Advancing Health Equity through Protecting and Promoting Access to Voting

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Abstract

The existence of health disparities is an intractable public health problem. It is unacceptable not only that infant mortality, premature death rates, and disease burden are higher for racial and ethnic minorities such as Black and American Indian communities than they are for the general population but that these disparities persist despite decades of attention from public health. This is in part because while the public health system has begun to focus on the social determinants of health, there is a hesitancy and reluctance to engage in politics and address systems of power. States that make elections more accessible through policies such as automatic and same-day registration, flexible voter ID requirements, felon reenfranchisement, and mail voting options enjoy higher levels of voter participation and stronger public health outcomes. Conversely, communities that face significant barriers to voting suffer worse health outcomes. These barriers can become self-reinforcing because people who are experiencing poor health are less likely to vote and have shorter life spans (and thus fewer opportunities to vote over time) than healthier people. Having an APHA policy statement on voting and health would encourage public health systems to address the political determinants of health and make headway on health equity. Achieving health equity requires ensuring that all people have a voice in the political process. Actions include supporting inclusion of voting and civic participation objectives in the Healthy People initiative, adopting policies to advance civic participation and public health, and integrating voter registration and civic engagement into public health work.

Relationship to Existing APHA Policy Statements

• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 202117: Advancing Public Health Interventions to Address the Harms of the Carceral System

This policy statement builds on the policies listed above focused on improving health and racial equity by strengthening civic and voter participation. It also updates and expands upon the archived APHA Policy Statement 8322: Voter Registration and the 1984 Elections. The way Americans vote has changed significantly since APHA’s voter registration policy was adopted in 1983, but today it is even more relevant that public health professionals recognize that “many citizens, particularly members of high-risk populations such as minorities and poor people as well as youth, need to be engaged [and recognize] the necessity of exercising their franchise in local, state, and national elections.”

Problem Statement

Health disparities are an intractable problem for public health. It is unacceptable that key health indicators such as infant mortality, premature death rates, and disease burden are higher for people from racial and ethnic minority populations, including Black and American Indian communities, than they are for the general population. For example, Black infants born in the United States are 2.5 times more likely to die before their first birthday than their White counterparts.[1] Over the past few decades, public health research and efforts to address disparities and advance health equity have focused on the social determinants of health and on increasing access to quality health services among marginalized populations. The social determinants of health, the conditions in which we live, work, learn, pray, and age, account for 30% to 50% of health outcomes.[2] These determinants are created within a political context and are beyond the control of the individual.

Progress on health disparities will be limited if public health neglects to fully address the political determinants of health, including civic and voter participation. Throughout this country’s history, public health and health equity initiatives have been advanced through community organizing and voter participation. For example, advocates registered Black voters after the Civil War and elected representatives who then created a division of medical services for newly freed slaves[3]; with women’s suffrage, child mortality rates declined by 8% to 15%[4]; the 20th-century Civil Rights Movement spurred an expansion of voting rights and ushered in more inclusive policies in education, housing, economic opportunity, and health care, including the establishment of Medicare and Medicaid; and in 2010 health care and health equity champions organized to pass significant national health reform measures and others organized state-level ballot initiatives to ensure Medicaid expansion.[3] Since 2020, there have been significant efforts to advance health and racial equity spurred by the unjust killings of George Floyd, Breonna Taylor, Elijah McClain, and other victims of police violence and by the inequitable conditions that were exacerbated during the COVID-19 pandemic. In addition to improved health care, it has been clear for decades that access to healthy food and clean water, affordable housing, health care, quality education, and other conditions vital to community health is created through policies influenced by public and political will created by voters.

Current policy campaigns that aim to address health outcomes (such as access to reproductive health care and funding for mental health services) and social determinants of health (such as housing policies, transportation initiatives, and environmental regulations) require addressing the political environment. Within a fully functioning democracy, policy decisions are directly and indirectly determined through elections. Decisions made directly through elections include policies that communities vote on through ballot initiatives and referendums. People also decide on policy indirectly by delegating power to elected representatives who make policies through the legislative process.

Despite community efforts to build power and influence decision making to advance health and racial equity, there continue to be intentional efforts to limit civic and voter participation that lead to ongoing health inequities. Political leaders who falsely disputed the election results in 2020 have gone on to sponsor voter suppression bills in many legislatures, with 19 states adopting restrictive voting laws as of December 2021.[5] A salient example of restrictive voting laws is Texas’s Senate Bill 1 (2021), which controls how and when voters cast ballots. Specifically, this legislation prohibits localities from having 24-hour voting windows such as the one established in Harris County, which includes Houston (the nation’s most diverse city), during the 2020 election.[6]

The number of preemptive laws restricting the power of local governments and communities has also increased, with significant public health impact. At least 26 states have passed laws limiting public health authority in the last 2 years,[7] such as limiting what cities and counties can do to address the COVID-19 pandemic and restricting discussion of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) issues in public schools. In 2021, for example, Governor Brian Kemp signed an executive order prohibiting local governments in Georgia from imposing mask and vaccine mandates in order to control the COVID-19 pandemic.[8] In addition, Florida enacted a “Don’t Say Gay” bill that went into effect July 1, 2022, and forbids local public schools from teaching students about sexual orientation or gender identity.[9]

Public health outcomes are linked to voting policies, with more inclusive policies consistently associated with better health outcomes. The links between health and democracy are both direct and indirect. The direct links are well known. For example, people vote on budgets and ballot initiatives that affect our health, such as Medicaid expansion, reproductive health care, and clean air laws, and candidates for public office routinely make people’s health part of their campaigns because they know it is among the top issues voters care about. For example, voters in Maine, Missouri, and Oklahoma approved expansion of Medicaid eligibility through the ballot initiative process.[10] Links can also be indirect. The United States Census Bureau helps guide congressional funding decisions and legislative representation proportions for our communities at every level. When people fill out their census forms, they help determine how much funding their communities receive for transportation, education, housing, and health services and how many representatives they have in legislatures.[11] High levels of civic participation help ensure that people in communities are connected to each other and see how their own agency affects themselves and others. This improves neighborhood cohesion, health outcomes, and community resilience.[12]

Recent research shows a consistent association between voting and health.[12] People who vote tend to report better health than those who do not vote. Voters show better future mental and physical health than nonvoters, even after adjustment for a range of other factors including age.[13] One way to assess this association is by comparing health outcomes against the Cost of Voting Index (COVI), which was developed by political science researchers at Northern Illinois University in 2016 and measures the relative cost of voting in each state based on the time and effort associated with casting a vote.[14] According to an analysis visualized in the Health and Democracy Index, states with lower COVI scores have less restrictive voting policies and exhibit better health outcomes.[15] For example, Colorado has a low COVI score, inclusive registration policies, no restrictive ID requirements, a vote-at-home option, and voting rights restoration and ranks in the top 15 states in overall health outcomes. By contrast, Tennessee has a high COVI score, restrictive voter registration policies, restrictive ID requirements, no vote-at-home options, and no voting rights restoration and is ranked 41st in overall health outcomes nationally.[15]

Over the past decade, there have been significant political efforts to undermine democracy and restrict civic and voter participation. In 2013, the Supreme Court of the United States decided Shelby County v. Holder, holding that the preclearance requirements of Section 4(b) of the Voting Rights Act of 1965 are unconstitutional. This ruling eliminated the formula to identify areas where racial discrimination in voting was more prevalent along with requirements for prior approval for new voting changes in those areas.[16] Preclearance was successful at improving voting access in covered jurisdictions. After this ruling, states that were previously covered by preclearance engaged in significant efforts to disenfranchise voters. For example, within 24 hours of the decision, Texas announced implementation of stricter voter ID laws. Between 2012 and 2018, more than 1,600 polling locations were closed, and states previously covered have purged voter rolls at higher rates than those that were not covered.[17] In 2021, the Supreme Court decided Brnovich v. DNC, holding that Arizona’s out-of-precinct voting policy and ballot collection law do not violate Section 2 of the Voting Rights Act, which prohibits the denial or abridgement of the right to vote on account of race or color, and that the ballot collection law was not enacted with discriminatory purpose.[18] While this ruling did not establish a general test for Section 2 challenges, it will make it more difficult to use this section in future challenges to discriminatory voting laws. As access to democracy becomes more tenuous, it is incumbent on the public health community to protect the right to vote and promote policies that ensure an inclusive democracy for all as a pathway to better health.

Despite record voter turnout in the 2020 election, approximately one third of eligible Americans still did not cast a ballot.[19] In addition, disparities in voter turnout continue to persist even with overall increases in voter participation. Historically, voter turnout has been lower among Hispanic or Latino, Asian American, Pacific Islander, and American Indian people, as well as among younger voters and voters at lower educational levels.[20–22] A 2021 study conducted by the Center for Inclusive Democracy analyzed voter turnout in California and revealed that although turnout was up overall in 2020, the gap in turnout for the total population versus Latino and Asian American communities actually widened.[23]

People experience barriers to registering to vote and casting a ballot for many reasons, some of which intersect with barriers to receiving health care. These reasons include a lack of identification documents,[24] frequent changes of address,[25] limited English proficiency,[26] misconceptions about the rights of people with disabilities,[27] a combination of poor health and low income,[28] and voter registration office closures due to emergencies such as COVID-19.[29] For example, extensive ID requirements for registration can be a major barrier: 13% of Black eligible voters and 10% of Latino eligible voters lack photo identification, as compared with only 5% of White eligible voters. Individuals with lower incomes are also less likely to have photo identification: 12% of adults living in households with annual incomes below $25,000 lack photo ID, versus only 2% of those living in households with incomes above $150,000. These disparities in photo identification prevent eligible voters in disenfranchised communities from registering to vote.[30] In addition, one in four nonregistered voters after the 2016 elections cited “recently changing their address,” “forgetting to register,” “time constraints,” and “confusion over how to register” as their reasons for not voting.[31]

Black, Latino, and American Indian voters face heightened barriers in terms of voting and participating in democracy. These voters are more likely to experience longer polling lines, be disproportionately burdened by stringent voter identification laws, and have fewer polling locations per capita than their White counterparts. These barriers are often promoted under the guise of efficiency and security. For example, in a study of the 2016 elections, the researchers used anonymized smartphone locations to track waiting lines across 93,658 polling stations nationwide and found that voters in predominantly Black neighborhoods were 74% as likely to wait more than half an hour as voters in majority White neighborhoods.[32] Long polling lines are related to a lack of election infrastructure investment, often determined at the county level, which can result in consolidation of polling places, fewer poll workers, and the use of outdated equipment. American Indian voters also face unique barriers to mail voting on reservations as a result of nontraditional addresses, homelessness, overcrowding, language barriers, and lack of broadband access and post office boxes.[33] In 2018, 9% of Black and Latino voters experienced being told that they lacked the proper identification to vote, while only 3% of White Americans had the same experience.[34] In addition, 15% of Black voters and 14% of Latino voters had difficulty finding their polling locations, as compared with only 5% of White voters.[34] During the 2018 election, Latino and Black voters were more likely than White voters to wait in long lines on election day. Latino voters waited on average 46% longer than White voters, and Black voters waited 45% longer than White voters.[35]

Voters with disabilities face numerous challenges to voting. Eligible voters with disabilities were 7 percentage points less likely to vote than eligible voters without disabilities in the 2020 election, even after adjustment for age.[36] Voters with disabilities were also nearly twice as likely as nondisabled voters to experience problems when voting, and one in nine voters with disabilities faced barriers accessing ballot boxes.[36] People with vision and cognitive impairments were especially likely to face obstacles during the 2020 election; these individuals accounted for roughly 7 million eligible voters and 13.1 million eligible voters, respectively.[36] Not only do people with disabilities face hurdles in casting a ballot, they also are less likely to report being registered to vote.[36] While many states have adopted new and innovative ways to increase voter registration through same-day registration, online options, and automatic registration at the department of motor vehicles (DMV), these systems have not been successful in fully registering the community of voters with disabilities.[36]

Communities that face challenges when casting their ballots also face the greatest health challenges. A higher cost of voting value (as determined by the COVI[14]) is associated with worse individual and state health outcomes, and this relationship is strong and statistically significant. Achieving health equity requires that we focus on building an inclusive and representative democracy that addresses the root causes of both voting and health disparities and the role of law and policy in creating and perpetuating these disparities. Racial health disparities are pervasive throughout the United States, as evidenced by, for example, higher rates of premature mortality and chronic disease. Mortality rates for most of the 15 leading causes of death are higher in Black communities than in White communities.[37] Nearly 100,000 Black people die prematurely each year due to health disparities.[37] In fact, research has shown that many close state-level elections would have had different outcomes if the mortality profiles of voting-age Black people matched those of White people.[38] Voting is a way to change laws and policies and thereby change access to resources, power, and opportunity that shape the social determinants of health. Voting, engagement, advocacy, policy, money, and technology are all factors in the political determinants of health framework. If public health is truly going to advance health equity, the public health community must pay greater attention to the political context in which disparities occur at all levels of government and embrace its role in shaping these determinants by implementing strategies to remove barriers to political and civic participation among the populations experiencing the greatest health disparities. Removing barriers to voting and working to ensure inclusive voting systems are essential to advance health equity and improve health and well-being for all, a concept recently recognized by the American Medical Association in a policy statement supporting safe and equitable access to voting and recognizing voting as a social determinant of health.[39]

Evidence-Based Strategies to Address the Problem

Voting shapes public health policy and health outcomes, but Black, Latino, Asian American, and American Indian people; people with disabilities; and people from groups that have been historically marginalized all experience barriers to participation in the electoral process, barriers that have been exacerbated by the COVID-19 pandemic and ensuing legislation to curb both public health and election authority. These are problems that can be addressed by monitoring civic participation as a leading health indicator in our national health goals and prioritizing measurable objectives and research related to voter registration and voter turnout, removing barriers to engaging in the electoral process, and recognizing, as noted in APHA Policy Statement 8322, “that an informed voting public is necessary and obligatory for adequate funding for public health” and that “APHA members can play an important role in educating the public about the effects of funding cuts” and other policy measures on the health of the public.

There are four strategies the public health community can focus on to improve civic and voter participation: (1) supporting inclusion of voting and civic participation objectives in the Healthy People framework, (2) engaging and educating public health professionals and partners on the importance of inclusive voting policies for community health, (3) encouraging voter registration as a key path to civic participation, and (4) advocating for policies that make voting easier, more accessible, and inclusive.

Strategy 1—Supporting inclusion of voting and civic participation objectives in the Healthy People framework: The national Healthy People framework is a roadmap for achieving national-level health goals over 10-year spans. Measuring and tracking these goals deeply informs local and state-level health plans, including through governments and hospital systems. For example, the Healthy People 2020 goal “Adults meeting aerobic physical activity and muscle strengthening federal guidelines” achieved its 2020 target[40] and was prioritized by states via programs such as Let’s Move! Rockbridge in Virginia to promote healthy living and physical activity through collaborations with local businesses, government, health care facilities, and the community.[41]

In 2010, in recognition of the importance of civic participation for health outcomes, the Healthy People initiative introduced a social determinants of health topic area for Healthy People 2020 that included a social and community context domain in addition to four others. Civic participation was identified as a key issue within this domain, and two informational areas without targets were added: “Proportion of persons eligible to participate in elections who register and who actually vote” and “Proportion of persons eligible to participate in elections who are registered and report voting in the most recent November election.”[42] Healthy People 2020 included data from the Current Population Survey, the U.S. Census Bureau, and the Department of Labor for both objectives, disaggregated by sex, race and ethnicity, and age, every 2 years between 2010 and 2018.[42]

While civic participation was included in Healthy People 2020 and voter registration and participation were included as measurable objectives in the social determinants of health topic area,[43] these objectives were not initially included in Healthy People 2030. In 2017, leading up to the development of Healthy People 2030, the National Academies of Sciences, Engineering, and Medicine Committee on Informing the Selection of Leading Health Indicators for Healthy People 2030 was charged by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Health with assisting in the development of leading health indicators for Healthy People 2030. The proposed list of 34 recommended indicators included “the proportion of the voting eligible population who voted in the last election,” with an objective to “Increase the proportion of the voting-eligible population who votes” (also in Healthy People 2020). The committee noted that voter participation met the indicator selection criteria in that it is measurable, it has both baseline and additional data points, “the evidence base for it is fairly strong and growing, and it has considerable bearing on health equity and disparities given the robust understanding of what shapes structural inequities.”[44] Despite the committee’s recommendation and evidence supporting the relationship between voting and health, voter participation was not included as a research objective in Healthy People 2030 until being reinstated in July 2022 on the basis of community-driven efforts to reestablish the metric.

The Department of Health and Human Services should include civic participation as one of Healthy People’s leading health indicators, building on the framework established in Healthy People 2020, which included metrics on voter registration and the portion of people who actually voted from U.S. Census Bureau data and data from other government sources that track these trends. The National Academies of Sciences, Engineering, and Medicine—the congressionally chartered experts who advise the government on critical science issues—recommended including voting among 34 leading health indicators.[45] Additional research illustrating the connection between civic and voter participation and health outcomes is called for to inform policymakers. States and local organizations should mirror this effort and prioritize improving and tracking civic and voter participation metrics as part of their public health planning process.

Strategy 2—Engaging and educating public health professionals and partners on the importance of inclusive voting policies for community health: Health professionals and their networks are a vital part of civil society, something that becomes much clearer in times of crisis. It is necessary for the public health sector to work collectively with partners and develop the tools needed to build capacity, broaden and strengthen coalitions, and contribute to the creation and growth of inclusive democratic systems. The American Public Health Association has a robust advocacy portfolio that includes working to advance issues such as racial healing and transformation, climate change, gun violence prevention, smoking cessation, and reproductive health access. These issues require an engaged electorate in order to see progress on policy objectives.

Of course, doing so requires resources, including professionals’ time, training, and dedicated support for community outreach and engagement. In its 1983 policy statement Voter Registration and the 1984 Elections, APHA recognized the value of educating the public health workforce on the importance of funding to support public health activities and how participation in the election could affect the future of public health programs. This continues to be a salient issue today. In its May 2021 report Challenges and Opportunities for Strengthening the US Public Health Infrastructure, the National Network of Public Health Institutes identified financial resources as a key domain of our public health infrastructure and noted that the chronic underfunding of public health can be countered by improving communication on the value of the sector so that public health professionals and their partners can better advocate for policies and funding.[46] Law is also a key domain, and in this same report the top two self-identified training needs for the public health workforce were how to influence law and policy development and how to understand the effects of law and policy on health.

These findings are reinforced by the 2017 Public Health Workforce Interests and Needs Survey, which revealed that one of the top training needs of the public health workforce is how to develop a vision for a healthy community.[47] To create a vision, the workforce needs to understand how the scaling back of public health authority, restrictions on elections, and failure to invest in our public health infrastructure shape public health and health equity and that voting is a way to advocate for more informed and inclusive health policies.[48] This vision should include community partners and priorities and provide opportunities for community leadership and engagement.

It is essential for public health professionals to intentionally build the public and political will necessary to address public health challenges. State and local governments and organizations can promote civic engagement year-round by promoting opportunities for community members to serve on advisory boards, attend and provide testimony at town halls, participate in public meetings, engage in volunteer activities, and advocate on salient issues. A strong public health system relies on providing opportunities for community members to learn about policy issues that will shape our health and well-being and how to take action. However, building this capacity will require dedicated funding, professional support for public engagement, and a deeper understanding that this sort of service work and community building is a key aspect of public health.

Strategy 3—Encouraging voter registration as a key path to civic participation: In order to encourage civic participation, the public health community can support efforts to streamline voter registration because it is in a position to engage voters who are often left off of voter rolls, including people who are more likely to access public health services. Under the National Voter Registration Act, automatic voter registration (AVR) allows eligible voters to be automatically registered when they interact with the state DMV through data sharing between the DMV and the state’s voter registration system. AVR removes barriers to registration for eligible voters, which is a first step in increasing voter participation. According to the Brennan Center for Justice, states that have enacted AVR have seen up to a 94% increase in voter registrations.[49]

The success of AVR in DMV offices is a demonstration of the opportunity to expand this model to additional government agencies, such as those that provide social services, to reach eligible voters who might not interact with the DMV—especially older voters, younger voters, voters who move frequently, and voters in urban areas who are less likely to drive. AVR should be expanded to incorporate other agencies, including federal and state public health programs. A particular opportunity to advance health equity through voter registration is the implementation of AVR within Medicaid. Nearly 60% of Medicaid beneficiaries identify as Black, American Indian, Hispanic, and other groups of color,[50] and 15% have disabilities.[51] As referenced above, these same groups are underrepresented at the ballot box.[20–22] In addition, state Medicaid agencies gather relevant information for voter registration, such as name, date of birth, and current address, as part of their normal operations.

However, AVR is not appropriate in all public health settings. When AVR is not plausible or appropriate, community health programs and state agencies can ensure that members of the public can update their voter registration by including voter registration in all external operations, providing the necessary paperwork, and educating them on how to exercise their voting options. Broad voter registration efforts can be solidified through state and federal policies. For example, the Biden administration issued Executive Order 14019 (Promoting Access to Voting) on March 7, 2021. This executive order requires executive department and agency leaders to consider ways to “expand citizens’ opportunities to register to vote and to obtain information about, and participate in, the electoral process” through evaluation of programs and provision of relevant information to the public about how to register to vote, request a vote-by-mail ballot, and cast a ballot in upcoming elections.[52] One example of the impact of this order is the Health Resources and Services Administration’s recent voter registration guidance for Federally Qualified Health Centers.[53] An example of a state taking action is Minnesota, where Statute §201.162 requires government agencies and nonprofit organizations that contract with the state to provide voter registration services for employees and the public.[54]

Strategy 4—Advocating for policies that make voting easier, more accessible, and inclusive: While voter registration is a key step in ensuring that more people can participate in democracy, more needs to be done to address access to the ballot because more accessible voting is associated with better individual and state health outcomes.[12] The public health community can help ensure that all people have equitable access to the ballot by advocating for policies that make it easier to vote. Policies such as increasing access to mail voting (which research indicates has no impact on partisan turnout[55]), increasing the window for early voting, expanding available polling locations’ hours of operations to accommodate nontraditional schedules, and ending restrictive voter identification policies would go a long way toward that ensuring community members have a direct say in policy decisions that affect their health. In addition, advocating for policies that make our democracy more inclusive such as restoring the right to vote to people with felony convictions and allowing noncitizens to vote in local elections would expand community representation in decision making on policies that affect community health. The importance of these policies was recognized in Healing Through Policy: Creating Pathways to Racial Justice, an initiative of the de Beaumont Foundation, APHA, and the National Collaborative for Health Equity that launched in October 2021 to explore policies and practices that advance health, racial equity, and justice.[56] Voting rights protection and expansion was included as a practical example in the Healing Through Policy law brief, which noted that voter suppression is a form of structural racism that influences policies directly affecting community health.[56]

An estimated 6.1 million Americans are denied their voting rights due to policies that disenfranchise people with felony convictions. These policies disproportionately affect Black Americans.[57] Currently, only two states and Washington, D.C., allow people with felony convictions to vote, even while incarcerated.[58] In addition, voter identification laws have been shown to suppress voter turnout among racial and ethnic minorities in both primary and general elections.[59] The public health community has an opportunity to promote policies that increase participation and open the electoral process to members of our communities who have experienced disproportionate barriers to civic and voter participation and worse health outcomes.

Opposing Arguments

This policy statement relies on the assertion that having a more engaged and involved electorate is good for public health and that inclusive democratic practices support positive community health outcomes. Some may argue in opposition of these assertions by positing that only those who have expertise should make policy decisions. They may argue that community health can improve only when well-educated individuals make informed policy decisions that address health outcomes. However, this viewpoint is not supported by historical or scientific evidence and neglects the reality that people are experts on their own lived experience.

The narrative that asserts that only informed voters should participate in democracy is rooted deep within the fabric and history of this country. In fact, as early as post–Civil War, White Southerners imposed literacy tests and poll taxes to keep Black men from voting in elections because they were viewed as inferior.[60] The narrative that some people are deserving while others are not persists within current health policy debates. For example, those who support work requirements for Medicaid eligibility sometimes argue that only those who are deserving—by being poor but still employed—should have access to affordable health insurance.[61] This argument is deeply rooted in the individualistic framework of our country’s founding. It is argued that individuals can become deserving (of voting rights or access to health insurance) by simply attaining a better education or gaining employment. Those who see health and voting as individual choices may also value preserving treasured institutions over individual rights, so they see policies that make accessing health and voting systems more complex as protecting the respective institutions.

However, there is a more robust set of evidence that illustrates how health is not solely an individual choice and that restrictive voting policies have an unequal impact on entire population groups. As noted, the social determinants of health, the conditions in which we live, work, learn, pray, and age, account for 30% to 50% of health outcomes.[2] These conditions are not uniform across the population and do not occur randomly; as discussed in previous sections, marginalized groups often experience worse health outcomes tied to inequities across the social determinants of health.[1] Just as health disparities are driven by external factors, disparities in access to voting are driven by similar social factors. Also as noted, people experience barriers to registering to vote and casting a ballot for many reasons, including those that intersect with barriers to receiving health care. Examples are a lack of identification documents,[25] frequent changes in address,[26] limited English proficiency,[27] and misconceptions about the rights of people with disabilities.[28] If public health is truly going to advance health equity, then the public health community must pay greater attention to the political context in which disparities occur and implement strategies to remove barriers to political and civic participation among the populations experiencing the greatest health disparities. Removing barriers to voting and working to ensure inclusive voting systems are among the strategies that are essential for advancing health equity and improving health and well-being for all.

Action Steps

APHA encourages all public health and health care professionals to participate in the electoral process by registering to vote, facilitating voter registration through programs and services and in health care spaces, and educating and engaging the public about the importance of civic participation to community health. APHA recommends the following action steps:

Strategy 1: Supporting Inclusion of Voting and Civic Participation Objectives in the Healthy People Framework

• The Department of Health and Human Services should prioritize measuring and tracking voter and civic participation in the Healthy People framework by including voter registration and voter turnout and other evidence-based measures of civic and voter participation as core objectives.
• Federal, state, and local public health agencies should include civic and voter participation metrics in state and community health improvement plans and processes.
• Public health researchers and practitioners should evaluate the individual and community factors that lead to high levels of civic and voter participation, explore the causal relationship between civic participation and health outcomes, and the implications for health equity.
• Public health researchers and practitioners should examine how voting laws and policies are determinants of health and monitor where voting laws and policies have changed to assess the relationship between those changes and health outcomes over time.

Strategy 2: Engaging and Educating Public Health Professionals and Partners on the Importance of Inclusive Voting Policies for Community Health

• Public health practitioners should educate colleagues and community partners on how civic and voter participation affects health equity and community health.
• Public health practitioners should develop working relationships with people and groups experiencing the greatest inequities in health and voting to identify and support strategies that expand access to civic and voter participation.
• State and local health departments should design and support workforce training and education on topics such as the social and political determinants of health, racism as a public health issue, public health authority, and their role in promoting inclusive civic and voter participation.
• Public health practitioners should design and implement public outreach efforts and tools that support and promote voting to reach people who are traditionally underrepresented in voter turnout and who experience greater health disparities.
• State and local governments and public health organizations should promote civic participation year-round with community groups, including opportunities to serve on advisory boards, attend and provide testimony at town halls, participate in public meetings, engage in volunteer activities, and advocate on salient issues.

Strategy 3: Encouraging Voter Registration as a Key Path to Civic Participation

• The federal government should continue to require federal agencies to expand access to voter registration and election information, assist states under the National Voter Registration Act, and modernize the systems used by the federal government to share information and forms (e.g., Vote.gov).
• State and local public health agencies should evaluate their ability to implement laws related to voter registration and take steps toward implementation such as offering voter registration as a regular part of programs and services or implementing automatic voter registration programs.
• Public health leaders should work with partners to advocate for the elimination of felony disenfranchisement laws and restore the right to vote to people with felony convictions.

Strategy 4: Advocating for Policies That Make Voting Easier, More Accessible, and Inclusive

• Public health agencies and professionals should implement policies and practices that advance health, racial equity, and justice through projects such as Healing Through Policy or similar truth, racial healing, and transformation frameworks, including electoral reforms.
• Public health agencies and health systems should support civic participation among their workforce by implementing policies that support voting and volunteering during elections and allow for nonpartisan voter registration efforts.
• Public health agencies and practitioners should work collaboratively with multisector partners to advocate for laws and policies that improve civic participation and educate policymakers on the important link to better health outcomes.
• Public agencies and professionals should partner with community members, organizations, and coalitions to promote inclusive voting policies such as Healthy Democracy Healthy People, Voting is Social Work, and similar efforts.
• Policymakers should establish federal elections standards and necessary resources to increase civic and voter participation such as national no-excuse absentee voting; a nationwide early vote period; the use of secure drop boxes; automatic, same-day, and online voter registration; increased incentives for poll workers; standards for polling place closures and consolidation; and establishment of election day as a national holiday.
• In the absence of federal standards, states should evaluate legal barriers to voting, such as restrictive voter identification laws, and enact laws that facilitate voter access and protect the right to vote.

References

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2. World Health Organization. Social determinants of health. Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Accessed November 3, 2022.

3. Dawes DE. The Political Determinants of Health. Baltimore, MD: Johns Hopkins University Press; 2020.

4. Miller G. Women’s suffrage, political responsiveness, and child survival in American history. Q J Econ. 2008;123(3):1287–1327.

5. Brennan Center for Justice. Voting laws roundup: December 2021. Available at: https://www.brennancenter.org/our-work/research-reports/voting-laws-roundup-december-2021. Accessed November 3, 2022.

6. Ura A. The hard-fought Texas voting bill is poised to become law. Here’s what it does. Available at: https://www.texastribune.org/2021/08/30/texas-voting-restrictions-bill. Accessed November 3, 2022.

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