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HPC Weighs in on Impact of Question 1

According to HPC, Massachusetts Ballot Question 1 Could Lead to Increased Costs of up to $949 Million and Decreased Access to Care

In our post last week about the Massachusetts Health Policy Commission Health Care Cost Trends Hearing, we discussed the legislative outlook around curbing health care costs in the next legislative session. Next week, though, Massachusetts voters will have the opportunity to make a decision that impacts health care costs and the accessibility of care in the Commonwealth when they vote on November 6, 2018 on Ballot Question 1 – the proposed Nurse Staffing Ratio Mandate.

The Health Care Cost Trends Hearing included a “Spotlight on Impact of Nurse Staffing Ratios,” which covered the report initially issued by HPC on October 3, 2018. That report, which includes a comprehensive overview of the proposed initiative and the potential impact on health care costs in Massachusetts, is available here.

HPC’s presentation featured Dr. Joanne Spetz of the University of San Francisco’s Institute for Health Policy Studies and Dr. David Auerback, Director of Research and Cost Trends for HPC. Following the presentation, HPC hosted a reaction panel on the potential impact of nurse staffing ratios. During that panel, health policy and industry experts weighed in on the ways in which mandated nurse staffing ratios will affect cost, access, and quality of care in Massachusetts.

As discussed during the Hearing, the HPC report compares the proposed Massachusetts initiative to the existing California mandated nurse staffing ratio law and summarizes California’s experience with mandated staffing ratios, highlighting that there was no systematic improvement in patient outcomes following the implementation of the ratios. The report also reviews the current Massachusetts landscape as compared to California and the country over all, pointing out that as of 2016, Massachusetts had higher hospital RN staffing levels than California and the national average. The HPC report notes that it is not clear whether nurse staffing increases from current Massachusetts staffing levels will actually result in savings.

During the panel, much of the discussion focused on whether the workforce in Massachusetts would be able to meet the demand of the mandated ratios by the January 1, 2019 effective date. In its report, HPC estimated that Massachusetts would need to increase its nursing workforce by 15-20% to meet the proposed mandated requirements. As such, hospital providers will need to recruit many more nurses, including nurses willing to work on a per diem basis, to address fluctuations in patient loads. Employers will also be forced to renegotiate collective bargaining agreements to address the effects of the mandated staffing ratios.

According to the HPC report, the increase in nurses required to meet the proposed mandate would be greatest in community hospitals. Due to data limitations, HPC was unable to include emergency departments, observation units, and outpatient units in its full cost impact analysis, but HPC expects mandated nurse ratios to have significant impact on access to emergency care, wait times, patient flow, boarding and ambulance diversion.

HPC found that the proposed staffing mandates may result in “reductions in hospital margins or assets, reduced capital investments, closure of unprofitable (and/or other) service lines, and reductions in non-health care workforce staffing levels.” According to HPC, these costs could also lead to higher commercial prices for hospital care, potentially leading to higher premiums. Over all, HPC conservatively estimates that the mandated nursing ratios would result in $676 million to $949 million in annual increased costs to providers and to the Commonwealth once fully implemented, and could reduce access to care across the state.[1]



[1] A study conducted earlier this year by Mass Insight Global Partnerships and BW Research Partnership found that the mandate would cost the state’s healthcare system $1.31 billion in the first year, and $900 million annually thereafter. Analysis of Proposed Mandated Nurse Staffing Ratio, available at


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Elissa Flynn-Poppey

Member / Chair, Government Law Practice

Elissa Flynn-Poppey helps prominent Mintz clients resolve issues at the intersection of law and government. She works with government agencies, individuals and nonprofits. Massachusetts Lawyers Weekly recognized Elissa as one of the 2016 Top Women of Law and in 2021 the Circle of Excellence.
Cassandra L. Paolillo is Of Counsel at Mintz whose practice involves advising health care clients on transactional and regulatory matters, including mergers and acquisitions, regulatory compliance, and general contracting. Cassie primarily works with providers and payors.

Stephen M. Weiner

Member Emeritus