Building a Bottom-Up Path to Health Equity

In 2019, the National Academies of Sciences, Engineering, and Medicine outlined a strategy grounded in advocacy to guide healthcare institutions in addressing the social determinants of health. In November 2020, the American Medical Association formally adopted a policy that recognized racism as a public health threat and promised to fight racist policies and practices in healthcare. Both examples underscore the healthcare system’s growing shift from prioritizing awareness about systemic racial and social inequities in our communities to engaging in meaningful action aimed at addressing their root causes.

In addition to these and other top-down approaches to increasing health equity and access, we have the opportunity to empower individual patients and healthcare providers to take action from the bottom-up. Voting—and civic engagement more broadly—are viable pathways for patients and providers alike to have a voice in shaping the policies that drive inequities and create disparities in health outcomes. 

As a central and often trusted community touchpoint, healthcare settings are a powerful place to promote access to the ballot box. It is imperative that healthcare institutions and providers engage in concrete and sustained efforts to increase civic participation as a means of empowerment and better health. 

Racial and social inequities at the neighborhood level often correlate with both low voter turnout and poorer health outcomes. In the 2018 New York City mayoral election, voter turnout in East Harlem was 35% lower than the citywide rate. In that same year, life expectancy in East Harlem was decades lower than neighboring voting precincts. In Michigan, over 19 of the 100 lowest-turnout voting precincts in the state are located in Southwest Detroit. Home to more than 24 industrial sites, Southwest Detroit has asthma hospitalization rates that are twice the statewide rate and five times the nationwide rate, in addition to a life expectancy seven years below the U.S. average. Both East Harlem and Southwest Detroit are overwhelmingly Black and Latino neighborhoods with poverty levels higher than their respective city averages. 

While the act of voting alone cannot instantly lengthen life spans and reduce asthma, increasing voter turnout in areas like Harlem and Southwest Detroit empowers community members to have a voice in shaping the policies that drive inequities and affect health outcomes.. To make this happen, we must expand opportunities for voter engagement at institutions that are frequently visited by unregistered or low-turnout voters. The DMV, for instance, can serve as one potential place for this because it provides services to individuals who are unregistered to vote, such as 18-year-olds receiving their first drivers license. In a similar way, the healthcare system often interfaces with unregistered voters: those same newly minted 18-year-olds from the DMV may head to the optometrist for their DMV-required vision test or the pediatrician for their yearly physical. 

More broadly, there is strong demographic overlap between the patients most marginalized by our healthcare system and unregistered eligible voters: the young, the lower income, and people of color. These three groups have previously been found to have the largest increases in voter turnout when engaged by the nonprofit they receive services from. As service-providing institutions, healthcare settings are equally well positioned to make this kind of  impact on the traditionally underrepresented communities that walk through their doors by promoting voter engagement in their patient population. 

Geographic overlap between voter turnout and racial, social, and health inequities is more than a coincidence: it is the manifestation of the ways in which civic participation is deeply connected to the health of our communities. We know that factors beyond hospital or clinic walls, called the social determinants of health, are responsible for up to 80% of health outcomes. Everything from education quality, to housing safety, to economic opportunity plays a role in an individual’s physical and mental wellbeing. Working to reduce inequities in these areas is a key way for healthcare institutions and providers to advocate for their patients. 

Because the social determinants of health are shaped by policies at the federal, state, and local level, participation in our elections gives us representation in the decisions being made that will ultimately affect our health. Candidates run on platforms that aim to attract as many supporters as possible. When our most marginalized patients vote consistently, campaigns label them as likely voters and start to contact them, which provides more opportunities for patients to voice their needs and have them addressed. This extends to local officials as well because they must also be responsive to the needs of their constituents. One example of this is government spending. When voter turnout increases, the electorate becomes less skewed by factors such as race and income, which could result in governments raising the amount of funding allocated towards redistributive programs by 30%. These programs include education, public housing, and welfare—all social determinants of health. 

Furthermore, healthcare providers—as a duty to both themselves and their patients—should have a seat at the table when decisions are being made about our country’s health policies. This starts by making sure providers participate in our elections. For example, the voting rate for doctors has decreased over the past few decades: eligible physicians voted at roughly 9 percentage points less than the general population between 1996-2002, and 14 percentage points less between 2006-2018. Healthcare providers, therefore, are another demographic of underrepresented voters who are present in healthcare settings and can be engaged to increase their participation in elections. 

Caring for Our Democracy and Our Health

The importance of civic engagement for health outcomes and in healthcare settings has become increasingly clear over the past year. Over 300 hospitals, clinics, and health centers, along with more than 100 medical associations and organizations, have already stepped up to help their patients, members, and staff vote in local, state, and federal elections. This is reflective of the sector’s response to an awakening happening in all corners of the country: optical allyship—or allyship that makes a surface-level statement but does not actually try to break away from oppressive systems of power—is not enough. True allyship requires action. Empowering patients and colleagues to vote is a concrete action that healthcare institutions and providers can and should take in order to better advocate for their patients and reduce racial and social inequities. 

In continuing to build true allyship with those most marginalized by both the healthcare system and society, we must recognize that this is not a one-time commitment. Our democracy can only be strengthened through persistent and intentional efforts to exercise our collective voice while also empowering new voices to join us. 

The 2020 presidential election may be over, but participation in state and local elections in 2021 and beyond will continue to shape the factors that impact the health of our communities. In other words, the strength of our democracy is tied to the state of our health, and it’s up to us to care for them both.