Addressing Health Disparities Through Voter Engagement
======================================================

* Nicholas Yagoda

## Abstract

Although the public’s essential capacity for self-rule in the United States lies in the power of the ballot, there exist many barriers to voting, particularly for marginalized communities. These barriers cultivate less representative government and less inclusive public policy. Nonprofit and private health organizations, and in particular community health centers and safety-net hospitals, can help marginalized voting-eligible individuals overcome barriers to the ballot. With augmented, unbiased voter participation, elections would yield government that is more representative and public policy that is more equitable, while reducing costly and preventable health disparities. Health organizations can promote comprehensive, nonpartisan voter engagement through registration, mobilization, education, and protection of all voters.

Key words
*   health
*   disparities
*   integrated
*   equity
*   voter engagement
*   voter registration
*   mobilization
*   education
*   voter education
*   protection

## INTRODUCTION

In 2016, more than 90 million Americans, nearly 40% of our voting-eligible population, did not vote.1 Significant gaps in voter participation occurred along racial, educational, and income-level divides, which may largely be attributable to voting restrictions and a sense of alienation from government.2 Barriers to the ballot have long been a threat to our country’s most fundamental democratic process. Ballot barriers have evolved from the original constitutional disenfranchisement of people of color and women to more contemporary voter suppression techniques such as voter ID laws and voter registry purges, but the outcomes of biased elections and perpetuation of inequity remain.

The United States is host to avoidable and costly health inequalities.3,4 Those facing barriers to the voting process are also those disproportionately at risk to suffer from health disparities. Research has demonstrated that the views of voters in the 2016 election diverged significantly from those of nonvoters, with the former favoring less inclusive health, social, and economic policy.5 Furthermore, politicians are more responsive to voters than nonvoters,6 and healthier constituents vote more frequently.7 Thus a negative feedback loop is created, wherein health disparities generate biased voter participation gaps; these gaps yield biased heath policy, further reinforcing health disparities. For example, state electorates with disproportionately higher rates of healthy voter participation saw less health spending and less generous Medicaid programs,7 reinforcing disparities in health care coverage.8

Public policy shapes our health ecosystem, influencing the accessibility of comprehensive health care, secure housing, nutritious food, quality education, jobs with livable wages, and freedom from crime and discrimination. Nonprofit and private health organizations, particularly community health centers and safety-net hospitals that serve vulnerable communities, are well poised and eligible9 to promote nonpartisan voter participation in furtherance of health-advancing public policy. Notably, private entities, with fewer governance and funding considerations, may have even broader latitude to engage voters than federally funded organizations. Integrated voter engagement (IVE) is a year-round issue-based model that health organizations can utilize for sustainable, impactful community action to address public policy.

## INTEGRATED VOTER ENGAGEMENT

The 4 facets of IVE are voter registration, mobilization, education, and protection. As applied to health, IVE can foster social determinants of health capital in marginalized communities in promotion of health equity.10 For example, IndyCAN is a nonpartisan organization in central Indiana that employed IVE strategies to achieve increased transit equity through expanded bus service, fueling economic development and increased access to jobs for low-income communities.11,12 Applying similar models, eligible health organizations could scale their health equity impact by influencing regional, state, and even federal legislation.

### Voter Registration

Voter registration is one of the most influential elements of voter engagement. Overwhelmingly, people of color, people with disabilities, low-income Americans, the uninsured, and young people are those most likely to be unregistered and to experience barriers to voter registration.13 But these same groups have political preferences that differ from dominant voter groups—Medicaid expansion is a telling example. Views towards Medicaid differ dramatically according to race, with people of color holding more favorable opinions than whites.5 States with the greatest barriers to voting, disproportionately affecting people of color, tend to be those states that rejected Medicaid expansion. In fact, analysis has shown that state decisions to adopt Medicaid expansion have been responsive to white opinion only, and that racial resentment may play an important role.14 Health status bias of voters also is associated with likelihood of Medicaid expansion.7 Additionally, arbitrary and needlessly early voter registration deadlines exacerbate participatory disparities2 and are tied to reduced welfare eligibility.15

Targeted efforts to bring equity to voter registration have yielded reductions in important health-associated disparities. The enfranchisement of black voters is associated with a narrowing of the black-white education gap,16 while the enfranchisement of women has led to increased spending on children and a reduction in child mortality.17

Under the National Voter Registration Act of 1993, venues that provide public assistance, including Medicaid services, are empowered to register eligible voters.18 Community health centers and hospitals, venues regularly engaged with marginalized groups, have hosted and promoted nonpartisan voter registration drives.19,20 Community Health Vote (CHV), a program of the National Association of Community Health Centers, has developed a Health Center Tool Kit to guide implementation of voter engagement initiatives.21 In 2012, over 200 community health centers across the United States registered more than 25,000 voters.22 Finally, regardless of funding source, health organizations can educate the community about important voter registration options, including pre-registration, automatic or same-day registration, or even online registration where applicable.

### Voter Mobilization

Voter mobilization—encouraging individuals to vote—is also within the scope of nonprofit and private health organization work, and targets new or low-propensity voters in particular.23 Robust mobilization efforts increase voter turnout24 and are associated with more inclusive policy, such as reduced income inequality.6 These health organizations can mobilize voters in a nonpartisan manner by highlighting the linkage of their vote to elements of their health, including access to care, health care insurance coverage, and pharmaceutical pricing, in addition to relevant social determinants of health. Moreover, mobilization can highlight all region-specific options for casting a ballot. This might include early voting, absentee ballot voting, and vote-at-home with vote centers, in addition to the more traditional in-person voting at polling stations.

### Voter Education

Voter education addresses recalcitrant voting barriers, including cynicism about government2 and concerns that one’s vote does not matter.25 Additionally, voter education can reframe campaign issues that might diminish health advancement. For instance, in the 2016 presidential election, studies have shown that many white voters, including women and people of low income, perceived their dominant social status to be under threat as a result of the country’s increasing racial and ethnic diversity and global trade.26 Consequently, these white voters prioritized policies to preserve their dominant social status (opposition to social welfare programs, and restricted immigration and international trade) over policies to promote their health (reduced income inequality, and expanded health care coverage and early childhood education).

Nonprofit and private health organizations can educate the community and combat cynicism by providing community-led, culturally competent, nonpartisan health impact assessments of political candidate positions and proposed legislation. In so doing, these health organizations can prepare voters to vote in their best health interest.

### Voter Protection

Finally, health organizations can promote voter protection by combating voter suppression techniques, including debunked myths of voter fraud.27 In collaboration with local nonpartisan community advocates, these health organizations can lobby against restrictive laws and practices that make it difficult to vote, such as voter ID laws, inflexible voting hours, polling place closures, voter registry purges, voter caging, and unfair voter challenges. Additionally, advocacy to eliminate gerrymandering, a practice utilized by both political parties to dilute the value of select votes, would promote the equitable impact of every voter.

The promotion of voter engagement among marginalized communities—people of color, low-income Americans, and people living with disabilities, among others—could increase equitable health policy and mitigate costly and preventable health disparities. By integrating voter engagement as a health equity strategy, nonprofit and private health organizations can help communities leverage health-promoting change through more representative government and more equitable health policy.

## Acknowledgments

Thank you to Jaeson Fournier, DC, MPH and Alan Schalscha, DO for their guidance and leadership.

## Footnotes

*   Conflicts of interest: author reports none.

*   To read or post commentaries in response to this article, see it online at [http://www.AnnFamMed.org/content/17/5/459](http://www.AnnFamMed.org/content/17/5/459).

*   Received for publication September 30, 2018.
*   Revision received February 20, 2019.
*   Accepted for publication March 28, 2019.


*   © 2019 Annals of Family Medicine, Inc.

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