Jennifer Caputo-Seidler, MD, is an assistant professor of medicine in the Division of Hospital Medicine at the University of South Florida. Dr. Caputo-Seidler presented about Vot-ER in Grand Rounds for Internal Medicine, Pediatrics, Emergency Medicine and OB /GYN. Vot-ER spoke with her by email to ask her about her experience.

This interview has been edited for length and clarity.

Why did you feel Grand Rounds was the right place to share Vot-ER with your colleagues?

Grand Rounds is a very traditional structure in academic medicine, so I knew presenting Vot-ER there would give this work a certain level of legitimacy. I had the support of my department chair and vice chair because they had sponsored me in doing the Vot-ER fellowship , so I knew my presentation would be accepted for Grand Rounds.

When the chair of the largest department in the College of Medicine gives their public support by saying this is a topic important enough to be presented at Grand Rounds, that is a powerful show of support when introducing something new.

How was your presentation received?

The response was overwhelmingly positive.

I’ve received emails or texts from attendees ranging from students to faculty thanking me for bringing up this topic and asking how they can get involved.

I didn’t realize there were so many people interested in civic engagement at my university until I started talking about it.

What questions come up most frequently when you present Vot-ER at Grand Rounds?

One of the most common questions is whether I’ve ever had a patient respond in a negative way when I approached them about voting.

So I’ve shared the “worst” response: On the eve of the 2020 election, a patient who saw my Vot-ER badge said something along the lines of “What’s with your voting lanyard? I guess you’re voting for Biden.” I responded that I was encouraging my patients to make sure they were registered to vote. I then redirected the conversation by saying, “Let’s get back to why you are here in the hospital,” and there was no further issue.

Which Vot-ER resources were most helpful in preparing your presentation?

The Vot-ER slide decks! It made the presentation so easy to put together.

I also included the following research, which I found in the Vot-ER slide deck:

• Engaging New Voters: If Nonprofits Don’t, Who Will? | Nonprofit Vote
• Socioeconomic inequality in voting participation and self-rated health | American Journal of Public Health
• Voting, health and interventions in healthcare settings: a scoping review | Public Health Reviews
• Impacts of Adolescent and Young Adult Civic Engagement on Health and Socioeconomic Status in Adulthood | Child Development
• Some Benefits of Being an Activist: Measuring Activism and Its Role in Psychological Well-Being | Political Psychology

How did you follow up after your Grand Rounds presentation?

I distributed badges to internal medicine and pediatrics residents and hospitalists, then launched a team for the Healthy Democracy Campaign with a medical student captain who heard about one of my talks.

As the country recognizes the unique health concerns of our veterans with the recent passage of the PACT Act through Congress, it is important to spotlight the crucial role the Department of Veterans Affairs (VA) plays in providing health care to those who have served. The VA is uniquely positioned to not only care directly for the physical and mental health of veterans, but also indirectly by supporting veterans’ access to the ballot box as a place for health advocacy. By deepening its nonpartisan voter engagement efforts, the VA can honor the sacrifices of our nation’s veterans by ensuring they can fully participate in our democracy and live the healthiest lives possible. 

Decades of policies protecting voting rights for military service members and veterans—along with studies linking civic participation to health and documenting the elevated health burdens faced by VA patients—provide both the foundation and motivation for the VA to amplify the voices of veterans and advance health equity. By focusing on this today, the VA can solidify its stated commitment to helping homeless veterans vote, while also supporting voter registration more broadly for all VA patients. 

By deepening its nonpartisan voter engagement efforts, the VA can honor the sacrifices of our nation’s veterans by ensuring they can fully participate in our democracy and live the healthiest lives possible. 

Expansions in voter access have been tied to wartime service for over 150 years. When the 1864 election took place during the Civil War, new laws enabled white Union soldiers in twenty states to cast ballots from the battlefield—the first instances of absentee voting. During World War II, the Soldier Voting Act of 1942 marked the beginning of overseas military absentee voting. Democratic and Republican administrations alike have championed subsequent legislation protecting service members’ voting rights, including under Presidents Eisenhower, Ford, Reagan, and Obama.

Similar to laws addressing military absentee voting, the VA has been working to remove barriers to voter participation for VA patients who cannot physically vote at a poll site. The Code of Federal Regulations explicitly affirms the right of both residents and inpatients of VA medical facilities (including hospitals and nursing homes) to “register and vote.” Veterans unable to leave these facilities are guaranteed assistance with voter registration and absentee ballot voting. Additionally, hospitals and outpatient clinics are permitted to invite election officials and non-partisan groups on-site to support VA officials with voter registration as long as patient care is not disrupted.

While these policies protect the civil rights of patients who cannot leave VA facilities to vote, the VA has yet to focus on the evidence that more proactively expanding voter access can improve health equity for veterans who use VA services. The VA patient population faces greater health challenges than the general public. One study comparing civilian outpatients in three major metropolitan areas to outpatients from four Boston-area VA clinics found that the latter had over twice the illness burden. Another showed worse self-reported health status, more chronic health conditions, and higher medical resource use among VA patients, when compared to the general population. A RAND Corporation analysis demonstrated that veterans using VA health services face higher rates of chronic conditions like cancer, diabetes, and ischemic heart disease, in addition to mental health conditions, than non-VA patients. 

The VA patient population faces greater health challenges than the general public. One study comparing civilian outpatients in three major metropolitan areas to outpatients from four Boston-area VA clinics found that the latter had over twice the illness burden.

Since it is estimated that 80% of health outcomes are determined by socioeconomic factors outside the health care setting, voting is an important path to addressing these determinants of health. VA patients experience greater challenges across these factors, including higher rates of unemployment and homelessness as well as lower household income. To help address these inequities and their contribution to disparate health outcomes, the VA can support its patients by empowering them with broader access to the vote, leading to a louder voice in the decisions shaping their health. 

In response to the Biden Administration’s March 2021 Executive Order on Promoting Access to Voting—which asked each federal agency to promote voter registration among their constituents—the VA committed to providing voter registration services for homeless veterans. Now, a little over a year after the Executive Order was issued, the VA has built on their commitment by releasing a survey to millions of veterans to capture their voter registration experiences and help address challenges with the process. The VA has also announced plans for a summer pilot program in six states, which will seek to designate VA Medical Centers and other offices as voter registration agencies under the National Voter Registration Act of 1993.  

By following through on these actions with strong implementation, the VA will not only support the veterans these changes focus on to have a say in the policies that impact their health, but also pioneer new ways to advance voter access in service of the wellbeing of all veterans nationwide.

The day after Christmas, I drove an elder to vote early in the Georgia runoffs. I asked her why she was voting. She responded that she wanted to elect leaders who put people over money. She was voting for democracy. 

The vision of democracy that she treasures remains in peril: Almost every state legislature is revisiting their voting laws – some for better, but too often for worse. 

In the US, we often fall into a cycle where we pay close attention to the health of our democracy every 4 years. When we are lucky, we may get closer to an even-year cycle where our interest peaks for midterms, governor’s races, and other major milestones. 

But as our advisor Miles Rapoport has shared with us, this year is an odd year like no other – and it deserves both our immediate attention and our commitment to sustain our interest even when it isn’t clear who or what is directly on the ballot. 

In a conversation with the Brennan Center last week, they commented that while COVID-19 forced the hands of state and local governments across the country, that many saw this as a necessity because of COVID – not because of democracy. So far, the heightened access to the ballot in a year otherwise marked by the restrictions of a pandemic is currently playing out as an ironic fluke in peril of being undone, not as a model that should permeate both our democratic infrastructure specifically and our approach to designing policy generally. 

Even in the context of a race where our elections leadership worked around the clock and persisted through both time pressures and death threats, the final day of the Georgia runoff shows why expanded access is so critical. On that day, I drove three women to the polls. One had requested an absentee ballot that never showed up. Her car had broken down so she needed help getting to the polls on election day. Another – a visually impaired woman – had gone with a friend to vote early, but had landed up at the wrong location. Yet another had tried to go in the morning before her shift at Goodwill, but the line was too long. She took her “lunch break” to go vote. All three of these women embody the human stories that build our democracy, along with the social and economic landmines hidden on the path to the ballot box. 

When the best intentioned people try to vote early and the best intentioned elections officials try to make that possible, and when it is still hard to vote, the last thing we should be doing is making it any harder than it already is. 

It does not have to be this way. And it isn’t this way everywhere. 

There are 700 bills introduced in state legislatures around the US to expand access to the ballot. Many of these are in unlikely places – Texas, Mississippi, and Missouri (I have worked in two of three of those states – I say “unlikely” with the love of a Southern neighbor). The authors of these bills see something that is now also echoed in the recent COVID relief package – that we have an imperative to design policy to support our most vulnerable, not to appease our most skeptical. 

If we take this odd year as one that is truly odd in multiple ways – not just the final digit of 2021 but in its unique position following upon a disruptive year – then we find ourselves in an odd year like no other. It is not simply the year after a Presidential election. It is a year when we are defining our new normal. 

That new normal can be remarkable or regressive. We each play some part in pushing for the remarkable.

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. 

George Zimmerman’s acquittal in 2013 took me to my first protest. At the time, I was one of few non-black participants, marching through downtown Atlanta, demanding justice for Trayvon Martin. Introverted at heart, I treasure quiet and restful weekends, but I knew that day that I had to march.

As a former 11th grade teacher, my students used to walk home in their hoodies, bought Skittles and Arizona Iced Tea at the corner store, and to this day remain some of the most inspiring people in my life. Back then, they taught me about resilience, about teamwork, and about compassion. These days, they still teach me — about everything from discipline to branding, from mindfulness to patent law.

You can probably tell without me even saying it that almost all of my students happen to be black. It’s not an accident, but it’s also not inevitable.

So it was clear to me that the protest was my only possible response. Standing side-by-side with strangers, holding hands in solidarity, I saw a woman walking through the crowd, waving a clipboard over her head. She was handing out voter registration forms, and I had recently moved states, so I took one and completed it. In the darkness of that moment, what I desperately needed was to know that there was something I could do about it — and that piece of paper helped me see a path to hope.

Today, on the anniversary of the March on Washington for Jobs and Freedom, I think about the hope that protest gave me. Today the context is completely different, and yet it is exactly the same. COVID’s disproportionate impact on America is a byproduct of our nation’s persistent inequality. Violence against unarmed black men remains frequent, heartbreaking, and intractable. And the need to march (virtually or physically) while also exercising our democratic voice as a crucial form of expression is clear as day.

I miss the days when we could hold hands with strangers. I’m proud of all the work that has gone into creating collective action and power in the isolation of a pandemic. And I am excited to see how it crescendos in the coming months and years as we combine the light from our protests with the accountability of our votes.