Montana’s Legislature Could Decide Medicaid Expansion’s Fate
By Eric Whitney, Montana Public Radio A ballot initiative that would have continued funding Montana’s Medicaid expansion beyond June 2019 has failed. But advocates say they’ll continue to push for money to keep the expansion going after that financial sunset. “We now turn our attention to the legislature to maintain Montana’s bipartisan Medicaid expansion and protect those enrolled from harmful restrictions that would take away health insurance coverage,” said a concession statement Wednesday from Chris Laslovich, campaign manager with the advocacy group Healthy Montana, which supported the measure. The initiative, called I-185, was the single most expensive ballot measure in Montana history. Final fundraising tallies aren’t in yet, but tobacco companies poured more than $17 million into Montana this election season to defeat the initiative. That’s more than twice as much cash as supporters were able to muster. Most of the money in favor of I-185 came from the Montana Hospital Association. “I’m definitely disappointed that big money can have such an outsized influence on our political process,” said Dr. Jason Cohen, chief medical officer of North Valley Hospital in Whitefish. The ballot measure would have tacked an additional $2-per-pack tax on cigarettes. It would have also taxed other tobacco products, as well as electronic cigarettes, which aren’t currently taxed in Montana. Part of the expected $74 million in additional tax revenue would have funded continuation of Medicaid expansion in Montana. Unless state lawmakers vote to continue funding the Medicaid expansion, it’s set to expire in June 2019. If that happens, Montana would become the first state to undo a Medicaid expansion made under the Affordable Care Act. In September, Gov. Steve Bullock, a Democrat, told the Montana Association of Counties that if the Medicaid initiative failed, “we’re going to be in for a tough [2019 legislative] session. Because if you thought cuts from last special session were difficult, I think you should brace, unfortunately, for even more.” Republican State Rep. Nancy Ballance, who opposed I-185, disagrees with Bullock’s position. “I think one of the mistakes that was made continually with I-185 was the belief that there were only two options: If it failed, Medicaid expansion would go away; if it passed, Medicaid expansion would continue forever as it was.” Ballance, who didn’t receive money to campaign against the initiative, said Medicaid expansion in Montana can be tweaked without resorting to a sweeping new tax on tobacco products. “No one was willing to talk about a middle-ground solution where Medicaid expansion is adjusted to correct some of the things that we saw as issues or deficiencies in that program,” she said. “I think now is the time to roll up our sleeves and come up with a solution that takes both sides into consideration.” Ballance said conservatives in the legislature want recipients of expansion benefits to face a tougher work requirement and means testing, so those with low incomes who also have significant assets like real estate won’t qualify. In any event, Ballance said she suspects that if the initiative had passed, it would have immediately faced a court challenge. North Valley Hospital’s Cohen said he hopes Montana will pass a tobacco tax hike someday. “We all know how devastating tobacco is to our families, our friends and our communities,” Cohen said. “And I think we also all know how important having insurance coverage is, and so I think people are dedicated to fighting this battle and winning it.” This story is part of a partnership that includes Montana Public Radio, NPR and Kaiser Health News. Montana Public Radio’s Edward O’Brien contributed to the story. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Midterm Election Boosts Medicaid Expansion, But Challenges Remain
By Phil Galewitz, Kaiser Health News Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday’s election. Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate. Three deep-red states passed ballot measures expanding their programs and two other states elected governors who have said they will accept expansion bills from their legislatures. Supporters were so excited by the victories they said they will start planning for more voter referendums in 2020. Medicaid proponents also were celebrating the Democrats’ takeover of the House, which would impede any Republican efforts to repeal the ACA and make major cuts to the federal-state health insurance program for low-income people. “Tuesday was huge for the Medicaid program,” said Katherine Howitt, associate director of policy at Community Catalyst, a Boston-based advocacy group. “The overall message is that the electorate does not see this as a Democrat or GOP issue but as an issue of basic fairness, access to care and pocketbook issue. Medicaid is working and is something Americans want to protect.” But health experts caution that GOP opposition won’t fade away. David Jones, an assistant professor in the Department of Health Law, Policy and Management at Boston University, said ballot organizers now have a blueprint on how to expand Medicaid in states that have resisted. “I see this as a turning point in ACA politics,” he said. Still, he added‚ “it’s not inevitable.” Medicaid is the largest government health program, insuring at least 73 million low-income Americans. Half of them are children. To date, 32 states and the District of Columbia have expanded it under the ACA. Before that law, Medicaid was generally limited to children, sometimes their parents, pregnant women and people with disabilities. The ACA encouraged states to open the program to all Americans earning up to 138 percent of the poverty level ($16,753 for an individual in 2018). The federal government is paying the bulk of the cost: 94 percent this year, but gradually dropping to 90 percent in 2020. States pay the rest. GOP opposition has left about 4.2 million low-income Americans without coverage in various states. “It’s not over until it’s over is the story of Medicaid expansion and the Affordable Care Act as the politics never ends and the opportunity for obstruction never ends,” said Jones. “But the trend overall has been to increasing implementation and increasing coverage.” Montana Fails To Endorse Funding Two years after President Donald Trump carried Idaho, Nebraska and Utah by double-digit margins with a message that included repeal of the ACA, voters in those states approved the ballot referendums Tuesday. Together, the states have about 300,000 uninsured adults who would be eligible for the program. In addition, Democrats secured the governor’s offices in Kansas and Maine, which will increase the likelihood those states pursue expansion. Legislatures in both states have previously voted to expand, only to have GOP governors block the bills. Maine voters also passed a referendum in 2017 endorsing expansion, but Republican Gov. Paul LePage again refused to accept it. Current and incoming Republican governors in Utah and Idaho said they wouldn’t block implementation of the effort if voters approved it. Nebraska Gov. Pete Ricketts said Wednesday he would follow the will of the voters but would not support paying for it with a tax increase. It wasn’t a clean sweep, however, for Medicaid on Tuesday. In preliminary results, a ballot issue to fund Montana’s Medicaid expansion — which is already in place and slated to expire next July — was failing. Tobacco companies had mounted a campaign to stop the measure, which would have partially financed the expansion with taxes on tobacco products. The Montana legislature and the Democratic governor are expected to address the issue in the session that starts in January. No state has reversed its Medicaid expansion, even though GOP governors in Kansas and Arkansas have threatened to do so. Nearly 100,000 Montana residents have received Medicaid since its expansion, twice as many as expected. Nancy Ballance, the Republican chairwoman of the Montana House Appropriations Committee who opposed the bill that expanded Medicaid in 2015, said she is confident the state legislature will extend the program past July. But she expects the legislature to put some limits on the program, such as adding an asset test and work requirements. “There are some people in the state who may not have disabilities but need some help to access coverage,” she said. “I think we can pass something without people having a gap in coverage. … That will be a priority.” “It was never our intent to simply sunset the expansion and have it go away,” she said. Rather, the legislature put the sunset provision in to revisit the provision to make any changes. Chris Jacobs, a conservative health policy analyst in Washington, D.C., said the Montana results showed that when voters are given a choice of having to pay for Medicaid expansion through a new tax they were not willing to go along. But in Utah, voters did agree to fund their state plan by adding 0.15 percent to the state’s sales tax, just over a penny for a $10 purchase. Fernando Wilson, acting director of the Center for Health Policy at the University of Nebraska Medical Center, said the vote on the state’s ballot question indicated many people wanted to help 80,000 uninsured Nebraskans gain coverage. “I think it showed there was a clear need for it,” he said. The legislature likely won’t block the expansion, Wilson said, though it may try to add a conservative twist such as adding premiums or other steps. Sheila Burke, a lecturer in health policy at Harvard Kennedy School, said voters approved Medicaid expansion not just because it would help improve health coverage for their residents but to help stabilize their hospitals, particularly those in rural areas. Hospitals have said this step helps their bottom
Nebraska Voters Approve Medicaid Expansion Ballot Initiative
Nebraska joined the likes of several other states who approved Medicaid expansion Tuesday, with more than 53 percent of the vote in favor with 90 percent of precincts reporting. As many as 90,000 newly eligible residents will gain coverage and the uninsured rate could fall from to 9.6% from 12.4% next year, according to an independent study by the Urban Institute. Along with the new Medicaid patients, the state will also see a cash flow of federal dollars—as much as $68 million annually—to help cover the program’s costs. The approval is a big win for advocates who have watched attempts to expand Medicaid fail six times in the state’s legislature. Advocates successfully petitioned and got the initiative added to the ballot in July. Voters also said yes despite heavy opposition from the Republican-controlled state representatives and Gov. Pete Ricketts, who saw it as a “government entitlement program.” Depending on when Nebraska’s Medicaid expansion program is officially implemented, the state could see a new wave of job opportunities in the travel healthcare market in 2019. Studies have shown that Medicaid expansion states have increased patient demands and healthier hospital budgets, which can lead to a higher volume of traveler needs. We will update this story with the final election totals when they are made available.
Question 1: Massachusetts Nurse-To-Patient Ratio Ballot Initiative Defeated
Massachusetts’ Question 1, a ballot initiative that would have established mandatory nurse-patient ratios in hospitals was defeated during the general election Tuesday. The Massachusetts Nurses Association, a union representing nurses in 51 acute care hospitals across the state, conceded defeat around 9 p.m. Tuesday evening. At approximately 10:20 p.m., the initiative had 969,400 votes against and 416,720 votes in favor, with more than 50 of precincts reporting, according to the preliminary results. “We are all disappointed by tonight’s results and the impact this will have on the patients we care for every day,” MNA President Donna Kelly-Williams said in prepared remarks. “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.” The outcome was a victory for the Massachusetts Health and Hospital Association, who opposed the initiative for fear that it would dramatically increase state healthcare costs. The association represents 70 hospitals across the state. “This is the beginning of a conversation, not the end,” MHA President and CEO Steve Walsh said in a statement to Mass Live. “Question 1 forced some difficult and necessary discussions about the future of healthcare and the future of our workforce going forward. 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.” An independent study conducted by the state’s Health Policy Commission found that implementing the mandate would cost an estimated $676-949 million per year and potentially save $34-47 million. The study also found that hospitals would need to hire 2,286 to 3,101 additional full-time equivalent nurses to meet the mandate.
The Election’s Impact On Healthcare: Some Bellwether Races To Watch
By Julie Rovner, Kaiser Health News Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many. But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions and state legislatures around the country. All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen — or not happen — over the next two years. For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not. Here are three big health issues that could be dramatically affected by Tuesday’s vote. 1. The Affordable Care Act Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans and the generic drug approval process, among other things. Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law. This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect. Polls suggest Cramer has a healthy lead in that race, but if Heitkamp pulled off a surprise win, health care might well get some of the credit. And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care. It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and two GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general — Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey — are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016. The attorneys general are running against Democratic incumbents — Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit. Although Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts. But in the end, the fate of the ACA depends less on an individual race than on which party winds up in control of Congress. “If Democrats take the House … then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health. Conservative healthcare strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday. “Republicans, if they maintain the majority in the House, will have a margin of a half dozen seats — if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently, there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017. And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so a change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there. 2. Medicaid expansion The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138 percent of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94 percent in 2018, gradually dropping to 90 percent in 2020. Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid. McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said. Four states — Nebraska, Idaho, Utah and Montana — have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs. In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov.
2018 Election: Healthcare Issues Travelers Should Watch
One of the benefits of being a travel healthcare professional can be the opportunity to avoid hospital politics, but national politics are much harder to ignore. Many hot-button healthcare issues decided at the polls can have a direct impact on the travel healthcare job market, both positive and negative, and the 2018 midterm election on November 6 is no exception. Below, we’ve provided brief summaries on ballot initiatives across the country that could have tangible effects on the travel healthcare market. For those who need more information on when, where and how to vote in the midterms, check out our 2018 midterm election voting FAQ. 2018 Election Healthcare Issues California Prop 4, Children’s Hospital Bond Initiative Proposition 4, also known as the Children’s Hospital Bond Act Fund, would authorize $1.5 billion in bonds that would be used to award grants to children’s hospitals for construction, expansion, renovation, and equipment projects. With interest over 35 years, the bond’s total cost would be $2.9 billion. The bonds would be repaid over a period of time from the state’s General Fund, according to the state website. According to Ballotpedia, the $1.5 billion would be distributed as follows: 72 percent ($1.08 billion) to eight nonprofit hospitals providing comprehensive services to high volumes of children eligible for governmental programs and children with special health needs eligible for California Children’s Services. 18 percent ($270 million) to five University of California general acute hospitals, including the University of California, Davis Children’s Hospital; Mattel Children’s Hospital at University of California, Los Angeles; University Children’s Hospital at University of California, Irvine; University of California, San Francisco Children’s Hospital; and University of California, San Diego Children’s Hospital. 10 percent ($150 million) to public and private hospitals that provide pediatric services to children eligible for California Children’s Services Why this is important for travelers If approved by Californa voters, the massive cashflow could provide many positive benefits for both children’s facilities and travelers. Hospitals would be able to update, renovate or construct new units, which could improve quality of care for patients, improve the working environment for healthcare professionals and potentially provide staffing opportunities for travelers. Idaho Proposition 2, Medicaid Expansion Initiative Idaho Medicaid expansion advocates successfully petitioned and gathered 75,314 verified signatures to add a Medicaid expansion measure to the ballot. The petition met both state requirements to qualify the ballot measure, gathering at least 56,192 verified signatures that represented at least 18 of Idaho’s 35 legislative districts. An expansion would allow Idaho residents under 65 and earning incomes at 138 percent of the national poverty level to apply for Medicaid insurance. About 62,000 Idahoans would qualify for this coverage. Expansion would also bring in $105 million in costs to the state over 10 years and $200 million in savings, according to an independent analysis by The Milliman consulting firm. Why this is important for travelers Studies have shown that hospitals in Medicaid expansion states have not only saved tremendously on uncompensated care costs, but they also have also seen more newly-insured patients coming in for healthcare services. The increased patient needs and loosened revenue streams could result in more opportunities for healthcare travelers. You can read more about this issue in our Medicaid expansion guide. Massachusetts Question 1, Nurse-Patient Assignment Limits Initiative Approval of Question 1 in Massachusetts would establish a set nurse-to-patient ratio across all state hospitals, except during a public health emergency. This measure would also require the limits to be met without a reduction in staff, and would allow the Massachusetts Health Policy Commission to regulate and enforce the initiative, which could result in $25,000 per incident for hospitals that violate the mandated ratios. If approved, Massachusetts would become the second state with mandated nurse-to-patient ratios—currently, California is the only state that has them. According to an independent study by the Massachusetts Health Policy Commission, implementing the mandate would cost from $676 million to $949 million per year. They also estimated possible savings of $34 million to $47 million from reduced hospital length of stay and potential for improved patient care with increased nurse staffing. State hospitals would also need to increase staffing by 2,286 to 3,101 additional full-time equivalent nurses to comply with the mandated ratios, according to the study. Medical-surgical and psychiatric nurses would present the greatest needs for increased staffing. Why this is important for travelers Of all the healthcare initiatives voters will decide on at the polls this fall, Question 1 could have the biggest and most direct impact on travel nurses. Mandated ratios mean more nurse hiring, which also means significantly more opportunities for travel nurses. You can find more information additional details on the impact of this change by checking out our recent coverage of the ballot issue. Utah Utah Proposition 3, Medicaid Expansion Initiative Utah Gov. Gary Herbert signed a bill on March 27, 2018, for partial Medicaid expansion, directing the state to seek federal approval to expand Medicaid to 100% of the federal poverty level. The bill stipulated using the ACA enhanced federal match rate and adding a work requirement for the expansion population. The Center for Medicare and Medicaid Services (CMS) has not approved waivers to access the match rate until Utah approves a full expansion. In the meantime, Utah expansion advocates garnered enough petition signatures to add a competing bill to November ballots that would approve a full expansion. An expansion would provide an estimated 150,000 Utah residents with Medicaid coverage. Why this is important for travelers Studies have shown that hospitals in Medicaid expansion states have not only saved tremendously on uncompensated care costs, but they also have also seen more newly-insured patients coming in for healthcare services. The increased patient needs and loosened revenue streams could result in more opportunities for healthcare travelers. You can read more about this issue in our Medicaid expansion guide. Nebraska Nebraska Initiative 427, Medicaid Expansion Similar to Idaho and Utah, Nebraska advocates have submitted a petition to add a Medicaid expansion initiative to the midterm election ballot. Supporters filed more than 133,000 signatures on July 5 and a large enough majority
Healthcare Tops Guns, Economy As Voters’ Top Issue
By Phil Galewitz, Kaiser Health News Healthcare has emerged as the top issue for voters headed into the midterm elections, but fewer than half of them say they are hearing a lot from candidates on the issue, according to a new poll released Thursday. Seven in 10 people list healthcare as “very important” as they make their voting choices, eclipsing the economy and jobs (64 percent), gun policy (60 percent), immigration (55 percent), tax cuts (53 percent) and foreign policy (51 percent). When asked to choose just one issue, nearly a third picked health care, according to the survey by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Still, midterm elections are traditionally a referendum on the president and his party, and that holds true this year as two-thirds of voters say a candidate’s support or opposition to President Donald Trump will be a major factor in their voting decision, the poll found. Health care was also the top issue chosen overall by voters living in areas identified in the survey as political battlegrounds, although the results varied when pollsters drilled down to political parties. Nearly 4 in 10 Democratic battleground voters and 3 in 10 independents chose health care as their most important issue in voting for Congress. Among Republican voters, immigration was their top issue, garnering 25 percent compared with 17 percent for health care. The poll results in two battleground states — Florida and Nevada — also underscored voters’ interest for keeping the Affordable Care Act’s protections for people with preexisting conditions, one of the most popular provisions in the law. Democrats have made that a key part of their campaign, pointing to Republicans’ votes to repeal the entire law and trying to drive home the message that the GOP’s efforts would strip that guarantee. Nonetheless, Republicans have recently sought to fight back on that issue, promising on the stump and in campaign ads that they understand the need to keep the protections and would work to do that. Nearly 7 in 10 Florida voters said they are more likely to vote for a candidate who wants to maintain the protections for people with preexisting conditions, while 9 percent said they are more likely to vote for a candidate who wants to eliminate these protections. In Nevada, nearly 70 percent of voters also said they wanted the ACA preexisting protections guaranteed. In Florida, where the deadliest mass school shooting in American history took place last February, health care also was the top issue among voters. Twenty-six percent of Florida voters listed health as their top issue. The economy and gun policy tied for the second-biggest issue at 19 percent. The shooting at Marjory Stoneman Douglas High School in Parkland, Fla., left 17 students and staff members dead, spurred massive marches around the country and stirred national debate on gun policy. Florida is traditionally a key battleground state but more so this year with close races for the U.S. Senate and governor’s race hanging in the balance. Nearly half of Florida voters said they are more likely to vote for a candidate who wants to expand Medicaid. Florida is one of 17 states that has chosen not to expand Medicaid under the health law, leaving tens of thousands of its adult residents without health insurance. The Republican-controlled legislature has refused to accept millions of dollars in federal funding to extend the coverage. Two in 10 Democratic voters in Florida said support for a candidate supporting a national health plan, or “Medicare-for-all,” is the most important healthcare position for a candidate to take. Andrew Gillum, the Florida Democratic gubernatorial nominee, has said he would support a national health plan. In Nevada, which also has a key Senate battle, the poll found nearly a quarter of voters said health care was the top issue in their decisions this year, but immigration and the economy were very close behind. Nearly a third of Democrats in Nevada said they are looking for a candidate who supports a single-payer health plan. Just under a third of Republicans in Florida and Nevada said that a candidate’s support of repealing the ACA is the most important health issue when they vote. The poll of 1,201 adults was conducted Sept. 19-Oct. 2. The national survey has a margin of error of +/-3 percentage points. This article originally appeared on Kaiser Health News Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Massachusetts Voters Split On Mandated Nurse Staffing
With only two weeks left until the Nov. 6 midterm election, Massachusetts voters are split evenly on establishing statewide mandated nurse-to-patient ratios, according to a new poll by WBUR, Boston’s NPR news station. Of the 506 Massachusetts residents surveyed, 44 percent were in favor of mandated nurse staffing, and 44 percent were opposed. The remaining 12 percent said they were undecided. Advocates for the mandate, also known as Question 1, have said establishing mandated nurse staffing ratios will lead to better patient outcomes and improve quality of care. Opponents have said the opposite and also claim mandated ratios will put an expensive burden on state hospitals. Both sides claim nurses fully support them. Both groups have spent a combined total of more than $14 million on competing TV advertisements and campaign initiatives. Because both groups have run similar ad campaigns, voters have had a difficult time figuring out how nurses actually feel about the issue, according to the WBUR report. The pro-mandate group, the Committee to Ensure Safe Patient Care, is sponsored by the Massachusetts Nurses Association. Most of the group’s supporters are nursing unions, labor unions, international labor unions and local community groups, according to their website. The group also earned key endorsements from several local, state and federal representatives, most notably Sen. Elizabeth Warren and Boston Mayor Martin J. Walsh. “Nurses work hard to take care of all of us when it matters the most, and we should do the same for them by establishing standards to ensure they have the help they need to do their job safely,” Senator Warren said in a press release. “I stand with our nurses and support a yes vote on Question 1 in November.” The opposing group, known as the Coalition to Protect Patient Safety, is supported mostly by hospitals, hospitals associations and local chambers of commerce, according to their website. The organization has also earned a handful of endorsements from local mayors, including Waltham Mayor Jeanette McCarthy. An independent study conducted by the state’s Health Policy Commission found that implementing the mandate would cost an estimated $676-949 million per year and potentially save $34-47 million. The study also found that hospitals would need to hire 2,286 to 3,101 additional full-time equivalent nurses to meet the mandate. You can read the full analysis of the study below: