The commonwealth's voters face a decision on ballot Question 1, the proposition that would, under threat of stiff penalties, mandate patient-to-nurse ratios in Massachusetts hospitals. Advocates on both sides of the question have poured millions of dollars into attempts to influence the electorate, and voters have found themselves pawns in a bewildering war of propaganda. Let there be no confusion, however: Should this question pass, it will threaten the very existence of smaller hospitals in Massachusetts, including Berkshire Medical Center.

The Eagle believes that Question 1, which would hamstring hospitals already juggling resources and personnel to provide the best possible care at the lowest cost, is counterproductive to the delivery of quality health care in a state that prides itself on being a world leader in that category. Adequate nurse-staffing levels may be a problem in the Bay State, particularly in smaller, regional systems like BMC. But it is more the result of a statewide shortage of nurses, which often requires traveling nurses to fill gaps. Locally, it's difficult to find RNs willing to locate to the Berkshires.

For years, the Massachusetts Nursing Association lobbied the Legislature to establish patient-to-nurse ratios, but it was ultimately unsuccessful. Question 1 is an end-run around the legislative process: It puts the issue directly to a populace that possesses little technical knowledge of the forces at play and, moreover, is susceptible to emotional appeals bearing little relation to realities on the ground.

On Oct. 3, the Massachusetts Health Policy Commission, the independent body tasked with conducting studies on topics that affect state health care costs, released its findings on the potential expense of Question 1. Should the question pass, the Health Policy Commission estimates the financial hit to Massachusetts hospitals will be between $646 million and $949 million annually. (The commission's numbers are nowhere near the MNA's estimate of $47 million and in the magnitude of the Massachusetts Health & Hospital Association's $1.3 billion.) In that event, hospitals, the communities they serve and those who pay premiums to private insurance plans will pay the cost.

In BMC's case, more than 71 percent of its revenue comes from Medicare, MassHealth (Medicaid) and Medicaid-managed care. But those programs won't raise reimbursement rates simply because Bay State voters decide they want more nurses on the job. Non-nursing — but equally critical — jobs may have to be cut, beds limited, departments closed, and RNs raided from other facilities like drug treatment centers, nursing homes and other non-hospital employers to satisfy the staffing quota at hospitals. Insurers will be forced to hike premiums as hospitals demand higher fees to help cover the added expense.

The Health Policy Commission estimated that nurses' salaries would between 4 and 6 percent in the mad scramble that would result from Question 1's passage. That outcome may or may not be a coincidence, considering that the MNA itself wrote the ballot question's language. Separately, what remains unexplained is the need to include a whopping $25,000 per incident staffing violation penalty in that language, along with the brutal constraints of a Jan. 1 implementation date.

The MNA's dissemination of a prebuttal attacking the Health Policy Commission's methodology days before the independent commission's figures were released spoke of an attempt to obscure or at least minimize the question's potential financial ramifications. Undecided voters would have benefited instead from a reasoned argument by the MNA supporting its stance — not an unfair request since that organization was responsible for placing the question on the ballot. Such an argument never emerged.

California, the only other state to impose nursing ratios, asked its citizens to vote to empower a panel of experts to work out the nuts and bolts of the question. Notwithstanding that process, studies show there has been no measurable improvement in California's medical outcomes.

In The Eagle's opinion, the people of Massachusetts have not been well served by the inclusion of Question 1 on the Nov. 6 ballot, and they should not be asked to make a yes-or-no decision on such a complex and highly technical matter. Therefore, we strongly recommend a "No" vote on ballot Question 1.

That is not the same as expressing doubt about the concerns of hard-working nurses or ignoring the nurse staffing issue. But this is primarily an issue for hospitals and nurses to address in a collective bargaining context, as they did when Berkshire Health Systems and nurses of the MNA recently reached a new contract agreement. It is not an issue to be addressed by a ballot referendum that will only worsen the situation.