Photo by Grandriver, courtesy iStockphoto
Millions of Americans will soon cast their votes in a national midterm election, choosing the candidates they believe have their well-being in mind. But the path to the ballot box is paved with inequity.
Strict citizenship and voting ID requirements on top of racially-motivated redistricting threatens to not only disenfranchise voters, but lock them out of choices that could improve individual and overall public health.
Civic participation as a whole, including voting, is a social determinant of health, according to Darlene Huang Briggs, JD, MPH, deputy director of special projects at the Network for Public Health Law. Who gets to vote affects public health decisions — spanning access to healthcare, air quality and safe places for kids to play — and the funding necessary to make that happen, she said.
“When communities are drawn out of power or excluded from voting, their health needs become easier to ignore and then our elected officials become less accountable to the public they're supposed to serve,” Briggs told The Nation's Health.
In April, the Supreme Court ruled in Louisiana v. Callais that the state's creation of a second majority-minority voting district was unconstitutional racial gerrymandering. The move led to a flurry of voting-map redistricting aimed at breaking up majority-minority districts once protected under the Voting Rights Act. Gerrymandering, the act of shifting a district's boundaries to favor a particular party, can have serious long-term consequences on investments in community health.
Gerrymandering across Georgia, North Carolina and Wisconsin in favor of politicians who shunned Medicaid expansion under the Affordable Care Act resulted in 3,000 more deaths and 1 million people uninsured in 2019 alone, according to a 2020 Center for American Progress report.
“It really threatens all of the representation at that local level that sets public health budgets, runs health departments and the decisions about where health clinics are, how data is tracked about people's health outcomes and where there are risks for infectious disease,” Briggs said. “Those are some of the ways this is directly impacting people's lives that they might not necessarily think about.”
Volunteers pass out voting information outside a polling place in Houston in March. Advocates are concerned new restrictions will hurt voting rights.
Photo by Brett Coomer, courtesy Houston Chronicle/Getty Images
In North Carolina alone, gerrymandered state Senate districts saw a 29% decline in the number of federally qualified health centers over an 18-year span, according to a study in February's American Journal of Public Health. Residents in communities split evenly between two state Senate districts traveled about 30% farther to their nearest center in 2022, the study found.
“The policy and the legal trend here is pretty clear in terms of who it makes it harder to fight for, which is minority groups,” study co-author Auden Cote-L'Heureux, a master's in economics student at the University of Bonn who completed the research as a University of Massachusetts-Amherst student, told The Nation's Health. “(The centers) serve disadvantaged groups and so disproportionately minorities as well.”
The retrenchment of provisions under the federal Voting Rights Act, originally meant to ensure that marginalized groups are not shut out of democracy, dovetails with the decades-long expansion of state voter ID laws that limit acceptable forms of identification, according to Marian Moser Jones, PhD, MPH, an associate professor at Ohio State University's College of Public Health and History Department.
Proponents of voter ID laws often present them as reasonable, given that forms of ID such as a driver's license are used often for other tasks such as renting a car. But not everyone drives, especially older adults or people experiencing homelessness, Jones said.
“It's definitely targeting people who already have less access to health, education,” Jones told The Nation's Health. “If you take the bus, maybe you don't need a driver's license to take the bus. If you experienced homelessness or you experienced eviction and you lost things, you could lose your driver's license. That disproportionately affects communities of color.”
Some laws go as far as prohibiting the use of post office boxes as voter registration addresses, which disproportionately affects Indigenous communities living on reservations as well as people in rural communities, Jones said. In 2013, the North Dakota state Legislature required voters to present IDs that had residential addresses instead of P.O. box addresses. After a series of court challenges, the Supreme Court ultimately upheld the restriction in 2018 that potentially disenfranchises tens of thousands of Indigenous voters, who face myriad health challenges. American Indian and Alaska Native people have the lowest life expectancy and die from chronic diseases such as diabetes at higher rates compared to Black, white and Hispanic Americans, according to the Centers for Disease Control and Prevention.
“Communities that are already at risk of adverse health outcomes are now being increasingly disenfranchised by restrictions on voting that have no basis in fact,” Dan Vicuña, JD, senior policy director for voting and fair representation at Common Cause, a nonpartisan organization focused on strengthening democracy, told The Nation's Health.
The proposed federal Safeguard American Voter Eligibility Act, or SAVE Act, would tighten voter ID and registration laws by requiring documents such as birth certificates and passports to register. The move disproportionately affects married women who may have changed their last name, as well as rural, low-income, transgender and older adult populations who cannot afford the cost of the documents or travel to obtain them.
“These are also many of the same populations that experience a disproportionate health burden from all of the health risks that we're all exposed to,” Briggs said. “And it's really just an outsized reaction to a statistically non-significant problem.”
As of July, the SAVE Act had stalled in the Senate. However, discussions were in progress about a multibillion dollar grant program in the House's fiscal year 2027 budget resolution that would encourage states to implement strict citizenship and voter ID requirements. Meanwhile, battles have played out across other forms of voter suppression, such as scaling back access to early voting and rescinding vote-by-mail privileges.
As of mid-July, a federal appeals court cleared the way for a March executive order from President Donald Trump that would require states to hand over voter lists before ballots are mailed via the U.S. Postal Service. The pre-approval process could disenfranchise older adults, rural populations and people with disabilities who already struggle with access to healthcare and support services.
As fights are waged in state legislatures, Congress and courts around access to voting, civic organizations are leading the charge to counter disenfranchisement and increase civic participation at the community level.
The nonprofit group Vot-ER trains healthcare professionals to hold voter registration drives, help hospitalized patients cast votes on Election Day and more. Hospitals and community health centers are some of the few places that nearly everyone in a community will interface with and capture populations other institutions may miss.
“The people who we have helped register or given them information about polling locations or early voting, they turn out to vote upward of 20 percentage points higher than the general electorate,” Emily Polak, MPP, Vot-ER's vice president of partnerships and coalition building, told The Nation's Health.
The League of Women Voters works on voting education and civic engagement programs to eliminate barriers to voting, said Jeanette Senecal, the group's chief of civic learning and impact.
The league assists with registration, helps people understand changing election rules in their communities and offers its Vote411.org website in English and Spanish for voters navigating the electoral process.
“The more we can help people make their voting plan, the more likely they are to turn out to vote,” Senecal told The Nation's Health.
For more information, visit www.whenweallvote.org, www.vot-er.org and www.vote411.org.
- Copyright The Nation’s Health, American Public Health Association
