Voting is Health Care: The Growing Movement to Help Patients Vote

A growing segment of the United States health care sector has been working to make nonpartisan voter engagement a routine aspect of clinical care. From networks of community health centers like AltaMed Health Services to large academic medical centers like Penn Medicine to national organizations like the American Academy of Pediatrics, over 240 institutions and more than 25,000 providers have added civic health to their checklist of ways to provide holistic care. In combination, these efforts are making the ballot box an accessible pathway to address long-standing health inequity. 

The COVID-19 pandemic has been a stark reminder that the social determinants of health account for up to 80% of health outcomes. These factors, including affordable housing, food security, education quality, environmental justice, and disability accommodation, are critical to promoting patient well-being and better public health. Policy decisions shape these social determinants and patient health, making it critical for policy to reflect our communities’ socioeconomic needs. Gun violence and baby formula shortages highlight the ways in which policy decisions directly impact the health of our country and our children. 

point of view putting election ballot envelope

One of the most fundamental ways to ensure that policy improves health is to ensure people vote. However, barriers to voting exist for many of the same people most impacted by COVID-19, creating an uncertain path forward to self-advocacy in health care. For children, it is especially important that their needs are met by the influence of their families on those holding public office. 

Fortunately, health systems are well positioned to address this inequity and uphold their mission to serve all people. The National Voter Registration Act of 1993 along with IRS guidance for nonprofits support government agencies and nonprofit organizations alike to provide nonpartisan voter registration. For two of us in our work with our patients—at AltaMed Health Services, where we serve over 300,000 patients in Los Angeles and Orange counties every year, and at Stanford Medicine in the San Francisco Bay Area—we see daily how hospitals and community health centers are cornerstones of our communities. We often serve those most marginalized by the health care system: people who are young, disabled, low-income, and people of color. Many of these patients are disengaged in our democracy not for apathy but for lack of campaign outreach and accessible voting information, or due to health barriers themselves. 

We often serve those most marginalized by the health care system: people who are young, disabled, low-income, and people of color. Many of these patients are disengaged in our democracy not for apathy but for lack of campaign outreach and accessible voting information, or due to health barriers themselves. 

AltaMed has acted on this potential by incorporating a 5-touch model to encourage patients, staff, community members, and other partner California community health centers to become civically engaged. In Fall 2018, the AltaMed Get Out the Vote campaign successfully contacted roughly 29,900 low-to-mid propensity Black and Latino voters. In these primarily Latino precincts, every one percent of total voters contacted by AltaMed translated into an eight percent increase in turnout between 2014 to 2018. Community health centers are viewed as trusted messengers, and organizations like AltaMed have had a unique role in increasing voter participation. During the 2022 Midterm Primary Election, AltaMed partnered with local civic engagement organizations and reached over 220,000 new and low propensity Latino voters within a five mile radius of all their clinic sites for an election that has traditionally seen historically low voter turnout.

Many individual health care providers across the country are bringing nonpartisan conversations about voting into their clinical practice. Health professionals in over 700 hospital sites and clinics nationwide are helping colleagues and patients register to vote through tools from nonprofit partners like Vot-ER. By asking patients to register to vote without influencing what or whom patients vote for, clinics and hospitals are uplifting a non-paternalistic approach to advocacy: health care workers facilitate nonpartisan voter registration for those who are eligible, and patients use their own voices to vote for leaders and policies that impact their health. 

Two pediatric medical residents, one white and one Black, both masked, and posing with a a blue and red ID badge with a QR code in center and side label that reads, “Ready to Vote?”

Much of the momentum for healthcare-based voter engagement was generated in response to the COVID-19 pandemic. In August 2020, the inaugural Civic Health Month was celebrated by nearly 100 partners across the health and democracy spaces, who joined together to make sure that patients could access voting resources and cast their ballots safely during the presidential election. This initiative received early support from national health associations like the American Academy of Pediatrics, which ran the Vote Kids campaign to highlight the connections between health equity and civic engagement while providing pediatricians with tools to help parents and voting-age patients register and turn out to vote. More than 80 medical schools joined together for the Healthy Democracy Campaign, with student-led efforts helping 15,692 people.

Overall in 2020, institutions and providers using Vot-ER tools helped more than 46,000 people initiate the process of registering to vote or requesting a mail-in ballot. 84% of the people who completed the registration process did so successfully, and of these individuals, 85% voted in the general election. Of those who voted after registering through Vot-ER, 39% were people of color compared to 26% of the general electorate. 56% were under 35, compared to 24% of the general electorate. These numbers speak to the success of a nationwide coalition that has come together to promote civic health, especially for populations facing barriers to democratic participation. 

In August 2021, the number of partners for Civic Health Month more than doubled to 240, with a focus on uplifting the importance of local elections on community health care and resources. Now in 2022, activated by recent events that impact the health and lives of our patients, the coalition is engaging our communities once again. Adding to the momentum, the American Medical Association just passed a resolution that affirmed voting as a social determinant of health. 

Regardless of the candidates or offices up for election, our health is always on the ballot. As such, from the national level to the individual health care worker, we need to continue taking action that underscores voting and health as part of the same conversation—one that encourages our colleagues and patients to advocate for themselves and to vote like our health depends on it, because it does. 

Voter Registration During Telehealth


Bookmark this page

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Prompt the conversation

Many health care professionals find that the best time to weave in the voter registration prompt is towards the end of the visit.

Conversation Prompt:

"Before I let you go, I wanted to acknowledge that with all the disruptions related to COVID19 it can be hard to do the important tasks like remembering to register to vote. Are you ready to vote in the next election?"

Making a direct invitation, and then sharing the Vot-ER platform website or text code is the most important step. The Vot-ER platform will walk them through the remaining steps on their phone or on the computer after your visit is over.

I want to help you prepare to have a healthy, safe voting experience. Register to vote where you live now and request a mail ballot at vot-er.org/healthy or text vote healthy to the number 34444 on your phone

Follow up

Follow up with messages like "any trouble with the voter registration process?" to close the loop and nudge completion of the voter registration process. Once clients are registered to vote, we'll send follow-up reminders and state-specific information about upcoming elections.

Civic Health at Grand Rounds

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.

Jennifer Caputo with Vot ER badge and vote mask

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.

Civic Engagement and Health Slides
A ready-to-present Google Slides template that Dr. Caputo-Seidler used during Grand Rounds

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

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.

Voter Registration at Vaccine Drives

What does voting have to do with vaccines?

How to talk about voting after vaccination

English

Hello friend, my name is _______. Congratulations on getting your vaccine! May I have a minute of your time to help you protect yourself and your community in another way?

Patient's Response

Your Response

No.

No problem, here is some information you can take with you to read later or share with others [give flyer].

Yes.

Awesome, thanks for your time. Voting is one of the most effective ways you can protect your community. Do you know if you are an eligible voter and are registered to vote?

I have an easy and fast way to get you registered. Let’s check it out! All you have to do is scan here [show QR code] or text the following code (VOTE VAX -or- VOTE VAXENG) to 34444.

I'm pretty sure.

Do you want to take 30 seconds to double-check your voter registration on your own phone?

I'm undocumented.

No problem. You’ve already done a great service to your community by getting your vaccination. Only citizens are eligible to vote so even though you can’t use this, we welcome you to take this flyer and share it with any family and friends who are citizens and want to vote.

Spanish

Hola amigo, mi nombre es _______. ¡Felicitaciones por recibir su vacuna! ¿Puedo tener un minuto de su tiempo para ayudarle a protegerse y a su comunidad de otra manera?

Patient's Response

Your Response

No.

No hay problema, aquí hay información que puede llevarse para leer más tarde o compartir con otros [dar volante].

Sí

Increíble, gracias por tu tiempo. Votar es una de las formas más efectivas de proteger a su comunidad. ¿Sabe si es un votante elegible y si está registrado para votar?

Bueno, tengo una manera fácil y rápida de inscribirle. ¡Vamos a ver! Todo lo que tiene que hacer es escanear aquí [mostrar volante con el código de QR] o enviar un mensaje de texto con el siguiente código (VOTE VAXSPA -o- VOTE VAXESP) al 34444.

Estoy bastante seguro

¿Quiere tomarse 30 segundos para verificar su registro de votante en su teléfono?

Si alguien es indocumentado.

 No problema. Ya ha prestado un gran servicio a su comunidad al vacunarse. Solo los ciudadanos son elegibles para votar entonces aunque no pueda usarlo, le invitamos a que tome este volante y lo comparta con familiares y amigos que sean ciudadanos y quieran votar.

Resources

Support our veterans and their health through expanded voter access

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. 

Black older doctor examines a mid adult male army soldiers injured ankle

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.

Old drawing of Civil War soldiers voting at an army campsite
Drawing published in Harpers's Weekly, October 29, 1864, Library of Congress

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.

Celebrating Women at the Intersection of Health and Civic Engagement

March 2021 marks a year since the WHO declared COVID a pandemic and since Vot-ER - a project incubated by MGH - shifted its work in light of the pandemic

March 2020 also marked the start of an enormous shift in how we celebrated some of our most precious milestones, including the centennial of women’s suffrage. Recognizing that, we wanted to bring these two themes together - the spotlight on health from COVID and the celebration of the incredible work of women to secure the vote - by highlighting a few of our most inspiring physician advocates. 

Trailblazers like Dr. Deborah Turner (OB/GYN and President - League of Women Voters) and Dr. Regina LaRocque (infectious disease specialist at MGH) paved the way through their work at the intersection of healthcare and civic engagement years before the founding of Vot-ER. Today, thousands of Healthy Democracy Kit users across the country embody the theme for Women’s History Month in 2021: “Valiant Women of the Vote: Refusing to Be Silenced”. From Dr. Smith’s rural health clinic in Raeford, North Carolina to Dr. Sharma’s neighborhood clinic in Santa Barbara, California, our work has just begun.

Below are just a few of the trailblazers and changemakers in the civic health movement.

Dr. Regina LaRocque

1

“Voting is one of the most healthy behaviors that we can get our patients to engage in… We’ve learned over the course of the COVID pandemic that hospitals are also community centers that provide things that people need: information, opportunities to participate in healthy behaviors, [etc.]. Encouraging people to be engaged in their communities [by registering people to vote] is an important part of the mission of any healthcare facility”

Dr. Regina LaRocque is an infectious disease specialist at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School. Dr. LaRocque— along with three colleagues—was motivated to engage MGH with voter registration starting in 2018. They realized that the hospital’s easy access to employees, patients, and visitors provided an opportunity to engage hundreds of voters in partnership with the League of Women Voters.

Dr. Karen Smith

IMG 4699 min

“I personally feel like voting matters because there are so many decisions that are made — even from the local government side all the way to our state [and] federal side — and those decisions have an impact on every person that lives in this community,” 

Dr. Karen Smith began registering patients to vote at the start of the pandemic, when she realized the impact that civic engagement could have on the health of her patients in Hoke County, North Carolina.

Read more about Dr. Karen Smith’s work here.

Dr. Anu Sharma

Dr. Sharma 1 min

“A pediatrician’s work begins with that first newborn visit, marking milestones, one by one, until the last and most momentous - the age to vote! The conversation with my teen patients about their health, social justice, and civic engagement as they enter adulthood is among the most rewarding joys of my work. THEY GET IT.  I identify with their idealism; they give me endless hope for bringing about change to an existing structure that continually fails them and so many.”

Dr. Anu Sharma is a pediatrician in Santa Barbara, California that exemplifies the potential for physicians across the country to incorporate civic health into their daily conversations with patients. Dr. Sharma is pictured registering a teen patient to vote this year with her Healthy Democracy Kit

Christina C. Morone, MHS, PA-C

Screen Shot 2021 03 25 at 4.51.55 PM min

“Working in the emergency department highlights individual healthcare challenges as well as the importance of better systems, representation, and governance. I feel so grateful to work alongside the amazing team in the emergency department, especially the advanced practice provider community to empower our patients to vote and demand social change.”

CC Morone, PA-C is a physician assistant at Massachusetts General Hospital and the Emergency Medicine APP Ultrasound Director in Boston, MA. She is a co-founder and operating manager of the non-profit organization One Nation Every Vote (OneV) working to increase civic engagement through stories, registration, facts, and voting resources. She has been working to increase APP involvement with the Vot-ER community.

Dr. Deborah Turner

D Turner Headshot

“I believe no child should be restrained by the circumstances of their birth. The League, through our leadership in the democracy space, can make this dream a reality”

Deborah Turner, MD, JD serves as the 20th president of the League of Women Voters of the United States (LWVUS) and currently lives in Nebraska. She practiced gynecologic oncology for 35 years, enhancing university programs at the University of Nebraska, University of Iowa, and the Medical College of Wisconsin teaching residents and students. Dr. Turner entered the Iowa Women’s Hall of Fame in 2013 and will be a keynote speaker at the upcoming Civic Health Conference


On April 23-24, students, clinicians, social workers, academics, and hospital leaders will come together to continue the civic health movement at the inaugural Civic Health Conference. We will learn, build community, and strategize through engaging keynote lectures, workshops, panels, and small-group discussions. RSVP for timely updates on speakers, sessions, and deadlines.

Addressing Health Disparities Through Voter Engagement: A Social Worker’s Point of View

Our health is a product of our environment. Therefore, a healthy community should be one in which all residents have access to quality education, safe and healthy homes, adequate employment, transportation, nutrition, and quality health care. Right? Sadly, the dominant public narrative blames individuals for their poor health and renders the social determinants of health inequity invisible, despite a large body of research documenting racial and class disparities in health. When it comes to flipping the narrative to focus on the upstream determinants of those disparities, social workers bring a valuable perspective. The social work profession has roots in structural change efforts and is committed to navigating the various dimensions that influence health, such as work, family, and neighborhood.  

As a graduate student at Boston University’s School of Social Work, I’ve been learning about racial justice and cultural oppression. My interest in macro social work led me to an internship placement with Vot-ER, a nonprofit nonpartisan voter registration organization. It sounds simple. But here’s what you might not have taken away from that sentence: Vot-ER was founded by an Emergency Medicine Doctor in Boston after he was inspired by a social worker. Yes, you heard that correctly. A social worker! Social workers are essential; they make a difference in addressing inequities within our various systems. 

As a part of the Vot-ER Social Work team, I have quickly learned this organization is more than a simple voter registration organization. Vot-ER is advancing the public narrative for health equity and social justice. Vot-ER has not only been working diligently to register patients to vote, but also has been helping make social injustice more visible, specifically within the healthcare system. Vot-ER has helped me understand the relationship between voting and its effects on the social determinants of health. 

One of Vot-ER’s core beliefs is that “by voting for our health, we can preserve what works or demand change for the things that don’t.” The power of this belief comes from the affirmation that when a system or policy does not work for us, for our families, and for our community, we have the power to demand changes to that policy or system through our vote. Through Vot-ER’s work and vision, I have become a firm believer that we can address health disparities through voter engagement. 

We need to understand that access to healthcare, adequate transportation, safe homes, and quality education are components of healthy communities. However, we also need to be mindful that there are many barriers for many people to receive these services. Yagoda (2019) stated that people of color, low-income Americans, the uninsured, and young people are the most likely to be unregistered and to experience barriers to voter registration. Let’s take a look at lack of transportation as a barrier to civic engagement. Adequate transportation is often a prerequisite for accessing healthcare, employment, grocery stores, and other public services. Nevertheless, according to the American Public Health Association (2011), low-income persons, people with disabilities, racial and ethnic minorities and people with limited English proficiency experience a transportation disadvantage.

You might be asking yourself, how do we build healthy communities? How do we break these barriers? As social workers, it is time for us to get involved in the work Vot-ER is doing. We need to start registering clients to vote in all settings whether it’s a hospital, a clinic, or a university. It is time for us to be a part of this nonpartisan process and help create a more inclusive and just democracy.

An Odd Year Like No Other

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.

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. 

Recognizing the Relationship Between Voting and Health Outcomes

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. 

Promoting Health Through Civic Engagement 

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. 

Dr. Karen Smith Helps Rural North Carolina Get Registered

Family physician Dr. Karen Smith has been helping patients register to vote while administering COVID-19 tests at her clinic in Raeford, a rural town in Hoke County, North Carolina.

Smith’s voter registration efforts stretch back to the beginning of the coronavirus pandemic. Though COVID-19 testing and treatment has strained community health centers across the nation, Smith has maintained a steadfast commitment to civic health over the past few months. Smith said she believes voting is important because she sees a direct connection between government action and community health.

“I personally feel like voting matters because there are so many decisions that are made — even from the local government side all the way to our state [and] federal side — and those decisions have an impact on every person that lives in this community,” she said.

Smith’s clinic serves around 3,500 patients in Hoke County and neighboring counties outside the Fayetteville, North Carolina metro area. The regional economy relies heavily on poultry processing, hog farming, cotton, corn, and textiles, so environmental issues are of paramount importance. Smith says soil contamination in rural North Carolina has been exacerbated by climate change, and the consequences of contamination trickle from the farmlands to the food on the table. Environmental degradation and pollution is associated with high blood pressure and impaired kidney function, in turn putting rural North Carolinians at higher risk for heart disease and stroke.

Effective leadership is key to addressing these issues, Smith said.

“People need to be able to voice their concerns,” she said. “They need to vote and get leaders who take time to understand and know how these issues have impact.”

Smith said that the biggest challenge for her community is that of access to healthcare. High rates of unemployment and lack of health insurance prevent some people from seeking care. Those who are employed mostly work in the agricultural industry and receive relatively low wages, making cost a barrier.

In addition to bolstering the local economy, Smith said that expansion of telehealth services could significantly improve health outcomes. Many people in Raeford lack reliable broadband, which is crucial for everyday telehealth services and emergency support. Before Hurricane Sally hit North Carolina last week, Smith predicted that her community would lose internet access and thus be left more vulnerable to disaster.

“We’re going to lose connectivity, but there are going to be other areas in the county where — if we have broadband and we have digital technology — we could be able to reach out, we could continue to have care for these individuals, we could check on them in their homes.”

By using VotER materials and engaging her patients in conversation about civic engagement, Karen is working to address the issues she sees firsthand and catalyze positive change in her rural community.