It’s a reasonable question to ask in a typical busy emergency room: Why are there so many patients and so few staff to care for them? Facing long waiting lines, cots spilling into hallways, and frazzled nurses rushing to juggle the hectic triage—why wouldn’t this be a dangerous scene that every hospital, or patient, would want to avoid? Maybe even set a rule to ensure it never happens? Yet on Election Day, Massachusetts voters said no to that question on the ballot by a wide margin. In dueling campaigns between the nurses’ union and the powerful hospital industry, what seemed like a commonsense prescription for modernizing the health-care infrastructure—safety standards for nurse-to-patient ratios—got muddled by the industry’s warnings that somehow, more nurses on duty would be bad for their health.

The ballot referendum, Question 1, would have mandated standard ratios of patients to nursing staff depending on the type of care they were receiving. Bristling at this modest regulation, the opposition warned of ballooning budgets, stiff cuts to other services to pay for mandates, and uncertain outcomes for patient care. Citing statistics from California, which successfully implemented a similar policy years ago, the pro-business lobby direly forecast that hospitals would struggle to fill the additional mandatory nursing slots.

The Massachusetts Nurses Association (MNA) pointed out that the law had built-in safeguards: To prevent funds being drained from other services or creating service staff shortage, hospitals would be required to comply to staffing mandates “without reducing its level of nursing, service, maintenance, clerical, professional, and other staff.” By law, hospitals had to ensure that meeting the nurse-staffing standard would not trigger reductions in other front-line staff—a guarantee that was supported by the union for non-nursing support staff, SEIU 1199.

While the opposition argued that limiting the patient load per nurse would lead to disruptions in operations and delays for patients, the MNA argued that this is precisely the problem the staffing ratio would remedy. The current staffing crisis wasn’t an issue of a limited nurse workforce overall, but inefficient distribution of resources, precipitating inadequate staffing and poor working conditions that make it harder to retain staff. Under current conditions, the union argued, “several thousand nurses…have left bedside nursing precisely because staffing conditions are so bad.”

The rules weren’t demanding redundancy but safety. Nurses’ workloads would be standardized for optimal care quality, based on various medical criteria. For instance, a nurse in charge of a patient with anesthesia would only have one case at a time; psychiatric units would have a ratio of six patients to one nurse.

The opposition pointed to statistics showing little difference in patient outcomes when nurse-staffing regulations were in place. However, multiple peer-reviewed, controlled studies show the opposite. A major recent study by University of Pennsylvania researchers, covering more than 730 hospitals, showed that “Improvements within hospitals in work environments, nurse staffing, and educational composition of nurses coincide with improvements in quality of care and patient safety.”

“There is no debate that better nurse staffing improves nurse-sensitive outcomes, including mortality,” says Judith Schindul-Rothschild, a professor of nursing at Boston College and a Question 1 supporter. Her empirical research on California, New York, and Massachusetts hospitals have clearly linked mandatory nurse-to-patient ratios and improved outcomes. The hospital lobby, she argues, has spread “misinformation and fearmongering” in order to stave off regulations.

But money talks in a health-care system where quality care often seems either ludicrously expensive or desperately scarce. Before the election, an alarming report was issued by the Health Policy Commission—an independent advisory state agency that tracks healthcare spending—estimating that the program would cost the state “$676 to $949 million in annual increased costs once fully implemented,” and deeply impact hospitals primarily dependent on public funding. The MNA argues that hospitals are flush with money, just not money for care: CEO salaries range as high as $4 million annually, and profits over the past five years have exceeded $7.5 billion statewide.

There’s also the basic business case for mandatory nurse-staffing levels. A separate study, published in JAMA Surgery, focused on surgery patient outcomes, revealed that high-quality workplace environments with “adequate nurse staffing” could mean the difference between safe recovery and dying from heart failure after discharge. In many cases, the improvements in nurses’ working conditions also resulted in overall health-care costs’ going down.

Linda Aiken, a professor of nursing at the University of Pennsylvania and co-author of the JAMA Surgery study, has researched the positive effects of staffing ratios in California, which pioneered the policy over a decade ago, and hospitals around the world. Long-term data sampled from several hospital systems, she says, reveal that “better-staffed hospitals with good work environments actually returned lower mortality for the same or lower cost. And they did that by sending 40 percent fewer patients to [intensive care]. So that’s the kind of cost trade-off you’re showing.”

The MNA’s campaign had tried to communicate the stakes of the safety trade-off through the union’s grassroots face-to-face outreach with patients, which surveys have shown to be the most significant factor in voters’ decisions on the referendum question. MNA spokesperson David Schildmeier pointed out that “the public trusts nurses more than any other profession or job category.… Our entire campaign has been based on getting nurses out in their communities talking to voters one on one.” But one-on-one ultimately got drowned out by the megaphone of the opposition, which cranked out its message out with a war chest that was more than double that of the union’s campaign.

Following the defeat, the MNA is for now still planning the next steps, but says it is has at least started a vital public conversation on the need for safe patient limits. Schildmeier said the referendum was “just one step in an ongoing process to fulfill our professional mission.”

On the politics of staffing mandates, Aiken does agree with the naysayers on one thing: The policy would require an investment of money and resources. She believes, however, that with all the extensive spending on capital investments and other overhead costs at hospitals, paying for more nurses would be money well spent: “Maybe it’s a better use of resources in terms of the ultimate outcomes to invest relatively more in labor and relatively less in some other things that hospitals could be doing.” Hospital administrators saw this as a business concern. But for patients, their only business at a hospital is getting better. And while hospitals might want to save some payroll costs by hiring fewer workers, the ballot question might have obscured the bottom line for front-line nursing staff: saving lives.