Dr. Alister Martin’s first encounter with voter registration in a health care setting happened in 2017, when he was a third-year emergency medicine resident at Boston Children’s Hospital.
A patient and their two children had come to the emergency department as a place of last resort to seek shelter. The patient had just moved to Boston and had no proof of residency, a requirement to qualify for transitional housing. A social worker told Martin that the only way to get the patient a proof of residence was by having them register to vote. The patient agreed.
“And it was really a light bulb moment for me,” says Martin, now an emergency medicine at Massachusetts General Hospital and CEO of A Healthier Democracy, a nonpartisan organization focused on the intersection of health and civic engagement. “I knew that it was legal and operationally feasible to do voter registration in a hospital, so then the question became, how do we scale it in a way that is most feasible across as many different hospitals as possible?”
Public health champions like Martin emphasize the importance of giving citizens the means to register to vote because voting and health are associated, a growing body of research shows. Voting determines which officials are elected to office, which in turn affects what community interests get advanced — from policies that allocate social assistance, education and housing to social services and child development.
One major barrier to voting is the voter registration process, which is not automatic in the United States.
In the 2020 U.S. election, nearly 80 million eligible voters didn’t cast a ballot. About 30% said they didn’t vote because they weren’t registered, according to an Ipsos survey of 1,103 non-voters and 740 voters, commissioned by NPR and the Medill School of Journalism. Costs associated with registration disproportionally affect voters who are low-income and racial and ethnic minorities, research shows. They are more likely to have more than one job, work during polling place hours, lack access to childcare and transportation and have higher rates of illness and disability.
The National Voter Registration Act of 1993, also called the “Motor Voter Law,” empowered and encouraged voter registration at organizations like state motor vehicle agencies, health care facilities that treat Medicare and Medicaid patients, as well as all nonprofit organizations, which includes many hospitals in the U.S., according to a 2021 article in the Annals of Emergency Medicine.
“Under the NVRA, hospitals and other health care institutions are allowed to facilitate nonpartisan voter registration activities and/or seek designation as voter registration agencies,” according to a fact sheet by the Association of American Medical Colleges.
Today, the most common way people register to vote is at the Department of Motor Vehicles, according to the U.S. Census Bureau. But health care institutions have yet to become a common place for voter registration.
Since that encounter in the emergency department, Martin’s goal has been to bridge this gap.
In 2019, he created Vot-ER (pronounced Vote-E-R) so health care institutions could host nonpartisan conversations with patients about voting and direct them to websites where patients can check their registration, register to vote, or request an absentee ballot.
In its first iteration, Vot-ER was a kiosk with an iPad at Massachusetts General Hospital’s emergency department, which allowed patients to register to vote. Today, the nonpartisan nonprofit project is present in more than 700 health care sites across the U.S., offering a variety of resources and tools, including staff badges with QR codes directing patients to check their registration status, register to vote, or request an absentee ballot. (Vot-ER’s list of participating hospitals is not public, although it features some of its key partners.)
“The goal is to make the concept of civic health a popularized term — the idea that our physical health is tied to whether and how we are engaging in the body politic,“ Martin says.
The project has caught the attention of the Republican National Committee. In early September Luke Bunting, an attorney for the RNC’s Election Integrity program, sent a letter to secretaries of state or election officials in six swing states, alleging that Vot-ER is “weaponizing the healthcare system,” and urging them “to monitor Vot-ER’s activity in your state to ensure compliance with state and federal law and to safeguard the integrity of your elections.” (The Washington Free Beacon, a conservative news site that covers politics and foreign affairs, published a news story last month in which it uploaded Bunting’s letters to officials in Pennsylvania, Wisconsin, Michigan, North Carolina, Arizona and Nevada.)
Vot-ER leaders say that the organization does not promote or endorse any political party or candidate, and their aim is to provide patients with the tools to register to vote, without pressure or influence.
“It’s disheartening to see this unwarranted attack on nonpartisan civic engagement, especially as our bipartisan advisory board provides guidance to ensure we maintain the highest standards of fairness and integrity,” Aliya Bhatia, Vot-ER’s executive director, said in an e-mail to Democracy Docket, a digital news platform that focuses on voting rights and election-related litigation.
Mobilizing voters in health care
There aren’t many research studies on the role health care institutions can play in mobilizing voters.
Over the years, there have been small clinic-level pilots showing voter registration in health care is possible and effective. In a 2014 study published in the journal Annals of Family Medicine, researchers reported positive outcomes from a nonpartisan voter registration drive in two federally qualified health centers in the Bronx, New York. Of 128 patients who were eligible to vote but previously unregistered, 89% registered through the project.
Vot-ER is providing some of the first national data on health care-led voter registration, which has gained momentum in recent years. There are several reasons for the wider recognition of voting in health care, Martin explains.
The American health care system has been through dramatic changes in recent years, from the implementation of the Affordable Care Act to the COVID-19 pandemic.
“And I think that clinicians are realizing basically the following, that politically if you’re not at the table in this country, you’re on the menu,” Martin says.
Young clinicians are very interested and focused on expanding the purview of what being a clinician means beyond the hospital walls, he says. And in June 2022 the American Medical Association passed a resolution acknowledging that “voting is a social determinant of health.”
“The AMA’s resolution marked a seismic shift: It acknowledged that the health of a community extends beyond the walls of hospitals and clinics — and that health is profoundly influenced by the ballot box,” write Martin and Bhatia in an August 2024 commentary published on WBUR, a local NPR station in Boston.
Martin and colleagues’ latest study, published in June 2024 in JAMA Health Forum, finds that the Vot-ER project reaches a younger and more racially and ethnically diverse population, groups that are typically underrepresented in elections, when compared with data from two nationally representative surveys.
“The most important validation of our hypothesis is the data that demonstrates that the people who are registering are folks who are not on any other voter registration or political campaigns lists,” Martin says.
Dr. Jean Junior and her colleagues analyzed Vot-ER data in pediatric settings in a 2023 study published in the journal Pediatrics. They find widespread interest in voter registration among health care providers in pediatric settings.
One interesting finding from the group’s analysis was the diversity of the groups, practices and hospitals that implemented the Vot-ER tool, says Junior, an attending physician at Lurie Children’s Hospital Division of Emergency Medicine and an assistant professor of pediatrics at Northwestern University.
“There are pediatricians all across the country using these tools, and there is also a great diversity in the types of staff,” including physicians, nurses, social workers, child-life specialists and dietitians who used the Vot-ER tool, she says.
More major medical organizations have also been taking note.
The American Academy of Pediatrics has led a long-standing nonpartisan Get Out the Vote campaign before major elections.
The Association of American Medical Colleges recently partnered with Vot-ER to develop resource guides for education and voter registration in health care settings.
In a 2023 national report, County Health Rankings & Roadmaps, a program of the University of Wisconsin Population Health Institute, found that civic participation, including voting, can help communities stay connected and healthy.
And researchers are calling for a better process for integrating voter education and registration into health system.
“Clinic-level pilots incorporating screening for and facilitating voter registration in individual clinical encounters must be generalized to a scalable, system level,” write the authors of a 2023 commentary in NEJM Catalyst.
The role of hospitals in voter registration is an important topic for journalists to consider in a major election year. To help bolster your reporting of the topic, we have curated and summarized several studies about voter registration efforts in health care settings.
Research roundup
Increasing Voter Participation Through Health Care–Based Voter Registration
Katherine McCabe, Yinlu Zhu, Simar S. Bajaj and Alister F. Martin. JAMA Health Forum, June 2024.
The study: This cross-sectional study examines the effectiveness of using health care settings as venues for voter registration, particularly for historically underrepresented populations, including young people and racial and ethnic minorities. Vot-ER collaborated with health care professionals and institutions to implement voter registration drives before the November 2020 U.S. elections. The study compares the demographics and voting behavior of individuals reached through Vot-ER with those engaged through traditional political campaign outreach, using data from the 2020 Cooperative Election Study and the 2020 American National Election Study.
The findings: The study finds that health care-based voter mobilization successfully reached a more diverse population compared with traditional methods.
- Of the 12,441 patients engaged in health care settings, 41.9% were aged 18 to 29, and 39.6% identified as racial or ethnic minorities. These proportions were significantly higher than in national surveys, which reported younger voters and racial minorities making up smaller shares of contacts.
- 9.6% of people who used Vot-ER identified as Asian, which is three times that of the CES sample and 2.8 times that of the ANES sample.
- 15.9% of Vot-ER users were Black, compared with 9.8% of the ANES sample and 12.0% of the CES sample.
- 12.7% of Vot-ER users were Hispanic, compared with 10.2% of ANES respondents.
- Voter turnout among those who came into contact with Vot-ER increased significantly, from 61.0% in 2016 to 79.8% in 2020.
The authors write: “With these communities’ electoral participation hampered by poor health, a self-perpetuating cycle persists in which policy is increasingly unable to serve people who need high-quality, low-cost health care the most. Health care–based voter registration is one potential response to this misalignment, more successfully engaging lower-propensity voters than traditional political campaigns.”
A National Voter Registration Campaign
Jean A. Junior, et al. Pediatrics, July 2023.
The study: This paper explores the feasibility and impact of incorporating voter registration efforts into pediatric health care settings. Using the Vot-ER platform, researchers partnered with academic and non-academic pediatric institutions across the U.S. to integrate voter registration materials and assistance into patient visits ahead of the 2020 presidential election. One registration resource was a staff badge with a QR code linking to a voter registration website. To find out if people had used these resources to register to vote, researchers analyzed a dataset from Vot-ER with numbers of voters registered per institution between May and November 2020. Personal identifying information was removed from the data.
The findings: Pediatric health care settings can serve as effective venues for voter registration initiatives, the authors write.
- 1,490 pediatric staff members ordered badges with QR codes from Vot-ER. Of them, 76% were physicians or physicians-in-training and 15.3% were nurse practitioners, physician assistants, nurses and social workers.
- The staff who ordered the badges were located in 353 pediatric institutions in 41 states and the District of Columbia.
- Among 21 institutions, a median of two people per institution completed their voter registration. The maximum number of people who completed their voter registration in a single institution was 118. In total 389 people were registered.
The authors write: “Voter registration efforts have the potential to increase political representation among patients and families, thereby driving policy changes affecting virtually every aspect of pediatric health. Thus, no matter one’s issue of interest, from Medicaid reimbursement rates and research funding to pediatric mental health, firearm safety, and child poverty, voter registration and voting are important.”
Voting As a Social Determinant of Health: Leveraging Health Systems to Increase Access to Voting
Anisha Ganguly, Danielle Morelli, and Kavita P. Bhavan. NEJM Catalyst, January 2023.
This commentary explores the connection between voting and health outcomes, highlighting how structural inequities that limit access to voting also affect health, particularly for marginalized populations. It discusses voting as a social determinant of health and emphasizes the need for health systems to integrate voter registration efforts into patient care to improve health outcomes.
The authors explain their efforts at Parkland Health, a health system in Dallas County, Texas, which promotes voter registration in its facilities by providing voter education and registration materials in high-traffic area.
The authors note:
- Voting is a “political determinant of health”, with marginalized populations facing structural barriers that limit their access to voting and health care, perpetuating cycles of disenfranchisement and poor health.
- Health systems, particularly those serving vulnerable populations, can play a vital role in promoting voter registration and education, as seen in successful efforts like the Vot-ER Healthy Democracy Campaign.
- Increasing access to voting can improve health outcomes by addressing social inequities, making voter engagement an essential part of public health interventions.
The authors write: “We mobilized medical students, residents, and high school student health ambassadors to staff voter registration booths in high-traffic areas of the hospital in the 2 weeks leading up to the 2022 midterm election voter registration deadline in partnership with the Dallas County Elections Department, which provided resources and personnel support. In the future, we plan to implement processes to screen patients for voter registration and provide resources for voter registration and voter education as a part of patient care delivery.”
Additional reading
Voter Registration in Hospitals Is the New Frontier in Health Care
Alister Martin and Aliya Bhatia. WBUR, August 2024.
Expanding Voter Registration to Clinical Settings to Improve Health Equity
Brooke Stanicki, et al. Health Services Research, October 2023.
Emergency Physicians Are Helping Patients Vote
Maura Kelly. Annals of Emergency Medicine, November 2021.
Health Care-Based Voter Registration: A New Kind of Healing
Alister Martin, Ali Raja and Halea Meese. International Journal of Emergency Medicine, April 2021.
Voting, Health and Interventions in Health Care Settings: A Scoping Review
Chloe L. Brown, Danyaal Raza and Andrew D. Pinto. Public Health Reviews, July 2020.
Results of a Voter Registration Project at 2 Family Medicine Residency Clinics in the Bronx, New York
Alisha Liggett, et al. Annals of Family Medicine, September 2014.
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