AMANDA S. OBERLIES & others
ATTORNEY GENERAL & another. DONNA KELLY WILLIAMS & others
ATTORNEY GENERAL & another.
Heard: April 3, 2018.
action commenced in the Supreme Judicial Court for the county
of Suffolk on January 19, 2018.
case was reported by Gaziano, J. Civil action commenced in
the Supreme Judicial Court for the county of Suffolk on
September 8, 2017. The case was reported by Gaziano, J.
V. Colbert, III (David Koha & Carmen F.
Francella, III, also present) for Donna Kelly Williams &
Juliana deHaan Rice, Assistant Attorney General (Michael B.
MacKenzie, Assistant Attorney General, also present) for the
N. Nathanson (Elissa Flynn-Poppey & Mathilda McGee-Tubb
also present) for Amanda S. Oberlies & others.
following submitted briefs for amici curiae: Thaddeus A.
Heuer, Andrew M. London, & Rachel C. Hutchinson for
Steward Health Care System LLC.
V. Colbert, III, David Koha, & Carmen F.
Francella, III, for Massachusetts Nurses Association.
Igoe, of California, & David Hadas for National Nurses
United & another.
R. Kiley, Carol Valvo, & Meredith Fierro for American
Nurses Association Massachusetts, Inc.
Flynn-Poppey, Andrew N. Nathanson, & Mathilda S.
McGee-Tubb for Massachusetts Health & Hospital
Association & others.
Present: Gants, C.J., Lenk, Gaziano, Lowy, Budd, Cypher,
& Kafker, JJ.
asked to determine whether two initiative petitions satisfy
the requirements of art. 48 of the Amendments to the
Massachusetts Constitution. The first, Initiative Petition
17-07, would limit the number of patients who may be assigned
to a registered nurse in Massachusetts health care
facilities, and would prohibit facilities from accommodating
those limits by reducing certain other health care staff. The
second, Initiative Petition 17-08, contains the same
provisions as the first petition, with an additional section
that would require publicly funded hospitals to make annual
public disclosures of their financial assets. The Attorney
General certified that Initiative Petition 17-07 meets the
requirements of art. 48, but declined to certify Initiative
Petition 17-08, after concluding that the mandate for
financial disclosure was not sufficiently related to or
mutually dependent upon the other provisions in the petition.
The opponents of Initiative Petition 17-07, and the
proponents of Initiative Petition 17-08, sought relief before
a single justice in the county court.
request of all parties, the single justice reserved and
reported both cases to this court. In the first case, the
plaintiffs challenge the Attorney General's decision to
certify Initiative Petition 17-07; they contend that the
nurse-to-patient ratios are not sufficiently related to or
dependent upon the requirement that, in implementing those
ratios, covered facilities are prohibited from reductions in
other health care staff. Because the restriction on staff
reduction pertains to implementation of the nurse-to-patient
ratios, we conclude that these two elements of the proposal
form "a unified statement of public policy, "
Carney v. Attorney Gen., 447 Mass. 218, 231 (2006)
(Carney I), and therefore are related "within
the meaning of art. 48." See Hensley v. Attorney
Gen., 474 Mass. 651, 672 (2016). The plaintiffs
challenging Initiative Petition 17-07 also argue that it is
not in the form required by art. 48 for presentation to the
voters, on a number of grounds, which we determine are
unsupported. As a result, we conclude that the Attorney
General's decision to certify Initiative Petition 17-07
second case, the plaintiffs challenge the Attorney
General's decision not to certify Initiative Petition
17-08; they argue that the financial disclosure provision is
sufficiently related to the nurse-to-patient ratios, because
it will shed light on facilities' capacity to meet new
staffing needs. We conclude that the Attorney General was
correct in declining to certify Initiative Petition 17-08 on
the ground that the financial asset disclosure requirement
and the limitations on nurse-patient staffing ratios are not
sufficiently related or mutually dependent, as required by
art. 48. See Massachusetts Teachers Ass'n v.
Secretary of the Commonwealth, 384 Mass. 209, 219-220
August, 2017, two petitions, each signed by ten registered
voters in the Commonwealth, were submitted to the Attorney
General for certification. The Attorney General numbered them
Initiative Petition 17-07 and Initiative Petition 17-08.
Although both are entitled "Initiative Petition For A
Law Relative To Patient Safety And Hospital Transparency,
" the petitions differ with respect to one section.
Petition 17-07 seeks to create a new statute, entitled
"The Patient Safety Act" (act or proposed act) that
would amend c. Ill. of the General Laws. The act would create
"patient assignment limits" for registered nurses
working in "facilities" in Massachusetts. The
proposed act defines the term "[f]acility" as
"a hospital licensed under [G. L. c. Ill. § 51],
the teaching hospital of the University of Massachusetts
medical school, any licensed private or [S]tate-owned and
[S]tate-operated general acute care hospital, an acute
psychiatric hospital, an acute care specialty hospital, or
any acute care unit within a [S]tate[-]operated healthcare
facility." "[R]ehabilitation facilities" and
"long-term care facilities" are explicitly
proposed by Initiative Petition 17-07 would set limits on the
number of patients who could be assigned to a registered
nurse in any given facility, based on the unit where the
nurse works and the condition of the patients. For example,
in any emergency services department, a registered nurse
would be assigned only one critical care or intensive care
patient; in pediatric units, up to four pediatric patients
could be assigned to one registered nurse. In any unit not
specifically listed in the proposed act, the patient
assignment ratio would be four patients per registered nurse.
The patient assignment limits would be in effect at all times
except "during a [S]tate or nationally declared public
proposed act provides, "Each facility shall implement
the patient assignment limits established by [G. L. c. Ill.
§] 231C [the nurse-patient limit provision of the
proposed act]. However, implementation of these limits shall
not result in a reduction in the staffing levels of the
health care workforce." We refer to this requirement as
the "workforce reduction restriction." The
"health care workforce" is defined by the proposed
act as all "personnel employed by or contracted to work
at a facility that have an effect upon the delivery of
quality care to patients, including but not limited to
registered nurses, licensed practical nurses, unlicensed
assistive personnel, service, maintenance, clerical,
professional and technical workers, and all other health care
workers." The proposed act would require each facility
to submit a written plan to the Health Policy Commission
(HPC),  certifying that the facility will
implement the patient assignment limits without diminishing
its health care workforce.
proposed by Initiative Petition 17-07 also would authorize
the HPC to promulgate regulations governing implementation
and operation of the act. These regulations would include,
but not be limited to, "regulations setting forth the
contents and implementation of: (a) certification plans each
facility must prepare for implementing the patient assignment
limits enumerated in [§] 231C, including the facility
obligation that implementation of limits shall not result in
a reduction in the staffing level of the health care
workforce assigned to such patients; and (b) written
compliance plans that shall be required for each facility out
of compliance with the patient assignment limits." The
HPC would not be authorized to promulgate any regulation that
directly or indirectly delays, waives, or modifies the
patient assignment limits, or the requirement that those
limits be implemented without resulting reductions in a
facility's health care workforce.
the terms of the proposed act, the HPC "may conduct
inspections of facilities to ensure compliance with the terms
of this act. A facility's failure to adhere to the
patient assignment limits, " as adjusted per the
act's requirements, "shall be reported by the [HPC]
to the Attorney General for enforcement." The Attorney
General would be able to sue a facility found to be in
violation of the act in the Superior Court for injunctive
relief and civil penalties up to $25, 000 per violation.
other initiative petition at issue in this case, Initiative
Petition 17-08, seeks to enact the "Patient Safety and
Hospital Transparency Act." Initiative Petition 17-08 is
essentially identical to Initiative Petition 17-07, but with
one additional provision. General Laws c. Ill. § 231K,
would require that "[e]ach facility that accepts funds
from the Commonwealth . . . report annually to the [HPC] all
financial assets owned by the facility, along with assets of
any holding company and any and all parent, subsidiary, or
affiliated companies." Under Initiative Petition 17-08,
the HPC would be required to make this information public
within seven days of its receipt, unless doing so otherwise
is prohibited by law.
September, 2017, the Attorney General certified that
Initiative Petition 17-07 is in proper form for submission to
the people; that it is not substantially the same as any
measure qualified for submission to the people at either of
the two preceding biennial State elections; and that it
contains only matters that are related or mutually dependent
and not excluded from the initiative process under art. 48.
By December 6, 2017, the petition's proponents had
gathered and filed sufficient voter signatures to require the
Secretary of the Commonwealth (Secretary) to transmit the
petition to the Legislature. The Secretary did so in January,
2018. If the Legislature does not adopt the measure, and if
the proponents submit sufficient additional signatures by
July 3, 2018, the Secretary intends to include the proposed
law in ...