The hospital industry has partnered with a major Democratic consulting firm in an unusual alliance against Massachusetts’s nurses and the bulk of its progressive infrastructure.

At issue is a ballot initiative that aims to improve patient safety by limiting the number of patients that can be assigned to a single nurse.

If passed, the initiative, known as Question 1, will make Massachusetts the second state in the country to have nurse staffing limits in place. (The exact nurse-to-patient ratio would vary depending on the hospital department.) But, as Election Day inches closer, the initiative’s supporters and opponents are engaged in a heated battle over the costs of implementing the initiative, and what it would mean for patients.

For more than two decades, nurses across the country have argued that they can’t do their jobs effectively — or safely — when they’re tasked with caring for too many patients at any given time, as is often the case. More recently, Rep. Jan Schakowsky and Sens. Barbara Boxer and Bernie Sanders have sponsored bills to establish “nurse staffing limits” in order to curb the number of patients assigned to nurses who work in hospitals and, thereby, improve care.

Most local labor groups and the Massachusetts Democratic Party have come out in support of Question 1. Its backers include Boston Mayor Marty Walsh; U.S. Sens. Elizabeth Warren and Ed Markey; and U.S. Reps. Katherine Clark, Jim McGovern, Joe Kennedy III, and Michael Capuano. A majority of likely voters polled by Suffolk University and the Boston Globe in mid-September supported the ballot initiative.

But a formidable opposition campaign, funded by the hospital industry and led by a prominent Democratic consulting firm, threatens to derail the nurse staffing effort. The opposition campaign, rallying under the banner of “the Coalition to Protect Patient Safety,” has raised more than $13 million since January; 95 percent of those funds have come from the Massachusetts Health and Hospital Association. Through an aggressive advertisement blitz, the coalition has worked hard to argue that Question 1 could destroy the state’s renowned health care system.

Republican Gov. Charlie Baker recently said he’ll be voting “no” on the measure, citing hotly disputed cost projections. Recent polling also reflects a shift in public opinion, suggesting that the opposition’s campaign is working. For the first time this year, polls now show that a majority of likely voters oppose Question 1, including a University of Massachusetts Lowell/Boston Globe poll from October that found 51 percent plan to vote against it.

The opposition campaign has led to confusion even among nurses, whose support for Question 1 has significantly declined. (There are 83,000 registered nurses in the state, though the ballot initiative would not affect all of them.) An April poll, commissioned by the Massachusetts Nurses Association, found that 86 percent of registered nurses planned to vote “yes” on the ballot initiative. But a new poll, published this week by WBUR, found that just 48 percent of nurses are backing Question 1, while 45 percent are opposed and 7 percent are undecided.

One of the biggest points of confusion right now is how much Question 1 would cost, with opponents and supporters battling back and forth with wildly different estimates.

A study conducted by Boston College nursing economist Judith Shindul-Rothschild found that the total cost of implementing the proposed nurse-to-patient staffing limits in Massachusetts would be about $35 million to $47 million per year, necessitating a 2-7 percent increase in the number of nurses employed. After studying data from the Massachusetts Health and Hospital Association and matching data comparing staffing levels and costs with the California hospital industry, Shindul-Rothschild concluded that most hospitals could easily comply with the law by shifting some money away from administrative expenditures. “At the end of the day, we estimate that after implementing the limits of Question 1 our state’s hospitals would still retain a mean profit margin of $15 million a year,” she told MassLive.com. Shindul-Rothschild is a former president of the Massachusetts Nurses Association, which backs Question 1.

But a report commissioned by the Massachusetts Health and Hospital Association puts the costs much higher, at $1.31 billion in the initiative’s first year and over $900 million per year thereafter. The report, published in April, argues that those costs would be paid by residents in the form of higher insurance premiums, copays, and taxes.

The opposition campaign got a boost in October, when the Health Policy Commission, a state agency charged with monitoring health care delivery in Massachusetts, put out estimates that Question 1 would cost somewhere between $676 million and $949 million per year. The Health Policy Commission is the agency that would be tasked with developing regulations to implement the law if it passed.

Question 1 supporters have called those Health Policy Commission figures bogus. In an interview with The Intercept, Shindul-Rothschild said the biggest difference between her figures and those calculated by the Health Policy Commission is that the commission’s model assumes that nurse staffing limits will produce far greater levels of wage inflation — upward of 6 percent. “Not only did they assume 6 percent wage inflation, but they assumed it for every nurse working in Massachusetts, regardless of if they work in hospitals or not,” she said. “They said if wages go up in hospitals, they’ll go up across the board for every nurse, no matter where they work. I’m a nurse on faculty at Boston College, and there’s no way they’re increasing my salary by 6 percent.”

One reason the Health Policy Commission’s model assumes greater wage inflation is based on what California experienced after it implemented nurse staffing ratios. But unlike California at the time, Massachusetts has a surplus of registered nurses, with 3,000 to 3,500 new ones graduating every year. Many of these nurses end up moving out of state because they can’t find local employment, and a 2012 report published in the American Journal of Medical Quality found that Massachusetts was one of just two states in the country to have no nursing shortage.

The Health Policy Commission’s analysis is “fully consistent with the HPC’s statutory purpose and mission and is not intended to promote or oppose the pending ballot question,” said spokesperson Matthew Kitsos.

But since its founding in 2012, the Health Policy Commission has not conducted similar studies for other ballot initiatives that could have impacted health care, and the commission has also stayed quiet on more than 300 bills in the Massachusetts legislature that would have affected health care cost and delivery. Kitsos did not answer questions about why the Health Policy Commission avoided past health care legislation.

The Massachusetts Nurses Association slammed the Health Policy Commission study. “The HPC didn’t use third-party validated data, it used hospital industry data which it specifically said it would not rely on for its own analyses of hospital mergers,” said Julie Pinkham, the executive director of the Massachusetts Nurses Association, which represents 23,000 registered nurses. “I don’t want them to do an analysis, because it’s not their role, but if they are going to do an analysis, then use actual, real-time staffing data.”

For Pinkham, the nurse staffing debate has been laced with sexism. “If there were 23,000 men saying, ‘Hey, look, this is unsafe,’ do you think they would make you wait over 20 years to fix it?” she asked. “They treat us like we’re just these nice girls, trying to do a nice thing, but that we don’t know what we’re talking about and can’t handle numbers.”

The debate over the cost of implementing a nurse staffing limit is unlikely to be settled prior to Election Day, but Massachusetts voters can look to California for an example of how such a policy would work. The Golden State passed a nurse staffing limit law in 1999, and it’s been in effect since 2004. The hospital industry, which bitterly fought the law’s passage in California, has successfully defeated similar attempts in other states since then.

Researchers have found that California’s law improved care — especially for poor patients — and contributed to a greater decline in mortality than other states have seen.

Linda Aiken, the director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, said California has “the best nurse staffing in the country” in terms of patient outcomes. One study Aiken conducted looked at how outcomes would change in New Jersey and Pennsylvania if they adopted California’s nurse-to-patient ratios; she determined that in-patient mortality would drop in those states by 10-13 percent.

“We’ve done many studies in the U.S. and around the world and found for each additional patient that a nurse takes care of at one time, there’s a 7 percent increase in the patient’s likelihood of dying,” she told The Intercept. “There’s good evidence that California’s staffing improved directly as a result of the [1999] legislation, and that over time it led to a greater decline in mortality in California compared to other states.”

What works in California won’t necessarily work the same way in other locations, but Aiken pointed out that Ireland and Wales have also followed California’s lead and adopted nurse staffing limits. She suggested that opposition in the U.S. is based more on ideological resistance to government mandates than anything else. There are some, however, who argue that the research evidence is not clear enough to justify changing policy. Hospital executives, including nurse administrators, generally oppose nurse staffing limits, arguing they’re too blunt of an instrument and hinder needed flexibility.

Dewey Square Group, a prominent political consulting firm that often works with Democratic candidates, liberal groups, and labor unions, is leading the opposition campaign. Consultants from the firm have been paid over $800,000 since April for their efforts, according to state campaign finance data.

Dewey Square is leading “a progressive campaign” that “helps people in need of quality, affordable, accessible health care along with the nurses and doctors who provide it,” said spokesperson Ginny Terzano. Their coalition comprises “more than 170 health care organizations and every hospital in Massachusetts,” Terzano added.

Among those groups is the Organization of Nurse Leaders, which represents 700 nurse administrators, and the Massachusetts chapter of the American Nurses Association, a group that, unlike most similar groups, has not disclosed how many registered nurses it represents. (The nurse trade group did not return The Intercept’s request for details.) Both groups have fought past legislative efforts to establish nurse staffing limits in Massachusetts.

In 2016, Dewey Square was hired by the Massachusetts Teachers Association to run a campaign on behalf of labor and progressive groups against a ballot measure that would have raised the state’s cap on charter schools. The measure, rejected by more than 62 percent of voters, failed. That the consultants who led the 2016 campaign on behalf of liberal groups are now leading the campaign against those same organizations has sparked intraparty turmoil in the state.

Barbara Madeloni, who stepped down as president of the 110,000-member Massachusetts Teachers Association this past summer, told The Intercept that she “doesn’t know how [Dewey Square consultants] sleep at night” while leading the opposition campaign. “The ways they’re running it, their comfort with distortions and misinformation, and that they’re aligning with people who are really looking to undermine the well-being of the patients of the commonwealth — well, they’re just exposing themselves as mercenaries,” she said. “Quite honestly, there’s a part of me that’s embarrassed to have ever worked with them.”

Terzano of Dewey Square dismissed the idea that their work opposing Question 1 puts them at odds with organized labor. “We may have a different policy position than some labor organizations on this issue but we continue to work alongside labor on a number of issues,” she said. “And I would say it’s also important to note that not every relevant labor union has taken a position on Question 1.”

Terzano was referring to 1199SEIU Massachusetts, which represents 60,000 health care workers in the state — and has notably taken a “neutral” position on the initiative. But even 1199SEIU hasn’t been sitting on the sidelines since the start. In fact, the union worked directly with the Massachusetts Nurses Association in July 2017 to draft the ballot initiative language. SEIU’s input resulted in language that ensures that the nurse staffing limits could not be implemented by eliminating other health care workforce jobs. (Administrative positions, however, may be reduced if the initiative passes.)

According to 1199SEIU President Tim Foley, the union’s change in perspective is due to “concerns about reforms not focusing on the staffing needs for the entire health care team as well as the potential unintended consequences on the health care workforce and health care services.”

SEIU nurses in California have come out in support of Question 1, saying that fears of health care workforce cuts in their state did not materialize after transitioning to nurse-to-patient ratios. In a recorded video, the executive director of the SEIU Nurse Alliance of California emphasized that no hospitals closed and no services ended as a result of implementing nurse-to-patient ratios.

Sal Rosselli, the president of the National Union of Healthcare Workers and the former president of the SEIU United Healthcare Workers West, the statewide local union for health care workers in California, also endorsed Question 1 in Massachusetts.

“Fourteen years ago, when our RN safe patient limits law was being passed here in California, many hospital executives were spouting the same line of doom and gloom as they are today in Massachusetts,” he wrote in a statement. “Our union represents mostly non-RN hospital workers. The truth is there were no layoffs of non-RN caregivers and no hospital closures as a result of California’s law. The only outcome was that it made care much better for patients.”

Madeloni, the former Massachusetts Teacher Association president, who now works as the education coordinator for Labor Notes, said “it’s really troubling” that 1199SEIU Massachusetts has not joined the coalition of labor groups on this. “Solidarity matters, and we should never accept a lack of funds and the incitement of fear that if some workers get something good to do their jobs well, that means other workers will lose. We engage the fights that are going to help each other, we do that however we can do it, and we don’t hold back.”

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