Civic Health & Registering Patients to Vote

Madeline Grade, MD MPH and Alister Martin, MD MPP

Edited by Emily Cleveland Manchanda, MD, MPH 

Now more than ever, we can and should empower our patients’ civic health and safe voting. This idea is not new to medical discourse, but takes on new acuity amidst the backdrop of 2020. A global pandemic continues to disproportionately affect low-income and marginalized groups. National discussions of racial inequity are fueled by unprecedented momentum from the general populace. An election is approaching, while the US is so polarized that even epidemiological observations appear partisan. Our communities need their voices heard.

How is this “our lane” as doctors? Simply put, the health of our patients includes civic health. Social emergency medicine explores and addresses the complex interplay of social factors (e.g. income, housing, education, health access, employment) that influence health — shown to impact up to 80-90% of health outcomes. Every patient, regardless of their sociodemographic background or political party affiliation, deserves to have their interests represented by those who make policy decisions that directly impact their health. In addition, health and civic engagement have cross-sectional and longitudinal associations across a variety of research studies. Individuals and states with higher civic participation tend to have higher self-rated health, independent of income. Adolescents who vote have been shown to have better mental health, health behaviors, income, and education later in life. 

However, about one in four eligible Americans are not registered to vote, according to 2018 data from the US Census Bureau. In a Pew poll of unregistered voters, a majority of respondents stated they had never been asked to register. Unlike other modern democracies which automatically or more proactively include their citizens on voting registers, US citizens must register themselves. This process varies greatly by state and can be obstructed by significant barriers that disproportionately disenfranchise racial minorities. Voter registration and subsequent turnout is historically lower for people with less education, people with lower income, younger age groups, and racial and ethnic minority groups (Figure 1). 

Figure 1. Voter registration rates across select demographics.

Data Source: US Census Bureau, 2018

Moreover, earlier mortality in marginalized groups can further exacerbate their civic underrepresentation. Political and social scientist Dr. Javier Rodriguez calculated that 2.7 million excess black deaths due to racial inequality led to 1 million lost black votes in the 2004 election. In other work, he has characterized the effects of “early disappearance of the poor” from the electorate, describing a feedback cycle between population health and politics that effectively perpetuates inequities in social policy. These challenges provide insight into opportunities for addressing both health inequities and civic engagement. Promisingly, prior targeted expansions of civil rights have been associated with subsequent improvements in relevant health-related outcomes: enfranchisement of black voters with the Voting Rights Act of 1965 led to narrowing of the black-white education gap, while expansion of women’s voting rights led to increases in public health spending and improvements in child mortality. Progress is possible through our collective action to bridge these well defined gaps.

As emergency medicine providers, we have a unique opportunity to address these issues. Importantly, some of these same marginalized groups (e.g. patients with lower income, less education, and those from certain racial and ethnic minority backgrounds) have a greater likelihood of presenting to the emergency department. This demographic overlap in our safety net settings creates an opportunity for intervention, particularly if patients spend significant time waiting for care in the ED. While our patients who otherwise face barriers to registration and civic participation spend time in healthcare settings to address their physical, mental, and social health, why do we not also also address their civic health? We are taught to ask our patients about their smoking habits and housing status; why not ask if they would like information on registering to vote? 

In addition to being clinically relevant, voter registration in healthcare settings has legal and logistical precedent. The 1993 National Voter Registration Act — the “motor voter” bill that normalized DMVs as places of voter registration — also enables hospitals to provide nonpartisan voter registration information and even register patients on site. Since 1993, a variety of initiatives promoting integrated voter engagement (including registration, mobilization, education, and protection) have spread across healthcare settings. In 2008, the National Association of Community Health Centers started a successful nonpartisan campaign called Community Health Vote and created a toolkit to guide implementation. Across hundreds of participating clinics, they registered 18,000 patients ahead of the 2008 election and 25,000 patients ahead of the 2012 election. An example project at two Federally Qualified Health Centers in the Bronx, the poorest urban county in the US, registered 89% of eligible patients who visited their clinics. Now, organizations like Patient Voting help patients’ ballots get counted on election day even while they are hospitalized, while initiatives such as VotER and Med Out the Vote mobilize physicians, nurses, social workers, and medical students to help patients prepare to vote. This year for the inaugural Civic Health Month, over 100 hospitals, healthcare organizations, and nonpartisan civic engagement organizations came together to promote civic health and safe voting throughout the month of August which resulted in over 10,000 people receiving assistance with preparing to vote in this year’s election.

At VotER, we envision a more inclusive American democracy and we are creating a future where those most hurt by the healthcare system are empowered to fix it by inviting their voices into the democratic process. An extension of this work relies on normalizing conversations about civic health between health providers and patients with the goal of closing the civic engagement gap. Initially our approach focused on iPad-based kiosks in emergency department waiting rooms, allowing patients to register themselves while waiting to be seen. Since the onset of the COVID-19 pandemic, we have expanded our touchless digital approaches. Individual providers can utilize Healthy Democracy Kits to direct patients to a simple mobile voter registration platform using a QR- or text-based prompt worn on a badge alongside their hospital ID. Links for checking and updating registration status can be easily shared through telemedicine visits. Hospitals and clinics can also perform SMS and email outreach to their patients with key voting information. In order to minimize crowd size and potential transmission risk on election day, we are also collaborating with organizations like Vote Early Day to emphasize the public health importance of voting early and voting by mail. Some partner hospitals like Boston Medical Center are also helping to facilitate requests for Vote-by Mail ballots, by providing request forms and then mailing these to election offices on behalf of patients. After a noticeable increase in participation after the George Floyd protests in June, now more than 100 hospitals are implementing our site-based voter registration, more than 70 medical schools are competing in our Healthy Democracy Campaign, and more than 22,000 providers have individual Healthy Democracy Kits. Importantly, while this work began in emergency departments, we now have clinical partners spanning a diverse range of medical specialties, including family medicine, surgery, pediatrics, obstetrics & gynecology, and psychiatry.

A healthy democracy is one in which all individuals have the opportunity for their voices to be heard. Voting has direct and indirect associations with health, and healthcare settings are appropriate and effective venues for voter registration and education. In our practice of social emergency medicine, we address both the immediate and underlying needs of our patients. We owe it to our patients to ask them: how can we help you vote safely this November?