Case Title: Oberlies v. Attorney General

Citation: 

Docket Number: SJC-12472; 12473

State: massachusetts

Court: Massachusetts Supreme Court

Date: 2018-06-18T00:00:00Z

Document:
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SJC-12472 
SJC-12473 
 
AMANDA S. OBERLIES & others1  vs.  ATTORNEY GENERAL & another.2 
 
DONNA KELLY WILLIAMS & others3  vs.  ATTORNEY GENERAL & another.4 
 
 
 
Suffolk.     April 3, 2018. - June 18, 2018. 
 
Present:  Gants, C.J., Lenk, Gaziano, Lowy, Budd, Cypher, 
& Kafker, JJ. 
 
 
Initiative.  Constitutional Law, Initiative petition.  Attorney 
General.  Nurse. 
 
 
 
 
Civil action commenced in the Supreme Judicial Court for 
the county of Suffolk on January 19, 2018. 
 
 
The case was reported by Gaziano, J. 
 
 
Civil action commenced in the Supreme Judicial Court for 
the county of Suffolk on September 8, 2017. 
 
                     
 
1 Sharon Gale, Patricia M. Noga, and Timothy Quigley. 
 
 
2 Secretary of the Commonwealth. 
 
 
3 Karen A. Coughlin, Susan Wright Thomas, Mary Elizabeth 
Amsler, Daniel R. Rec, Nora A. Watts, Linda Barton, Ellen Smith, 
Paula Ryan, and Harley W. Keisch. 
 
 
4 Secretary of the Commonwealth. 
2 
 
 
 
The case was reported by Gaziano, J. 
 
 
 
Edward V. Colbert, III (David Koha & Carmen F. Francella, 
III, also present) for Donna Kelly Williams & others. 
 
Juliana deHaan Rice, Assistant Attorney General (Michael B. 
MacKenzie, Assistant Attorney General, also present) for the 
Attorney General. 
 
Andrew N. Nathanson (Elissa Flynn-Poppey & Mathilda McGee-
Tubb also present) for Amanda S. Oberlies & others. 
 
The following submitted briefs for amici curiae: 
 
Thaddeus A. Heuer, Andrew M. London, & Rachel C. Hutchinson 
for Steward Health Care System LLC. 
 
Edward V. Colbert, III, David Koha, & Carmen F. Francella, 
III, for Massachusetts Nurses Association. 
 
Carol Igoe, of California, & David Hadas for National 
Nurses United & another. 
 
Thomas R. Kiley, Carol Valvo, & Meredith Fierro for 
American Nurses Association Massachusetts, Inc. 
 
Elissa Flynn-Poppey, Andrew N. Nathanson, & Mathilda S. 
McGee-Tubb for Massachusetts Health & Hospital Association & 
others. 
 
 
LENK, J.  We are 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 
3 
 
 
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. 
 
On the 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 
4 
 
 
Attorney General's decision to certify Initiative Petition 17-07 
was correct. 
 
In the 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 (1981).5 
 
1.  Background.  In 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 
                     
 
5 We acknowledge the amicus briefs submitted by the 
Massachusetts Nurses Association, Steward Health Care System 
LLC, and National Nurses United and the California Nurses 
Association in Oberlies's case.  We also acknowledge the amicus 
briefs submitted by the Massachusetts Health & Hospital 
Association, Massachusetts Council of Community Hospitals, 
Conference of Boston Teaching Hospitals, and Massachusetts 
Association of Behavioral Health Systems; Steward Health Care 
System LLC; and the American Nurses Association Massachusetts, 
Inc., in Williams's case. 
5 
 
 
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. 
 
Initiative Petition 17-07 seeks to create a new statute, 
entitled "The Patient Safety Act" (act or proposed act) that 
would amend c. 111 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. 111, 
§ 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 excluded. 
 
The act 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 
6 
 
 
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 health emergency." 
 
The proposed act provides, "Each facility shall implement 
the patient assignment limits established by [G. L. c. 111, 
§] 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),6 certifying that the 
                     
 
6 The Health Policy Commission was created in 2012 to 
"monitor the reform of the health care delivery and payment 
system in the [C]ommonwealth."  See St. 2012, c. 224, § 15; 
G. L. c. 6D, §§ 2, 5. 
7 
 
 
facility will implement the patient assignment limits without 
diminishing its health care workforce. 
 
The act 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. 
 
Under 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 
8 
 
 
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. 
 
The 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. 111, § 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. 
 
In 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 
9 
 
 
(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 the Information for Voters guide 
that will be printed in the summer of 2018.  See art. 48, The 
Initiative, V, § 1, of the Amendments to the Massachusetts 
Constitution, as amended by art. 81, § 2, of the Amendments. 
 
In January, 2018, four registered voters commenced an 
action in the county court, challenging the Attorney General's 
decision to certify Initiative Petition 17-07.  These 
plaintiffs, whom we will call the Oberlies plaintiffs, sought 
writs of mandamus and certiorari and a declaratory judgment, and 
asked the court to declare that Initiative Petition 17-07 is 
invalid, to quash the Attorney General's certification of the 
petition, and to enjoin the Secretary of the Commonwealth from 
placing the petition on the 2018 Statewide ballot.  On the 
parties' joint motion and an agreed-upon statement of facts, the 
single justice reserved and reported the case to the full court. 
 
At the same time that she certified Initiative Petition 17-
07, the Attorney General declined to certify Initiative Petition 
17-08, after having concluded that the financial disclosure 
requirement was not sufficiently related to or mutually 
dependent upon the patient assignment limits to satisfy the 
10 
 
 
requirements of art. 48.  Shortly thereafter, ten registered 
voters filed a complaint in the county court, seeking an order 
of mandamus reversing that decision.7  We refer to these 
plaintiffs as the Williams plaintiffs. 
 
The single justice allowed the parties' joint motion to 
enter a preliminary order that, without passing on the 
likelihood that the Williams plaintiffs would succeed, required 
the Attorney General to release a summary of the petition to the 
Secretary of the Commonwealth.  This order also directed the 
Secretary to prepare blank signature forms so that signatures 
could be gathered while the challenge to the Attorney General's 
decision was pending.  In December, 2017, upon the joint request 
of the parties, the order was amended to require the Secretary 
to advance the petition to the Legislature, if the proponents 
collected sufficient signatures prior to December 6, 2017.  Also 
that month, on the parties' joint motion and an agreed statement 
of facts, the single justice reserved and reported the case to 
the full court. 
 
2.  Discussion.  When a new law is proposed by initiative 
petition, before it can be presented to the Legislature and then 
to the voters for their consideration, the Attorney General must 
                     
 
7 The original Williams plaintiffs moved, with the assent of 
the defendants, to substitute ten different registered voters as 
the Williams plaintiffs.  The single justice allowed this 
motion. 
11 
 
 
review it and certify that it meets the requirements of art. 48.  
See art. 48, The Initiative, II, § 3, as amended by art. 74.  We 
review the Attorney General's decision regarding whether to 
certify a ballot petition de novo, bearing in mind "the firmly 
established principle that art. 48 is to be construed to support 
the people's prerogative to initiate and adopt laws."  Abdow v. 
Attorney Gen., 468 Mass. 478, 487 (2014), quoting Carney v. 
Attorney Gen., 451 Mass. 803, 814 (2008). 
 
The primary question at issue with respect to both 
Initiative Petitions 17-07 and 17-08 is whether the subjects 
addressed in each petition are related or mutually dependent.  
See art. 48, The Initiative, II, § 3, as amended by art. 74.  
The opposition to Initiative Petition 17-07 also raises an 
additional question whether it is in a proper form for 
submission to the voters as required by art. 48.  See Nigro v. 
Attorney Gen., 402 Mass. 438, 443 (1988).  We address each issue 
in turn. 
 
a.  Whether subjects are related or mutually dependent.  
Under art. 48, if a petition addresses multiple subjects, those 
subjects must be "related or . . . mutually dependent."  
Art. 48, The Initiative, II, § 3, as amended by art. 74.  See 
Albano v. Attorney Gen., 437 Mass. 156, 161 (2002).  We have 
held that two provisions that "exist independently" of each 
other are not mutually dependent.  See Gray v. Attorney Gen., 
12 
 
 
474 Mass. 638, 648 (2016).  No "bright-line" test exists for 
determining whether two subjects are related.  See Dunn v. 
Attorney Gen., 474 Mass. 675, 680 (2016); Abdow, 468 Mass. at 
499.  "The decisions of this court illustrate how we have 
endeavored to construe the related subjects requirement in a 
balanced manner that fairly accommodates both the interests of 
initiative petitioners and the interests of those who would 
ultimately vote on the petition.  On the one hand, the 
requirement must not be construed so narrowly as to frustrate 
the ability of voters to use the popular initiative as 'the 
people's process' to bring important matters of concern directly 
to the electorate."  Abdow, supra.  On the other hand, while 
art. 48 does not demand that an initiative concern only one 
subject, "relatedness cannot be defined so broadly that it 
allows the inclusion in a single petition of two or more 
subjects that have only a marginal relationship to one another."  
Id.  Otherwise, a petition "might confuse or mislead voters, 
or . . . place them in the untenable position of casting a 
single vote on two or more dissimilar subjects."  Id. 
 
Indeed, the drafters of art. 48 were concerned that 
initiatives could confuse voters, or could be used for 
"logrolling."  See Dunn, 474 Mass. at 679-680; Carney I, 447 
Mass. at 226-228.  "Logrolling" refers to the bundling of 
multiple provisions such that they all gain approval, even if 
13 
 
 
one or more of them would, standing alone, be rejected.  Carney 
I, supra at 219 n.4.  Logrolling is of particular concern when 
an unpopular provision could be hidden or made less apparent by 
a more attractive proposal that catches voters' attention.  See 
id. at 229. 
 
We accordingly have held that the related subjects 
requirement is satisfied where "one can identify a common 
purpose to which each subject of an initiative petition can 
reasonably be said to be germane."  Massachusetts Teachers 
Ass'n, 384 Mass. at 219-220.  "We have not construed this 
requirement narrowly nor demanded that popular initiatives be 
drafted with strict internal consistency."  Mazzone v. Attorney 
Gen., 432 Mass. 515, 528-529 (2000).  "But we have also 
cautioned that '[a]t some high level of abstraction, any two 
laws may be said to share a "common purpose."'"  Dunn, 474 Mass. 
at 680, quoting Abdow, 468 Mass. at 500. 
 
"[W]e have posed two questions to be considered in 
addressing the related subjects requirement."  Dunn, 474 Mass. 
at 680.  First, "[d]o the similarities of an initiative's 
provisions dominate what each segment provides separately so 
that the petition is sufficiently coherent to be voted on 'yes' 
or 'no' by the voters?"  Abdow, 468 Mass. at 500, quoting 
Carney I, 447 Mass. at 226.  Second, does the initiative 
petition "express an operational relatedness among its 
14 
 
 
substantive parts that would permit a reasonable voter to affirm 
or reject the entire petition as a unified statement of public 
policy?"  Abdow, supra at 501, quoting Carney I, supra at 230-
231. 
 
The Oberlies plaintiffs challenge the Attorney General's 
determination that Initiative Petition 17-07 contains subjects 
that are related or mutually dependent.  The Williams plaintiffs 
assert that the Attorney General erred in determining that 
Initiative Petition 17-08 fails this test.  For the reasons 
discussed infra, we conclude that the Attorney General was 
correct in reaching both of these determinations. 
 
i.  Initiative Petition 17-07.  The common purpose of the 
provisions in Initiative Petition 17-07 is to establish and 
enforce nurse-to-patient ratios in facilities in the 
Commonwealth.8  This common purpose is not "so broad as to render 
the 'related subjects' limitation meaningless."  Massachusetts 
Teachers Ass'n, 384 Mass. at 219.  The patient assignment limits 
                     
 
8 The Oberlies plaintiffs contend that Initiative 
Petition 17-07's purpose is "patient safety," based on the title 
of the proposed act, references to patient safety in the 
petition's text, and a memorandum submitted by its proponents to 
the Attorney General.  The court agrees with the Attorney 
General's characterization of the proposal's purpose, which is 
to achieve patient safety specifically through the 
"establishment of patient-to-nurse assignment limits in 
hospitals and other specified health care facilities."  See 
Opinion of the Justices, 422 Mass. 1212, 1220-1221 (1996) 
(rejecting initiative drafters' asserted purpose, and accepting 
purpose advanced by brief of counsel to House of 
Representatives). 
15 
 
 
"can reasonably be said to be germane" to the petition's common 
purpose, because they implement the nurse-to-patient ratios that 
the petition seeks to achieve.  Id. at 219-220.  Notwithstanding 
the Oberlies plaintiffs' claims to the contrary, the workforce 
reduction restriction also advances the petition's common 
purpose. 
 
First, "the similarities of [the] initiative's provisions 
dominate what each segment provides separately so that the 
petition is sufficiently coherent to be voted on 'yes' or 'no' 
by the voters."  Abdow, 468 Mass. at 500, quoting Carney I, 447 
Mass. at 226.  The workforce reduction restriction only 
prohibits reduction in a facility's health care workforce that 
results from putting in place the patient assignment limits.9  In 
other words, the restriction on workforce reduction is triggered 
by the implementation of these limits.  It does not prohibit 
reduction of the health care workforce for any other reason, 
but, rather, dictates how nurse-to-patient ratios may be 
maintained:  in a manner such that there be no reductions in 
staff among other members of the health care workforce.  Because 
the patient assignment limits and the workforce reduction 
                     
 
9 Initiative Petition 17-07 provides, "Each facility shall 
implement the patient assignment limits established by [G. L. 
c. 111, §] 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." 
16 
 
 
restriction both determine how nurse-patient staffing ratios 
will be implemented, their similarity "dominate[s] what each 
segment provides separately."  See Abdow, supra, quoting 
Carney I, supra. 
 
Second, Initiative Petition 17-07 "express[es] an 
operational relatedness among its substantive parts that would 
permit a reasonable voter to affirm or reject the entire 
petition as a unified statement of public policy."  Abdow, 468 
Mass. at 501, quoting Carney I, 447 Mass. at 230-231.  Because 
it anticipates and addresses a potential consequence of the 
nurse-patient staffing ratios, the workforce reduction 
restriction is "simply one piece of the proposed integrated 
scheme."  See Hensley, 474 Mass. at 659.  If hospitals were 
economically burdened by hiring more registered nurses, they 
might attempt to compensate by reducing the numbers of other 
staff.  Indeed, when California implemented nurse-to-patient 
ratios, the health care industry protested that hospitals would 
be forced to lay off personnel to pay for additional nurses.  
See California Nurses Ass'n vs. Schwarzenegger, Cal. Super Ct., 
No.04CS01725, slip op. (Sacramento County May 27, 2005).  
"Neither the Attorney General nor this court is required to 
check common sense at the door when assessing the question of 
relatedness."  Carney I, 447 Mass. at 232.  Because the 
workforce reduction restriction would shape the impact of the 
17 
 
 
patient assignment limits, it forms part of the proposal's 
"unified statement of public policy."  See id. at 230-231. 
 
In this sense, the situation at bar is similar to that in 
Dunn.  In that case, we considered a petition seeking to 
prohibit confinement of specified farm animals in a cruel manner 
(farm provision), and also banned the sale, within the 
Commonwealth, of certain products produced from animals so 
confined (sales provision).  Dunn, 474 Mass. at 676.  We 
concluded that the provisions were related within the meaning of 
art. 48, because the sales provision "protects Massachusetts 
farmers who comply with the law by preventing Massachusetts 
businesses from selling eggs, veal, and pork obtained from out-
of-State farmers who confine their animals in a cruel manner and 
who, by doing so, may be able to underprice their Massachusetts 
competitors."  Id. at 681, 682.  In other words, the sales 
provision anticipated and mitigated private actors' foreseeable 
reactions to the farm provision. 
 
Similarly, here, the workforce reduction restriction seeks 
to address facilities' potential responses to the nurse-patient 
staffing ratio requirement.  Indeed, because the workforce 
reduction restriction regulates the same facilities as those 
affected by the patient assignment limits, the two requirements 
are more closely related than the farm provision and the sales 
provision we considered in Dunn, supra; the farm provision 
18 
 
 
governed farms that produced certain goods, while the sales 
provision constrained businesses that purchased those goods.  
Id. at 676. 
 
"The 'unified statement of public policy' called for by 
Carney I, 447 Mass. at 230-231, does not require that an 
initiative petition be a comprehensive piece of legislation that 
would entirely cover its field.  It requires that the portion of 
the field covered by the petition be presented in a way that 
permits a reasonable voter to make an intelligent up or down 
choice."  Abdow, 468 Mass. at 503.  A voter who approves of the 
registered nurse-patient staffing ratio requirement, but 
believes health care facilities should be able to accommodate 
this requirement by eliminating other members of the health care 
workforce, "is free to vote 'no' . . . , but the proposed act 
does not place anyone 'in the untenable position of casting a 
single vote on two or more dissimilar subjects'" (emphasis in 
original).  Hensley, 474 Mass. at 659, quoting Abdow, supra at 
499. 
 
The argument that Initiative Petition 17-07 violates the 
related subjects requirement because it might impose a financial 
burden on facilities is unavailing.  The Oberlies plaintiffs 
point to Gray, 474 Mass. at 647, where, in concluding that the 
proposal did not satisfy the relatedness test, we noted the 
costs associated with one of the initiative's provisions.  That 
19 
 
 
case concerned a proposal that would have altered the 
educational curriculum of publicly funded elementary and 
secondary schools, and would have required the release of 
certain test information included in the prior year's 
comprehensive assessment tests mandated for those schools.  See 
id. at 638-639, 648.  We concluded that those two subjects were 
not sufficiently related, because educational curricula and 
school transparency represented "two separate public policy 
issues."  Id. at 649.  Although we observed that there could be 
a high "price tag" associated with the "test items" disclosure 
requirement, this observation was not dispositive of our 
conclusion.  See id. at 647-649.  The Oberlies plaintiffs' 
reliance on Gray is misplaced. 
 
The Oberlies plaintiffs also suggest that the workforce 
reduction restriction is simply an attempt to make Initiative 
Petition 17-07 more politically palatable, by providing job 
security to health care workers.  The proposed act, however, 
would prohibit only health care workforce reductions resulting 
from the implementation of nurse-patient assignment limits; it 
is not an outright ban on reducing staffing levels at covered 
facilities.  Even if Initiative Petition 17-07 might be 
appealing to some hospital employees because they believed that 
they would stand to gain job security if it were enacted, the 
enjoyment, by some, of an "ancillary benefit" does not render 
20 
 
 
the proposal's provisions unrelated.  See Dunn, 474 Mass. at 
682.  "Nor is it necessary that all of an initiative's 
supporters share the same motivations" in order for the 
initiative to satisfy the relatedness test.  See Abdow, 468 
Mass. at 503.10 
 
The Oberlies plaintiffs also contend that voters will not 
understand the potential impact of the workforce reduction 
restriction.  Based on their expansive reading of the definition 
of "health care workforce," the Oberlies plaintiffs maintain 
that Initiative Petition 17-07 "mandates the retention of 
virtually every employee or contractor who works for or at a 
hospital."11  They argue that even the petition's proponents do 
not appreciate the possible sweeping consequences of the 
workforce reduction restriction.  Additionally, the parties 
dispute whether a separate section in the petition limits the 
definition of the "health care workforce," thereby narrowing the 
                     
 
10 Additionally, the Oberlies plaintiffs have not alleged 
that the electorate previously rejected an initiative proposing 
solely patient assignment limits, without any associated 
workforce reduction provision.  Cf. Carney v. Attorney Gen., 447 
Mass. 218, 222, 232 (2006) (voters' earlier rejection of one 
provision of proposed petition was relevant to relatedness 
analysis). 
 
 
11 Initiative Petition 17-07 defines "health care workforce" 
to include those "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." 
21 
 
 
scope of the workforce reduction restriction.  This section 
requires that facilities' certification plans, which must be 
submitted to HPC, address "the facility obligation that 
implementation of limits shall not result in a reduction of the 
staffing level of the health care workforce assigned to such 
patients" (emphasis supplied).  The parties disagree with 
respect to whether, pursuant to this language, only those 
employees who are assigned to individual patients would be 
considered part of the health care workforce. 
 
When determining whether an initiative meets the 
requirements of art. 48, we exercise "restraint in deciding 
whether a measure would or would not have the legal effect 
intended," and restrict such considerations to the extent 
necessary to determine whether a proposal satisfies the 
requirements of art. 48.  See Abdow, 468 Mass. at 507.  "In 
circumstances like these, the proper time for deciding 
definitively whether the measure has the desired legal effect 
will come if and when the measure is passed."  Id. at 508.  We 
need not, at this juncture, construe the definition of "health 
care workforce" or decide whether this definition could have 
consequences that its drafters did not intend.  Nor do we need 
to determine how to reconcile this definition with the proposed 
act's reference, in a separate section, to "the facility 
obligation that implementation of limits shall not result in a 
22 
 
 
reduction in the staffing level of the health care workforce 
assigned to such patients" (emphasis supplied).  The proper 
interpretation of these provisions is not dispositive of the 
question of relatedness.  Under any reading, the workforce 
reduction restriction merely constrains how nurse-patient 
staffing ratios may be implemented.  As a result, we conclude 
that Initiative Petition 17-07 "contains only subjects that are 
related or are mutually dependent.  It is therefore fair to ask 
the people of the Commonwealth to vote 'yes' or 'no' on" the 
petition.  Dunn, 474 Mass. at 682. 
 
ii.  Initiative Petition 17-08.  As stated, the text of 
Initiative Petition 17-08 is virtually identical to that of 
Initiative Petition 17-07, with the addition of one section.  
That section, the financial disclosure requirement, would 
require hospitals that accept funds from the Commonwealth to 
file annual reports of their financial assets with the HPC.  The 
HPC, in turn, would be required to make this information public 
within seven calendar days of its receipt, unless doing so is 
otherwise prohibited by law. 
 
In determining whether the financial disclosure requirement 
is sufficiently related to the remainder of Initiative Petition 
17-08, we look for "a common purpose to which each subject of 
[the] initiative petition can reasonably be said to be germane."  
Massachusetts Teachers Ass'n, 384 Mass. at 219-220.  The 
23 
 
 
Williams plaintiffs contend that the common purpose unifying 
Initiative Petition 17-08 is patient safety.  They assert that 
the financial disclosure requirement furthers this goal by 
shining a light on hospitals' economic capacity to hire new 
staff, as might be required by the nurse-patient assignment 
limits. 
 
These issues might be connected, in some sense, if 
hospitals' financial assets reflect their ability to pay the 
salaries of additional registered nurses.  The patient 
assignment limits, however, are mandatory and inflexible, and 
are not tied to a hospital's financial condition; under the 
terms of Initiative Petition 17-08, an inability to pay is no 
defense for a failure to comply.  Nor does the proposal provide 
a mechanism to increase funding to hospitals that would bear an 
economic hardship if forced to hire additional registered 
nurses.  The financial disclosure requirement, therefore, has 
"only a marginal relationship" to the nurse-patient staffing 
ratios.  See Abdow, 468 Mass. at 499.  Moreover, the initiative 
cannot be saved by assertion of a more general common purpose, 
such as regulation of hospitals.  "At some high level of 
abstraction, any two laws may be said to share a 'common 
purpose,'" Carney I, 447 Mass. at 226, but a petition's asserted 
common purpose cannot be "so broad as to render the relatedness 
24 
 
 
limitation 'meaningless,'" id. at 225, quoting Massachusetts 
Teachers Ass'n, 384 Mass. at 219. 
 
Initiative Petition 17-08 recalls Opinion of the Justices, 
422 Mass. 1212, 1220-1221 (1996), in which the Justices 
concluded that the goal of making "Massachusetts government more 
accountable to the people" was "unacceptably broad" as a 
"general purpose" for an initiative petition.  The petition at 
issue in that case primarily sought to regulate legislators' 
compensation, but contained one provision that would have 
permitted the Inspector General to request and summon records 
held by the commissioner of veterans' services.  Id. at 1213-
1214.  The Justices determined that the proposal's true common 
purpose was more narrow, specifically to improve legislative 
accountability.  Id. at 1220-1221.  The initiative failed the 
related subjects requirement because "permitting the Inspector 
General access to the records of the commissioner of veterans' 
services does not relate in any meaningful way to improving 
legislative accountability."  Id. at 1221.  Similarly, here, the 
financial asset disclosure requirement "does not relate in any 
meaningful way" to patient safety through the establishment of 
nurse-patient staffing ratios.12  See id. 
                     
 
12 The Williams plaintiffs alternatively assert that the 
common purpose of Initiative Petition 17-08 is "the safety of 
patients through adequate staffing and hospital transparency in 
disclosing their means and methods of staffing."  By its terms, 
25 
 
 
 
The subjects are unrelated because they concern "two 
separate public policy issues."  Gray, 474 Mass. at 649.  This 
becomes clear when one reads the section of Initiative Petition 
17-08 that would impose the financial disclosure requirement.  
That section provides, "It is in the public interest to have 
access to a transparent, detailed, and comprehensive record of 
the financial health of each facility that accepts funds from 
the Commonwealth to provide healthcare to its residents."  The 
stated policy goal of this section -- public access to 
hospitals' financial records -- has no apparent connection to 
the petition's purported purpose of ensuring patient safety by 
virtue of creating nurse-to-patient staffing ratios.  "The 
combination of these two issues in one initiative petition does 
not offer the voters a 'unified statement of public policy" 
(emphasis in original).  Id. at 649, quoting Carney I, 447 Mass. 
at 231.  "Rather, because the issues combined in the petition 
are substantively distinct, it is more likely that the voters 
would be in the 'untenable position of casting a single vote on 
two or more dissimilar subjects.'"  Gray, supra, quoting Abdow, 
468 Mass. at 499.  These subjects therefore lack "sufficient 
                                                                  
however, this "common purpose" purports to tackle "two separate 
public policy issues":  adequate hospital staffing and hospital 
transparency.  See Gray v. Attorney Gen., 474 Mass. 638, 649 
(2016). 
26 
 
 
operational connection . . . to be 'related' within the meaning 
of art. 48."  Gray, supra at 648. 
 
As a result, we conclude that Initiative Petition 17-08 
fails the two-part relatedness test.  First, the similarities 
between the financial disclosure requirement and the remainder 
of the initiative petition do not "dominate what each segment 
provides separately."  Carney I, 447 Mass. at 226.  While both 
elements of the proposal pertain to hospitals, even this 
commonality is limited; the financial disclosure requirement 
would be imposed only on State-funded hospitals, while the 
remainder of the initiative would apply to all facilities.  
Second, and more crucially, because they represent "two separate 
public policy issues," Gray, 474 Mass. at 649, there is no 
"operational relatedness" between the two requirements.  See 
Carney I, supra at 230-231. 
 
Additionally, "[t]he two subjects in this petition are 
clearly not 'mutually dependent.'  In fact, the opposite seems 
true."  Gray, 474 Mass. at 648, quoting Art. 48, The Initiative, 
II, § 3, as amended by art. 74.  In Gray, we held that 
terminating public schools' use of the national common core 
curriculum was not "mutually dependent" on the requirement that 
schools release certain testing information because, "whether 
the diagnostic assessment tests are based on the common core 
standards or some previous set of academic standards . . . will 
27 
 
 
not affect in any way the . . . obligation" to release the 
required test information.  Id.  Because these two subjects 
would "exist independently," they were not "mutually dependent."  
Id.  Similarly, here, a facility's implementation of, or failure 
to implement, the required nurse-to-patient ratios would "not 
affect in any way" its obligation to disclose its financial 
assets, and the two requirements would therefore "exist 
independently."  Id.  The provisions of Initiative Petition 17-
08 are thus not "mutually dependent."  See id. 
 
In sum, the nurse-patient staffing ratios and the financial 
disclosure requirement are neither mutually dependent nor 
related subjects.  The Attorney General was correct in declining 
to certify that Initiative Petition 17-08 satisfies the demands 
of art. 48. 
 
b.  Proper form requirement.  Only laws and constitutional 
amendments may be presented through the initiative process under 
art. 48.  See art. 48, The Initiative, I ("the popular 
initiative" allows specified number of voters "to submit 
constitutional amendments and laws to the people").  "[A]n 
initiative petition that proposes neither a law nor a 
constitutional amendment is not 'in proper form for submission 
to the people.'"  Dunn, 474 Mass. at 682, quoting art. 48, The 
Initiative, II, § 3, as amended by art. 74.  Although we have 
declined to "construe the word 'form' in a narrow and technical 
28 
 
 
sense," our analysis of whether a petition has the proper form 
has focused on the question "whether a law is proposed."  
Paisner v. Attorney Gen., 390 Mass. 593, 598 (1983).  In other 
words, we examine whether the petition presents a measure that 
has a binding effect, and "govern[s] conduct external to the 
legislative body."  Id. at 600.  The Oberlies plaintiffs 
contend, on five different grounds, that Initiative Petition 
17-07 does not take the proper form required by art. 48.  For 
the reasons discussed infra, we conclude that these claims are 
unavailing.13 
 
The Oberlies plaintiffs first argue that the title of 
Initiative Petition 17-07 -- "Initiative Petition For A Law 
Relative To Patient Safety And Hospital Transparency" -- is 
misleading, because, unlike the rejected Initiative Petition 17-
08, it contains no provision requiring hospitals to disclose 
their financial assets.  In this view, the title's reference to 
                     
 
13 The Oberlies plaintiffs properly do not contend that 
Initiative Petition 17-07, if approved, would not constitute a 
law.  We observe that, under Initiative Petition 17-07, "[e]ach 
facility shall implement the patient assignment limits," and 
"implementation of these limits shall not result in a reduction 
in the staffing levels of the health care workforce" (emphasis 
supplied).  It is well established that use of the word "shall" 
indicates a mandatory duty.  See Galenski v. Erving, 471 Mass. 
305, 309 (2015), citing Hashimi v. Kalil, 388 Mass. 607, 609 
(1983).  The proposed act thus would have a "binding" effect on 
facilities, thereby regulating "conduct external to the 
legislative body."  Paisner v. Attorney Gen., 390 Mass. 593, 600 
(1983).  The initiative petition therefore meets the requirement 
of art. 48 that it propose either a law or a constitutional 
amendment.  See id. 
29 
 
 
"hospital transparency" is "incongruous."  The Oberlies 
plaintiffs further contend that the title should include a 
reference to the workforce reduction restriction. 
 
"Nowhere is it provided that the title of a proposed law 
shall be descriptive of it to any particular degree, or wholly 
accurate so far as it is descriptive."  Nigro, 402 Mass. at 445, 
quoting Bowe v. Secretary of the Commonwealth, 320 Mass. 230, 
240-241 (1946).  "The legislative history and structure of 
art. 48 demonstrate that the 'proper form' requirement is not 
intended to require a title to give fair notice of the scope and 
essential nature of the underlying measure."  Nigro, supra.  
Rather, the Attorney General's summary serves the purpose of 
explaining the proposal's contents, and "any harm caused by a 
misleading title can be corrected by an accurate summary."14  Id. 
at 447, citing Opinion of the Justices, 309 Mass. 631, 640-641 
(1941).  Even if the title were inaccurate, therefore, and we do 
not conclude that the title here is, that alone would not render 
the form of an initiative petition invalid. 
 
The Oberlies plaintiffs' remaining challenges to the form 
of Initiative Petition 17-07 are related to its contents.  They 
contend that the terms "facilities" and "health care workforce," 
as used in the text, are internally inconsistent or open to 
                     
 
14 The Oberlies plaintiffs have not challenged the Attorney 
General's summary of Initiative Petition 17-07. 
30 
 
 
multiple interpretations.  They thereby ask us to conduct "an 
[impermissible] inquiry into substance."  See Nigro, 402 Mass. 
at 445-446 ("The debate concerning the original adoption of the 
'proper form' requirement reveals that the framers of art. 48 
were primarily concerned with avoiding errors of draftmanship," 
and did not intend that it "become an inquiry into substance"). 
 
In Mazzone, 432 Mass. at 530, we rejected a similar 
challenge to the form of an initiative petition in which the 
plaintiffs claimed that the definition of a key term was 
"circular" and "mystifying."  We explained that "[n]either the 
petitioners' skill at legislative drafting, the potential 
constitutional infirmities of an arbitrary or vague statute, nor 
the potential effects of a measure on current law are reviewable 
matters under art. 48."  Id.  "[T]he pros and cons of the 
measure, including its possible legal flaws," Abdow, 468 Mass. 
at 508, are not before us at this time. 
 
The Oberlies plaintiffs also challenge an exception 
included in Initiative Petition 17-07 that provides that "[t]he 
requirements of this act, and its enforcement, shall be 
suspended during a [S]tate or nationally declared public health 
emergency."  They argue that voters will misread this section, 
and believe that the proposed act's requirements will be 
suspended under any situation that commonly might be described 
as an emergency, such as food poisoning at a popular restaurant 
31 
 
 
or a multivehicle accident on the expressway, rather than only 
under the limited circumstances of a State or nationally 
declared public health emergency.  The proposal's language, 
however, plainly states that its requirements would be suspended 
only during a State or nationally declared public health 
emergency.  This claim does not assert any "errors of 
draftmanship," see Nigro, 402 Mass. at 446, but, rather, appears 
to challenge the narrow scope of the proposed exception.  "The 
plaintiffs' disagreements with the petition's purpose, the 
methods chosen to achieve that purpose and the possible effects" 
are not grounds upon which to reject an initiative petition.  
See Mazzone, 432 Mass. at 529. 
 
Finally, the Oberlies plaintiffs argue that Initiative 
Petition 17-07 is fatally flawed because it does not adequately 
set forth how the workforce reduction restriction will be 
enforced, or the grounds for determining whether a violation has 
occurred.  They assert that the proposal's failure to answer 
these questions will make the proposed act difficult to 
implement, and "deprive voters of the ability to make an 
informed electoral choice."  The proposal, however, if approved, 
would empower the HPC to "promulgate regulations governing and 
ensuring the implementation and operation of th[e] act."  A 
petition does not lack the proper form solely because, at this 
stage, the details of its administration are unclear.  See 
32 
 
 
Mazzone, 432 Mass. at 530 ("The plaintiffs' argument that 'a 
statutory scheme that demands arbitrary enforcement by providing 
no guidance to those who must administer it states no law' 
misconstrues the constitutional requirements for the enactment 
of legislation by the people or the Legislature").  "[T]he 
proper time for deciding definitively whether the measure has 
the desired legal effect will come if and when the measure is 
passed."  Abdow, 468 Mass. at 508.  That the full consequences 
of the proposed act would be fleshed out after its passage does 
not render its form improper.  See id. at 509-510. 
 
As a result, the Attorney General was correct in 
determining that Initiative Petition 17-07 is in a proper form 
for submission to the voters, pursuant to art. 48. 
 
3.  Conclusion.  We remand the matter to the county court 
for entry of a judgment declaring that the Attorney General's 
decisions to certify Initiative Petition 17-07, and declining to 
certify Initiative Petition 17-08, were in compliance with the 
requirements of art. 48. 
 
 
 
 
 
 
 
So ordered.