Democracy and Power: Why Voting Matters for our Health

My personal awareness of the connections between civic engagement and everyday life began with my early experience growing up on a family farm in central Minnesota. For over 140 years decisions about access to electricity, roads, schools, grain marketing cooperatives—even recovery from the cropland damage of the dust bowl years—were addressed through a combination of political, individual, and community efforts. These efforts were supported and sustained through public policies at a local, state, and national level. Our elected bodies made many decisions and investments to create the conditions to assure everyone had an opportunity to thrive. 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;1 with women’s suffrage, child mortality rates declined by 8 to 15%;2 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;1 and in 2010 health care and health equity champions organized to pass significant national health reform measures while others organized state level ballot initiatives to assure Medicaid Expansion.1 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 are created through policies influenced by the public and political will created by voters. Minnesota has many protective policies when it comes to voting—we enjoy inclusive voter registration, no excuse absentee voting, and our voters led the country with 80% turnout in 2020.3 However, our state is ranked 15th out of 50 on the Cost of Voting Index, a tool measuring ease of voting.4 This demonstrates there is more to be done in Minnesota. We can improve health and voting disparities by protecting and promoting inclusive policies such as restoring the right to vote for those who have been incarcerated and adopting automatic voter registration across all state programs. Although policymaking often feels distant from our lives, our participation is urgently needed and critical to our health. A recent analysis of health and civic participation demonstrates that inclusive voting policies and expanded voter participation contribute to improved collective health.3 Building our power and influence is necessary to address unacceptable health inequities. Since 2020 the nation has experienced adoption of some of the most restrictive voting laws we’ve seen in recent history. New restrictions on absentee voting, early voting, and drop boxes along with gerrymandering are expected to lead to even more barriers for communities already underrepresented at the ballot box. Conversely, robust and inclusive democratic practices can serve as a vehicle for building power and provide the foundation for healthy thriving communities. Health professionals working collectively can advance health and voting equity by championing policies that strengthen civic and voter participation. Faced with an urgent imperative to protect and promote inclusive voting policies, major public health and civic engagement groups came together in 2020 to form VoteSAFE Public Health now called Healthy Democracy Healthy People (HDHP). HDHP is a non-partisan coalition5 with the overall aim of advancing health and racial equity by strengthening civic and voter participation and ensuring access to the ballot for all eligible voters. The HDHP approach is centered on three practices shown to build power including: organize people and organizations, organize narrative and

data, and organize policy and resources. Building upon these community organizing strategies the 11 HDHP Coalition partners have: • Developed the Health & Democracy Index (HDI)3 to expand the current public health understanding of the relationship between health and voting. The HDI presents a wide range of health indicators and correlates these indicators to voting policies. It is designed to provide a shared health equity analysis of voting policy and serve as a tool for practitioners to use to strengthen civic and voter participation. • Sponsored educational events for health care, public health, civic engagement, and philanthropy groups to share the research on health and voting and build public support for inclusive democratic practices.6 • Identified policies and practices we can influence in our very own organizations including adopting policy statements in our professional and work organizations. • Engaged federal Health and Human Services (HHS) Administration officials to employ the policy and administrative levers they can influence such as: • Including voting as a Research Objective in Healthy People 20307 and continuing to work to formalize inclusion of voting as a Core Objective and Leading Health Indicator. • Developing guidance for federal HHS funding recipients on promoting civic and voter participation such as: registering staff and members of the public to vote, participating in state efforts to expand automatic voter registration, educating the public about their voting options during the months leading up to elections and expanding and improving voter registration opportunities such as Automatic Voter Registration (AVR) through government services and State Medicaid programs. Promoting registration through government supported services clearly offers opportunities to address persistent health and voter disparities.

What You Can Do as a Healthcare Provider

• Adopt policies and position statements in your professional, academic, and community organizations to promote civic and voter participation. • Build political will for promotion of inclusive civic and voting policies by conducting and sharing research on health and voting. • Serve as election workers and support organizational policies to encourage co-workers to serve as election workers. • Incorporate voter education into your everyday practice using tools such as the Healthy Voting Guide.8 • Engage with elected officials about issues that matter to you between election cycles. • Promote policies to restore voting rights to citizens with past criminal convictions. • Expand the opportunities to register to vote by promoting Automatic

Voter Registration through motor vehicle registration, hunting and fishing licensing, and healthcare services such as Medicaid. Go to www.healthydemocracyhealthypeople.org for information.

Jeanne F. Ayers, RN, MPH, leads Healthy Democracy Healthy People, a coalition of 11 public health organizations committed to advancing health and racial equity by strengthening civic and voter participation and ensuring access to the ballot for all eligible voters. Prior to establishing this coalition in August 2020, Ayers held leadership roles in state governmental public health for over nine years. She served as the Wisconsin State Health Officer and Assistant Commissioner and Chief Health Equity Strategist for the Minnesota Department of Health. She can be reached at: Jeanne.ayers@hdhp.us.

(Endnotes) 1. Dawes, Daniel E., and David R. Williams.

“Chapter 2: Setting the Precedent America’s

Attempt to Address the Political Determinants of Health Inequities.” The Political Determinants of Health, Johns Hopkins University

Press, Baltimore, MD, 2020, pp. 39–67. 2. Miller, Grant. “Women’s Suffrage, Political

Responsiveness, and Child Survival in American

History*.” Quarterly Journal of Economics, vol. 123, no. 3, 2008, pp. 1287–1327., https://doi. org/10.1162/qjec.2008.123.3.1287. 3. Health & Democracy Index, Healthy Democracy

Healthy People Initiative, Aug. 2021, https:// democracyindex.hdhp.us/. 4. Scot Schraufnagel, Michael J. Pomante II, and Quan Li. Cost of Voting in the American

States: 2020. Election Law Journal: Rules, Politics, and Policy. Dec 2020. 503-509. http://doi. org/10.1089/elj.2020.0666. 5. Healthy Democracy Healthy People coalition partners include: • American College of Preventative Medicine (ACPM) • American Public Health Association (APHA) • Association of Schools & Programs of Public

Health (ASPPH) • Association of State and Territorial Health

Officials (ASTHO) • Big Cities Health Coalition (BCHC) • National Association of County and City Health

Officials (NACCHO) • National Network of Public Health Institutes (NNPHI) • Network for Public Health Law (NPHL) • Public Health Accreditation Board (PHAB) • Trust for America’s Health (TFAH) • Society for Public Health Education (SOPHE) • Civic Engagement Groups • Center for Civic Design • Center for Tech and Civic Life • Institute for Responsive Government 6. Recordings of these presentations can be found on the National Academies of Science

Engineering and Medicine website: • https://www.nationalacademies.org/ event/08-31-2021/voting-and-health-evidenceand-new-tools-for-action. • https://www.nationalacademies.org/event /09-15-2021/webinar-voting-and-health-expanding-opportunities-for-inclusion. 7. https://health.gov/healthypeople/objectives-and-data. 8. Healthyvoting.org.