) facing the need to increase by 14% to 20% the number of RNs employed. And this comes at a time when hospitals are having great difficulty finding enough nurses to fill existing vacancies. Only nine states have tighter RN labor markets than Massachusetts, according to the HPC study.

One of the reasons that the Massachusetts League of Community Health Centers, the Home Care Alliance of Massachusetts, and the Hospice & Palliative Care Federation of Massachusetts are opposing Question One is they fear that if enacted, hospitals would be desperate to hire nurses and would recruit away with higher wages the RNs that now work in community health and mental health centers, nursing homes, addiction treatment centers, etc.

Assertion: The experience with mandated nurse ratios in California, the only state to implement such a policy to date, shows us how effective such an approach can be.

This is a very misleading comparison. The California legislature passed a mandated nurse staffing ratio law in 1999, that was implemented gradually starting in 2004. A state agency implemented unit-specific minimum staffing levels (less strict than those proposed in the Massachusetts initiative) by regulation, implemented in staggered fashion over several years. The California law, unlike the proposal for Massachusetts, did not treat all hospitals equally, allowing for waivers for rural hospitals.

The MPC study takes a careful look at some key comparisons between hospital care in California and in Massachusetts. The study finds that despite implementation of California's nurse staffing ratio law starting 14 years ago, Massachusetts nonetheless has higher hospital RN staffing levels than California. And, of critical importance, I believe, is the comparison of actual health outcomes in the two states. Massachusetts hospitals performed better than California hospitals on 5 of 6 nursing-sensitive quality measures reviewed.

On balance, I find persuasive the data assembled by those opposed to Question One. I have become convinced that its passage would indeed cause considerable harm to our health care system, especially regionally. I worry especially about its impacts on those who rely most heavily on the services of our community hospitals and the many other health care organizations that would doubtless be affected by the unintended ripple effects if this blunt instrument ballot initiative were enacted.

I urge a No vote on Question One on November 6.
Dennis Bidwell City Council Ward 2
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19 Forbes Avenue
Northampton, MA 01060