Next month the voters in Massachusetts USA will be asked to decide whether to enact a law mandating certain specific nurse-to-patient staffing ratios in hospitals. Why was there no compromise? Why did this question make it to the ballot?

Edit: More information on the particular ballot initiative here.

More information on the process here.


  • Ballot: the sheet of paper listing candidates and questions upon which a voter marks her choice: yes or no in case of a question. (Yes, we use actual paper in Massachusetts USA.)

  • Initiative: a law proposed by citizens.

  • Petition: before it gets on the ballot, about 75 000 registered voters must sign a petition requesting it. Gathering enough signatures is hard: it requires both organized people and money.

Background: in 2006, an initiative mandating universal health insurance coverage garnered enough petition signatures to be certified for inclusion on the ballot. As with any proposition put to voters, it was necessarily simplified.

Because the item was to appear on the ballot, the legislature and governor (one Mitt Romney) were highly motivated to act. Act they did, writing a law to create universal coverage. When the law passed, the ballot item was withdrawn by its sponsors.

The law was more workable than the ballot item would have been. It has been largely successful here in Massachusetts.

Health Care For All, the org who sponsored the signature drive for the ballot item, went into the process intending to force a compromise-intending to force the legislature and governor to act. Everybody who gathered signatures knew this was HCA’s strategy. They gave the parties a deadline to work out a compromise.

Why is this year’s ballot item any different? Hospital staffing isn’t simple work. The parties (the nurses’ association and the hospitals) would doubtless be better served by a compromise than by the simple and rigid ballot item.

What happened, or didn’t happen, in the legislature? Was it never the intent of the ballot item’s sponsors to compromise?

Does anybody know?

  • 2
    A link to the full details of the ballot items may help people unfamiliar with the issues understand the situation better. As one of those outsiders, my initial assumption would be the second issue sounds like it can be simply stated on a ballot without a big * and see more details somewhere else notification.
    – Jontia
    Oct 8, 2018 at 15:09
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    I wonder how the well-known fact that there just plain out there ain't enough nurses in USA plays into anyone's calculations on this.
    – user4012
    Oct 9, 2018 at 1:23
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    Again, I don't want to put this as answer as it just seems a bit glib. But the 2nd initiative only specifies a requirement to legislate. It doesn't have any numbers in and expects legislation on staffing levels to follow. Making it a simple Yes/No question. A Universal Coverage requirement could mean a lot of things and a public campaign for the vote could set expectations that might be costly to the state. Conversely the staffing numbers doesn't put that same pressure onto the state, it would be the hospitals that have to meet whatever legislation ends up being written.
    – Jontia
    Oct 9, 2018 at 10:40
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    The proposed law requires certain numerical patient :: nurse staffing levels for various hospital departments. And it requires US$25,000 per day fines for non compliance. It doesn't mandate legislation, just enforcement regulations.
    – O. Jones
    Oct 9, 2018 at 10:59

1 Answer 1


Why is this year’s ballot item any different? Hospital staffing isn’t simple work. The parties (the nurses’ association and the hospitals) would doubtless be better served by a compromise than by the simple and rigid ballot item.

What happened, or didn’t happen, in the legislature? Was it never the intent of the ballot item’s sponsors to compromise?

Does anybody know?

The Universal Health Insurance example in the question is the rare exception. I can think of only two or three times in the last twenty years or so that something like that kind of compromise has happened.

What you are seeing with the nurse staffing ratio ballot issue is by far the predominant way that an initiative process works, because there is no institutional process in a ballot initiative process for compromise or negotiation.

State officials are required to insure that a proposed initiative meets the formal requirements for inclusion on the ballot, but there is no requirement that initiative proponents negotiate in any way with anyone, and the vast majority of the the time, they don't.

Indeed, one of the biggest problems with a ballot initiative process, particularly when it concerns a constitutional amendment (on entrenched legislation that isn't formally a part of the constitution but can't be amended by the legislature) that cannot be later amended by legislation, is the rigidity of proposed initiative language. Even when minor tweaks to the language, which has to be decided on early in the process before many people are paying attention and before petitions are circulated, could make the proposal much better. The citizens initiative process is a crude instrument.

Typically, people choose to go the initiative route because they have an idea for legislation that they believe that the public would favor, but which his little prospect for success in the legislative process because of the perception that special interests or simply the current members of the legislature who have an important role to play in the legislative process, will shoot it down. Almost all citizen's initiatives follow attempts to have a legislator push the issue that fail, either for lack of a sponsor, or for lack of legislative support in one or both chambers as a whole, or due to a likely veto from the Governor.

Initiative sponsors almost never intend to compromise during the process of getting petitions and having it adopted by the voters, although in very rare instances, an initiative is part of such an elaborate primarily legislative strategy.

In the initiative process, compromise is primarily a purely internal process of the drafter of the initiative who must weigh what the drafter would really like the law to be in an ideal world, and what the drafter thinks can secure enough support when petitions are circulated and at the ballot box, to become law.

Also, it isn't uncommon to propose an initiative that is likely to fail the first time around, to determine which drafting points raise political opposition in the ballot campaign, and simply to get the general public used to the idea being proposed through political debate over the first time proposal, knowing that it may take two or three or more attempts before either an initiative is finally passed, or legislation is adopted to address the concerns raised and diffuse the political energy of people who supported the initiative efforts.

When legislative compromises are offered, they generally come from people in the legislative process reaching out to initiative sponsors (who must weight the certainty of a deal to enact legislation against the uncertain prospect of voters adopting their proposed plan), rather than the other way around. And, negotiation is much less likely in the case of a very simple proposal, like the one related to nurse staffing, than it is in the case of a big complicated effort, like one to adopt universal health care where lots of the devils are in the details.

And, a "near miss" initiative that gets on the ballot and gets considerable support, even if it doesn't pass, is likely to make legislators more receptive to similar proposals introduced in legislative channels in the future, because a "near miss" shows substantial public support for the general idea of the proposal and may cause legislators to reassess what voters really do or do not care about.

Legislation similar to a "near miss" ballot initiative is also likely to garner more media attention than it would have otherwise, making "back door deals" to kill good proposals that are possible when legislation is obscure and not carefully monitored by the media, or the politically aware public.

Finally, the need for compromise on imperfect initiative proposals is greatly reduced if the initiative itself is merely ordinary legislation that can be amended later, hence changing the status quo but not the capacity of the legislature to fine tune the process, or when the proposal affords the legislature or the executive branch an opportunity to fine tune the general thrush of the initiative in its implementation. Why compromise when adjustment can be made after the fact if there are problems?

  • In this case it happens not to be a consittutional amendment, but rather ordinary legislation. (In this jurisdiction an amendment is much harder to adopt, requiring both a plebiscite and positive votes in two different legislative sessinos separated by an election.) You are quite right that the 2006 Health Care For All campaign was very sophisticated and well-organized. The present campaign, not so much. It's probably going to fail, and not only because the hospitals and payers are pouring big bucks and astroturf organizing into defeating it. It seems a lousy idea.
    – O. Jones
    Oct 11, 2018 at 0:50

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