Elections directly impact health and health care delivery

Do you remember your first encounter with voting? I remember going with my mom to the polls when I was very young. She would always put on a nice outfit for the occasion, go into the booth, close the curtain, and pull lots of different levers. To me, this formality forged in my mind that voting is a sacred duty. In fact, when I first voted via absentee ballot in college, I was a little disappointed that I couldn't go into a booth and pull levers. Yet my view of voting as a sacred and civic duty has never wavered—yes, even through the drama of hanging chads and Supreme Court involvement.

The fight for voting rights has a long history in this country. In the 1700s, voting was generally limited to White male property holders, although it was largely left up to the states to determine who was qualified to vote in elections. Some states also used religious tests to limit voting to only Christian men. This started to recede somewhat in the 1800s, when state legislatures began to reduce the property requirements and, upon congressional passage and later ratification of the 15th Amendment to the Constitution, people could not be denied the right to vote based upon their race. However, in spite of this amendment, many states still used a number of methods to deny voting to Black men, like poll taxes and literacy tests.

The next significant change in voting rights was the ratification of the 19th Amendment to the Constitution in 1920, after decades of organizing and activism by the women's suffrage movement. This amendment ensured that the right to vote could not be denied based on gender. Yet many states continued with policies like poll taxes and literacy tests through the 1960s, until the 24th Amendment was ratified, stating that poll taxes were unconstitutional. Also, in 1965, the Voting Rights Act was passed by Congress in a very bipartisan manner. This law barred many of the policies and practices that states had been using to deny voting rights to Black Americans and other targeted groups and required that states and local jurisdictions with a history of suppressing voting rights based on race submit changes in their election laws to the U.S. Department of Justice for approval.

The 1970s saw additional changes. The voting age was reduced to 18 years via the 26th Amendment, and the Voting Rights Act was expanded to protect language minorities in the country. Then, in 1982, Congress passed a law to extend the Voting Rights Act for another 25 years and require states to improve accessibility to voting for those with disabilities and the older population. Finally, in the 1990s, the “motor voter” law was passed, allowing citizens to register to vote when applying for their driver's license.

It was not long after these efforts that the infamous “hanging chad” issue occurred during the Bush-Gore presidential election in 2000, due to faulty equipment and bad ballot design as well as inconsistent rules across local jurisdictions and states. The Supreme Court intervened in this case, but it was clear that more needed to be done. Congress went on to pass the Help America Vote Act in 2002 with the goal of streamlining election procedures across the country.

Following all this progress, the Supreme Court intervened again in 2013 via a case called Shelby County v. Holder and significantly reduced the authority of the Voting Rights Act. It was deemed that requirements aimed at states and localities with a history of suppressing certain voters' rights were unconstitutional. It is since this time that several states have ramped up policies that serve as barriers to voting.

These barriers, which include approaches such as gerrymandered districts, limits on early and absentee ballot voting, voter identification requirements, lack of language access, polling location closures and consolidations, and reduced voting hours, plus a growing sense that one's ability to influence the government is low (i.e., polling efficacy) and other factors, have led to reduced voter turnout. When this occurs, it typically skews policy decisions in a locality or state, as well as in the entire country, to benefit the preferences of a smaller group—those who can get past these barriers. In the 2020 presidential election, 33.2% of eligible voters did not vote. Further, a study published in January 2022 by JAMA Network Open found that between 2000 and 2020, the public voted at an average rate of 63.4% while physicians voted at an even lower rate of 57.4%.

ACP issued a policy brief in December 2023 on the issue of access to voting, “Ensuring Equitable Access to Participation in the Electoral Process.” Some might wonder why a physician society would take on this issue. The lower than average rate of voting among physicians is one reason, which I'll discuss shortly; however, the other reason is that voting has been shown to impact health and health care, both directly and indirectly.

As we outline in our paper, “When barriers prevent segments of the population from participating in elections, it creates a ‘dilution of representation’ in legislatures, which causes a shift in median voter preferences away from what would be preferred by the excluded voters.” One group of these excluded voters are those who are uninsured, who do have a lower turnout rate. Additionally, states with a lower Cost of Voting Index, which assesses the relative cost of voting in each state based on time and effort required to cast a vote, have better health outcomes than states with higher scores. Further, a study published in 2022 by the American Public Health Association found that, when other factors were controlled for, those who did not vote reported poorer health in subsequent years than those who did.

ACP's policy brief is the result of a fall 2022 resolution passed by the Board of Governors that called for the College to adopt policy recognizing political gerrymandering as a significant public health problem. This resolution was referred to ACP's Health and Public Policy Committee for implementation, and as the committee reviewed the data on this issue, as well as broader voting access issues, it felt that the policy should go even further.

Therefore, ACP supports “the drawing of fair, representative, and nonpartisan electoral districts” and states “that partisan gerrymandering may exacerbate health inequities through the disenfranchisement of vulnerable communities.” Further, the College also “supports policies that ensure safe and equitable access to voting and opposes the institution of barriers to both the process of voter registration and the act of casting a vote.”

While earlier I noted that many states are implementing barriers to voting, some states are implementing policies to ensure equitable access, such as Election Day, online, and automatic voter registration; “no excuse” absentee voting; drop boxes; voting by mail; and early/in-person absentee voting. If you want to know your state's voting options, you can find them at vote411.org or Ballotpedia.org, or engage with Vot-ER, as I'll discuss shortly.

Physicians and other health care professionals have been found to be less likely to vote than the general population, and also less likely to vote than other professions like lawyers, engineers, and teachers. Most commonly, physicians cite that they are not registered to vote and/or have a conflicting work schedule. This is an even larger challenge for medical students due to lack of time and low political efficacy. Therefore, ACP calls on medical schools and residency programs to play a role in encouraging participation in the electoral process by providing students and trainees with time off to vote and information on how to register to vote and obtain an absentee ballot. They should also share information on how elections affect health and health care.

ACP further “encourages nonpartisan health care-sponsored voter engagement as a strategy to increase health equity for patients and health care professionals.” This is why we have partnered with Vot-ER, a nonpartisan group that provides civic engagement tools and programs for health care professionals to use within their facilities, something that is allowed to occur due to the National Voter Registration Act of 1993. Through this partnership, ACP members and other clinicians can sign up to receive a free badge from Vot-ER that features a QR code that patients or physician colleagues may scan on their mobile devices, allowing them to check their registration status, update their voter records, register to vote, and/or request a mail-in ballot.

With Civic Health Month (August) just behind us and with National Voter Registration Day coming up on Sept. 17, this is the time to get engaged! Bring your kids along when you vote and talk with them about the process, including how your (and ultimately their) vote can impact the health and health care of others. Your influence and example likely mean more than you know.