Court Opinion

ID: 4285461
Source: CourtListenerOpinion
Date Created: 2018-06-18 18:11:17.275362+00
Date Added: 2024-06-11T07:49:09.209328
License: Public Domain

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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

       The Oberlies plaintiffs contend that Initiative
       8

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

       Additionally, the Oberlies plaintiffs have not alleged
       10

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).

       Initiative Petition 17-07 defines "health care workforce"
       11

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.

     12The 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

     13The 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

     14The 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.