Joyce Frieden, MedPage Today
What’s a good way to improve population health? One answer might surprise you: increasing the number of patients registered to vote.
“There is a high level of correlation between people who are engaged in voting and better health outcomes,” Adam Fox, deputy director of the Colorado Consumer Health Initiative, said last week at a webinar on voting and health sponsored by the National Academies Roundtable on Population Health Improvement, along with several other organizations. “Improving voting access is a fundamental way to improve our healthcare system. It is a parallel system to what we are already doing at the legislative and regulatory level to improve healthcare.”
Daniel Dawes, JD, made a similar point at an event several weeks ago announcing the launch of the Health & Democracy Index, a database of information on the relationship between voting and health. “Voting can mean the difference between life and death, health or sickness, for many people in our communities,” said Dawes, who is executive director of the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta. “The crucial act of voting immeasurably affects our lives, including our personal health and the overall health of our country.”
Even if it might be a good idea, registering more people to vote comes with challenges, Jessica Barba Brown, senior advisor for the Healthy Democracy Healthy People Initiative, said at last week’s event. “People experience barriers to registering to vote and casting a ballot for many reasons, including the lack of identification documents, frequent changes in address, limited English proficiency, and misconceptions about the rights of people with disabilities to vote,” she said at noting that “When asked why people did not vote in the 2020 elections, for people that sat it out, not being registered was the main reason that voters cited.”
Voter registration comes mainly from six sources, according to Neal Ubriani, JD, policy and research director for the Center for Secure and Modern Elections:
- In-person registration, in which the would-be voter fills out a voter registration form at the county clerk’s office, or uses same-day in-person registration in states that allow people to register on Election Day
- Mail-in registration, which involves filling out a form and then mailing it in
- Online registration
- “Motor voter” registration, which allows people to register at their local motor vehicles department, often when they’re there to get a driver’s license or perform a task pertaining to their car
- Private voter registration drives, such as people who volunteer to stand outside the local supermarket and register people to vote
- Government agency registration through agencies required by law to offer people the opportunity to register to vote
Of these six sources, motor voter registration is “far and away” the number one source, with almost 40% of new voter registrations coming in that way, Ubriani said. Online registration is next, with about 30%, and then things drop off precipitously with mail registration at 13%. Motor vehicle departments are in some ways the “perfect agency” to register voters because they reach 90% of the population, and because if people are getting a driver’s license or state ID, they are already giving the same information needed for voting registration such as name, address, and date of birth, he added.
However, there are problems with it in terms of who is left out, Ubriani continued. People who get IDs from the motor vehicles department “skew wealthier, older, and non-urban,” and disabled voters are often left out as well; both facts may contribute to disparities in registration. “So how do we reach the remaining 10% of the population?” he asked.
Other options each have their drawbacks, he said. For example, mail-in registration can be cumbersome and requires a printer; in-person registration is useful if it is done the same day as voting, but otherwise requires a person to get to a voter registration site; private registration drives can work but they depend on private funding.
Public assistance and disability agencies, on the other hand, are an “underexplored and under-used” resource, said Ubriani. Public assistance agencies and programs that can register voters include Medicaid, Temporary Assistance for Needy Families (TANF), and the Supplemental Nutrition Assistance Program (SNAP), otherwise known as food stamps. Currently, however, such government entities account for only about 1.7% of voter registrations.
Why is that? One reason is that even though these agencies are required by law to give enrollees an opportunity to register to vote, they don’t have to make it an automatic function. “People can just be provided a paper registration form in a stack of eligibility determination forms … So these things [slip] through the cracks, and you generally see poor compliance with these voter registration mandates at public assistance and disability agencies,” said Ubriani. “There’s a real opportunity here to expand the model of voter registration at these public assistance agencies to reach people without Department of Motor Vehicles-issued IDs.”
Roles for Medicaid, Individual Clinicians
One good option for registering people might be through Medicaid, said Daniel Meuse, lecturer on public affairs at Princeton University in New Jersey, adding that research has found a negative correlation between Medicaid enrollment and voter registration.
Implementing automatic voter registration through Medicaid could be a good way to reach the 10% of voters who aren’t interacting with the motor vehicles department, he continued. “It’s very possible that included in that 10% are folks who live in urban areas that are highly served by public transit, and therefore don’t need access to to a car for employment opportunities, or for their daily needs,” and these groups are likely to include Medicaid enrollees. “It’s also young folks — folks who are 16 or 17, or just turning 18 — who maybe are not accessing the [motor vehicles department] because they don’t have access to a vehicle, but they are accessing Medicaid services.”
Medicaid also would already be collecting much of the demographic information needed for voter registration. But Meuse cautioned that because Medicaid serves both citizens and immigrants, “as a state thinks about using Medicaid for automatic voter registration, it’s important to create protections for immigrant families so that they are able to receive their services, but don’t get into a voter registration kind of situation, since immigrants are barred from registering to vote.”
Individual physicians also can help their patients get registered to vote, said Alex Reardon, a civic health fellow at Vot-ER, an organization that connects healthcare institutions and clinicians with tools to get patients registered. “We know that the patients most marginalized by our healthcare system are also most likely to be left out of the political process, detracting from their physical, mental and civic health in a persistent, pervasive cycle,” said Reardon, a fourth-year medical student at the University of Michigan in Ann Arbor. “Your patients look to you for advice, and something you can do is go beyond the exam room … and talk to your patients about their civic health and civic engagement, and keep the focus on being engaged in their community rather than on any particular party or candidate — just getting them set up to have a voice.”