A Massachusetts ballot question that would have established mandatory nurse-patient ratios in hospitals was defeated Tuesday, in a victory for healthcare industry leaders who had issued dire predictions about the measure's costs.

The Yes on Question 1 campaign was spearheaded by the Massachusetts Nurses Association, a union representing nurses in 51 acute care hospitals across the state, in addition to other health facilities not affected by the proposal.

MNA President Donna Kelly-Williams conceded the vote in prepared remarks released shortly after 9 p.m.

"We are all disappointed by tonight's results and the impact this will have on the patients we care for every day," Kelly-Williams said. "We know that right now - as I speak to you here - there are nurses caring for too many patients and those patients are unnecessarily being put in harm's way. And the problem continues to grow every year. The status quo is not a solution here."

Opposition to the law was led by the Massachusetts Health and Hospital Association, an industry organization representing the interests of hospitals across the state.

The result gives hospitals "the ability to continue providing the best possible care for patients," MHA President and CEO Steve Walsh said in a statement.

"This is the beginning of a conversation, not the end. Question 1 forced some difficult and necessary discussions about the future of health care and the future of our workforce going forward," Walsh said. "These conversations with our care teams and in our communities have been critically important and will continue in bargaining sessions, legislative debates, board rooms and newspapers."

Tony Berry, a spokesman for UMass Memorial Health Care, said the hospital system was still open to "reasonable conversations" about improving their processes, including nurse staffing levels.

"We are thankful to have this issue behind us. Throughout much of this year the people of Massachusetts have been inundated with claims of unsafe patient care at Massachusetts hospitals. UMass Memorial Health Care, its member hospitals and 14,000 caregivers would never accept an environment that puts our patients at risk," Berry said in a statement. "The people of Central Massachusetts can have confidence that despite our differences on this ballot initiative, every caregiver at UMass Memorial is committed to not only ensuring patients receive the best care possible, but also the safest."

Baystate Health President and CEO Mark Keroack also cheered the result of the vote.

"Election Day is behind us and the Question 1 ballot initiative was voted down. Massachusetts hospitals stood together against this legislation because of the significant negative impacts it could have had on patients and their ability to access health care throughout the state," Keroack said in a statement. "At Baystate Health we value our nurses and the role they play on teams whose care has been recognized nationally for its safety and quality. We recognize the ongoing challenges of the national nursing shortage and will continue our efforts to advance our innovative strategies to educate, recruit, and retain our talented nursing workforce."

The campaign was contentious and well-funded. The Coalition to Protect Patient Safety, which was hospital-funded and opposed to the question, spent $24.5 million, flooding the airwaves with ads warning of financial consequences and cuts to services if the measure were to pass.

The Committee to Ensure Safe Patient Care, which was union-funded and supported the question, spent $10.4 million, according to state finance records. Proponents of the measure said that lowering nurse-patient ratios would lead to safer and better care, and describe the hospitals' predictions as empty scaremongering.

The ballot question would have mandated a series of patient ratio limits for hospital nurses -- a policy supporters say is needed to ensure better patient safety.

Nurses in step-down or intermediate care units would have been allowed a maximum of three patients. There would have been one-to-one ratios for patients under anesthesia and mothers who are either in labor or have just given birth. Pediatric, medical and surgical nurses would have been allowed four patients. And psychiatric or rehabilitation nurses would have been allowed five patients each, among other limits.

Hospitals would have been required to comply with the limits without reducing levels of nursing, maintenance, clerical or professional staff. And the proposal also would have barred hospitals from reducing services to cover the additional costs -- something hospitals say is not financially possible.

The law would have been implemented based on regulations created by the state's Health Policy Commission. It was set to go into effect on Jan. 1, though hospitals with nurse union contracts would have been allowed to maintain their agreed-on ratios until those contracts expire.

Hospitals would have had to submit compliance plans following any violations, and the Health Policy Commission would have had the power to refer violations to the state Attorney General -- who would have been able file suit to obtain penalties of $25,000 per violation.

The debate over the law set many nurses against the administrators who run their hospitals and other medical professionals' groups. And each side offered wildly diverging predictions about the proposals' impacts.

The MNA argued that the staffing limits would ensure better care for patients, citing studies that have found links between nurse staffing levels and patient outcomes. Proponents also said that hospitals could bear the cost of the measure without sacrificing services, citing a study by Boston University nursing economist and former MNA President Judith Shindul-Rothschild that estimated a cost of $47 million.

In an interview with MassLive, Shindul-Rothschild acknowledged that her estimate did not account for all the effects of the law, but argued it was closer to the true figure than the MHA's estimate of $1.3 billion.

That study estimated that hospitals would have to hire 5,911 nurses to comply with the law, including 4,500 new positions and 1,200 currently vacant positions. The hospitals' estimate also factored in the costs of wage inflation, recruitment, training and turnover due to the proposal.

The MHA-funded study also said that some medical facilities in Western Massachusetts, the Cape and Islands and Metrowest region may close entirely. Mercy Medical Center in Springfield estimated a $13.8 million cost, saying it would lead to bed closures and cuts to community health programs. UMass Memorial Health Care estimated a $38 million loss at its hospitals in Worcester, Marlborough and Leominster, predicting increased ER wait times and further community health program reductions.

Leaders from the Massachusetts Nurses Association argued that those dire forecasts -- along with hospital claims of a nursing shortage that would make it difficult to fulfill the requirements of the law -- were just the latest in a series of hospital industry efforts to block the measure.

The nurse's union had for years attempted to pass the staffing ratios through the legislature and collective bargaining, representatives said in an editorial board meeting with the Republican in late October. In 2014, those debates led to a compromise measure that implemented nurse staffing requirements in ICUs.

Nurses working on hospital floors frequently report being stretched too thin, according to the nurse's union. Unionized nurses in Massachusetts have filed about 3,000 "unsafe staffing" reports so far in 2018, the Boston Globe reported.

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