Will my neighborhood ever get a bus stop? Can the empty lot at the center of town be transformed into a public park? Will Medicaid be expanded in my state?
These decisions deeply affect health and health equity, and—whether directly or indirectly—they are made at the ballot box.
If the social drivers of health are where we live, work, play, and learn, then the political drivers of health are the public investments and disinvestments made in housing, jobs, infrastructure, and schools. The power to shape those decisions lie in the hands of people who vote. But commonly, the same structural inequities that make it hard for some populations to access health care, healthy food, or affordable housing, also make it hard to vote.
The less a community’s voice is part of civic dialogue and political decision-making, the less likely policies will advance their health and well-being. It’s a vicious cycle where the people and communities most disenfranchised at the polls suffer from the greatest health inequities. (See the Health & Democracy Index for information on how the restrictiveness of voting policies in each state affects 12 public health indicators.) People with lower incomes and education levels and people of color are impacted the most—groups that are also disproportionately enrolled in Medicaid.
But there is good news. Increasing civic participation can mitigate health inequities. For example, rates of infant mortality are higher nationally among Black and Native American communities than White communities, but this disparity shrinks for all racial and ethnic groups in states that have better civic health and voter registration.
All of this means that civic engagement is a social determinant of health equity, and we have both an opportunity and an imperative to address it as such.
Medicaid is increasingly a mechanism to advance health equity and address social drivers of health inequities, but nonpartisan civic engagement and voter registration is rarely addressed as one of its strategies. In this election year, there is an opportunity and an obligation to change that. HealthBegins hosted a webinar on May 14 highlighting ways to advance civic engagement and nonpartisan voter enfranchisement this election cycle and beyond. Here are four practices from that conversation that Medicaid-serving healthcare delivery organizations can adopt:
1) Lead sustained nonpartisan civic engagement and voter registration efforts year-round in your clinics. When you go to the Department of Motor Vehicles (DMV) to apply for a driver’s license, they also give you information about registering to vote. Why doesn’t this happen every time someone goes to the doctor’s office? Many people see healthcare providers more frequently, and there is nothing intrinsically more democratic about the DMV than a doctor’s office or hospital, especially one that receives federal funding (e.g., Medicare, Medicaid) or federal tax breaks. Some healthcare delivery organizations are embracing this opportunity.
AltaMed Health Services in California runs an integrated, nonpartisan civic engagement model called My Vote, My Health at all of their clinics. They increase voting access by talking with patients and staff about voter registration and educating them about when elections are occurring. Clinics serve as voting centers and have ballot drop boxes in clinics wherever possible. AltaMed also runs door-to-door canvassing, texting, and phone banking efforts with local community-based organizations within a 10-mile radius of each location to reach people they missed at the clinic. To date, they have made over 2.3 million direct voter engagements and had 5,678 ballots dropped off in their clinics. (Read more about the impact of this model.) Lizette Escobedo from AltaMed stresses that voting and civic engagement efforts must be sustained year-round to be effective. Relationships and trust are the cornerstone of programs like this one; groups can’t drop in and out of communities for a couple weeks before each election and expect results.
Healthcare staff are often hesitant to talk to patients about voting for fear that it’s illegal to do so. However, it is allowed as long as the information being shared is non-partisan. This fear can be overcome by providing staff with training on how voter registration works in their state. Civic Health Alliance, Nonprofit Vote, State Voices, and Vot-ER have helpful training materials for health care staff.
Civic engagement isn’t just about voting. For example, the Census not only determines the number of Congressmen a state has and how Congressional districts are drawn, it also determines how $1.5 trillion in federal funds for health care, food assistance, and education services are distributed. Clinics can use the same civic engagement infrastructure and strategies they create for voter registration to support Census enumeration.
2) Support efforts at the state and federal levels to enable voter registration through Medicaid. As part of The National Voter Registration Act of 1993, federal law requires that people receive voter registration information every time they apply for, recertify, or change their address with Medicaid, SNAP, WIC, and TANF programs. When the law is implemented well, roughly 10 to 15 percent of all voter registrations in a state come from these touchpoints. However, that is rarely the case, as states commonly fail to provide voter information the way the law intended. Douglas Hess highlights simple, inexpensive ways to optimize this law and maximize voter registration, such as automatically including voter registration forms in packets with Medicaid materials and providing voter registration information during online transactions. You can look at how Medicaid agencies in your state provide voter registration information and advocate for these types of procedural improvements.
However, the biggest impact would come from more states enacting automatic voter registration through Medicaid. Under this policy, Medicaid agencies check someone’s citizenship status when they apply for Medicaid and automatically and securely submit information to register every eligible person in the household to vote. If this creates a new or updated voter registration, that person can still later opt out, select a party, and change their address, but this approach greatly reduces the burden on the applicant. Nine states and the District of Columbia have laws pending or enacted to implement automatic voter registration through Medicaid, but Biden Administration officials are holding up the process over concerns about data confidentiality. Check out this resource from the nonpartisan Institute for Responsive Government to learn more about Medicaid automatic voter registration and ways to support this policy in your state.
3) Promote community-centered governance in health care delivery organizations and in state Medicaid agencies. In addition to promoting power at the polls, civic engagement means ensuring communities served by Medicaid have decision-making power in how healthcare delivery organizations and Medicaid agencies provide services, conduct research, set priorities, and allocate funding. This has profound implications for health equity. Without equity-centered accountability mechanisms, how can marginalized patient populations and communities partner with and ensure that Medicaid plans and providers are providing the highest quality care to everyone? Healthcare executives and boards can cede and share decision-making authority through community consultant boards, constituent-led boards, and governance partnerships with communities. These organizations can also strengthen community-based participatory research to help increase community participation and oversight of healthcare research.
4) Assess where your organization makes health equity investments to impact the political determinants of health. As health equity efforts grow, organizations must ensure their work promotes healing and doesn’t inadvertently perpetuate structural harm. To do this, organizations can adopt a portfolio approach that examines health equity investments and transformation across multiple levels of intervention—from patient care to institutional policy to societal practices—and multiple levels of prevention. (See HealthBegins’ Compass for Health Equity Transformation tool for guidance on how to do this.) For example, if you and your colleagues are looking for opportunities to close racial health inequities impacting Medicaid enrollees with diabetes, a strategic portfolio might include downstream interventions to close care gaps and improve patients’ food insecurity. At the same time, it could engage in more upstream work, like supporting local community-led coalitions’ efforts to increase the minimum wage and reduce economic hardship for people with lower incomes.
To advance health equity, we must promote civic engagement and nonpartisan voter enfranchisement. And to promote civic engagement this year and in years to come, we must pay particular attention to addressing structural barriers, find ways to amplify community voices, and reimagine our clinics and hospitals as places that promote healing—for our bodies, our communities, and our democracy.