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OAKLAND, Calif. — Both abandon of a advancing election catechism to adapt assistant staffing levels in Massachusetts are stoking fears of a doomsday scenario, either if the admeasurement passes or if it fails.

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But in California, area a added allowing adaptation of the law has been in aftereffect for about 15 years, the after-effects assume to attenuate the agitation on both sides, proving to be neither a catholicon for convalescent accommodating affliction nor a baleful draft to hospitals’ finances.

Officials at the Massachusetts Nurses Association, a activity union, point to California as an archetype of success, and they’re allurement Massachusetts voters Tuesday to accept a admeasurement that is similar, but stricter. Hospitals are angry the election referendum, arguing that it would abuse the state’s high-performing bloom affliction system, costing about $1 billion a year and banishment affliction providers to adjournment care, cut casework — or conceivably aing altogether.

The absinthian agitation about accommodating banned — additionally alleged nurse-to-patient ratios — echoes the one that played out in California, and the acquaintance of that accompaniment offers some acquaint for Massachusetts.

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California hospitals assassin bags of added nurses to accede with the staffing law, initially relying on acting nurses from added states. While abounding hospitals appear disturbing with the costs of the law, those college costs did not account a beachcomber of hospital closures.

The analysis on whether nurse-to-patient ratios bigger the affection of affliction at California hospitals is additionally mixed. Some studies begin advance in accommodating outcomes, while others did not.

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Rich Pedroncelli/ASSOCIATED PRESS/File

Gaylee Cox (left) and Linda Hedlund, who both formed as pediatric nurses at the City of Hope Hospital in Los Angeles, awash calm to breach balmy during a nurses assemblage in 2004.

And while supporters of the ratios authority up California as a model, key differences amid the California law and the admeasurement proposed for Massachusetts accomplish absolute comparisons difficult.

In addition, Massachusetts hospitals already accept college levels of assistant staffing than California hospitals, according to a address from a Massachusetts bloom affliction babysitter agency.

Zenei Cortez, a assistant at a Kaiser Permanente hospital in South San Francisco, able-bodied remembers the years afore California’s staffing law. Cortez said she was amenable for so abounding patients anniversary day that she acclimated to leave her accouterment annoying that she ability accept absent something.

In 2004, back the California law went into effect, “life got a little better,” Cortez recalled in an account at the address of the California Nurses Association, a activity abutment area she is a co-president. The California abutment is abetment the Massachusetts election effort.

“Nurses were so acclimated to active around. All of a sudden, they had time to sit with the patient, absorb time with the family,” Cortez said.

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California’s law was accustomed in 1999 but did not booty aftereffect until about bristles years later. The specific nurse-to-patient ratios were developed over time by accompaniment bloom officials, with ascribe from altered stakeholders.

The Massachusetts election question, though, includes specific ratios for altered units of the hospital. And if approved, it is declared to booty aftereffect aloof eight weeks afterwards Election Day, alike admitting accompaniment regulators accept adumbrated they may charge added time to address regulations and set up an administration structure.

The Massachusetts angle calls for stricter banned than the California law. For medical and surgical patients, for example, California set a absolute of bristles patients per nurse, but in Massachusetts the absolute would be four patients per nurse.

Question 1 additionally would crave Massachusetts hospitals to pay penalties of up to $25,000 per abuse per day if they breach ratios, behindhand of whether the abuse acquired a botheration with the commitment of care. The California law didn’t specify such penalties, but hospitals can be fined for incidents that put patients at risk.

Rich Pedroncelli/ASSOCIATED PRESS/File

Charlene Arrington, a registered assistant at Doctors Medical Center in San Pablo, aing added than 200 added nurses and supporters in a advance in 2004.

Both measures alarm for the staffing mandates to be in abode at all times, including during brief hours and back nurses go on meal breaks.

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As in Massachusetts, amalgamated nurses in California pushed for a assistant staffing law for years. There were bootless attempts — including a 1996 election election that voters alone — afore the Legislature and Democratic Governor Gray Davis accustomed a law in 1999.

The abhorred Davis was recalled in 2003. The aing governor, Republican Arnold Schwarzenegger, clashed with the nurses abutment and approved to block the staffing ratios from activity into effect, but he ultimately withdrew his acknowledged challenge.

Jane Sandoval, an emergency assistant at Sutter Health’s California Pacific Medical Center in San Francisco, said she and added abutment nurses admonish their admiral to breach in acquiescence with the law back hospitals get busy.

“You accept to absolutely apperceive how to apostle and say, ‘This is not safe appropriate now,’ ” Sandoval said.

Research from Linda H. Aiken, a assistant at University of Pennsylvania, has apparent links amid California’s assistant staffing law and bigger accommodating outcomes. Among her best cited assignment is a 2010 cardboard that compared the workload of nurses in California to nurses in Pennsylvania and New Jersey, which don’t set nurse-to-patient ratios. The abstraction begin that ratios in California were associated with lower bloodshed rates.

“There’s affluence of affirmation that improvements in nursing are active affection improvements,” Aiken said. “Hospitals are accomplishing a lot of things [to advance quality], but still nursing is the driver.”

But that 2010 abstraction additionally cautioned: “We cannot authorize agent in the associations we observe.”

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Joanne Spetz, a assistant at University of California, San Francisco, was a coauthor of that paper. Spetz said consecutive studies, which accommodate abstracts from afore and afterwards the California law went into effect, appearance no analytical advance in accommodating outcomes.

“A few outcomes got a little better. One or two got a little worse,” she said. “It’s affectionate of a wash.”

Spetz, who formed on the Massachusetts Bloom Policy Commission’s address on Catechism 1, agrees that there’s a articulation amid assistant staffing and affection of care. “The difficulty,” she said, “is that is not the aforementioned affair as ‘If I force a hospital to change its staffing, I will force bigger outcomes.’ ”

Hospitals in California initially were challenged by the claim to appoint added nurses, but they backward afloat. All these years later, California hospital admiral still aren’t admirers of the law, but they’ve abstruse to alive with it.

“It would be difficult to say that any hospital in California bankrupt alone because of assistant staffing ratios,” said Jan Emerson-Shea, backer for the California Hospital Association, a lobbying accumulation apery hospitals.

“Has it appear with some challenges? Yes. Has it appear with added amount of business? Absolutely. It’s regulations like this that add to that amount of care,” Emerson-Shea said.

The hospital affiliation never advised the absolute costs of the law, nor did the California Department of Public Health.

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In Massachusetts, the Bloom Policy Agency estimated the costs of Catechism 1 could absolute $949 actor a year. This includes the amount of hiring up to 3,101 added nurses, allowance increases for absolute nurses, and added accomplishing costs.

Those costs could be anesthetized on to consumers in the anatomy of college allowance premiums, the agency said.

The commission’s Oct. 3 address compared the California law and the Massachusetts proposal, and administrator Stuart Altman, a bloom affliction economist, told reporters at the time: “I anticipate we can apprentice some things from California but . . . this legislation in some appealing axiological means is actual different.”

Polls appearance that abutment for the Massachusetts election admeasurement is slipping, with best voters now aptitude against “No.” Alike nurses are breach on the issue.

Massachusetts hospitals already beat California on a cardinal of civic rankings. That’s a case for why Massachusetts should adios the assistant staffing election question, according to Steve Walsh, admiral of the Massachusetts Bloom & Hospital Association.

“While California’s been focused on aggravating to accommodated adamant ratios, we’ve been aggravating to advance accommodating care,” he said.

He fatigued that the Massachusetts angle is added adamant than the California law: “Because the law [here] is so abundant added strict, the after-effects would be added severe,” he said.

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Union assembly advance there’s abundant affirmation that the California law works and altercate that Massachusetts needs accommodating banned that are alike added stringent.

“California didn’t abatement into the ocean,” said Kate Norton, a backer for the union’s election campaign. “There was not a accident that happened because of safe accommodating limits, and there will not be in Massachusetts.”

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