On the morning of November 9th, the day after the 2016 U.S. Presidential Election, a visceral sense of shock was felt throughout the campus of Harvard Medical School. Donald Trump’s victory appeared to be an abrupt rebuke of so many of our commonly held values—equality, service, compassion. As medical students and physicians in Boston, we understood that we were isolated—both geographically and ideologically—from the myriad forces that swept Mr. Trump into office. However, there was something unsettling about our collective disbelief. How was it that so many of us had failed to recognize the depth of pain and divisiveness that existed within our country? There arose, in all of us, a need to understand.
In the aftermath of the election, political analysts have ascribed Trump’s victory to several themes—condemnation of the intellectual elite, widespread economic disaffection, and the rise of a potent strain of populism. However, closer inspection reveals another contributor to this startling election result. Though the final votes are still being tallied, it is clear that Mr. Trump will have received fewer votes in victory than the previous two republican nominees garnered in defeat. Instead of representing a powerful mandate, Mr. Trump’s victory hinged on vast portions of the electorate choosing to stay home. Nearly half of all Americans did not cast a ballot in this election1. As captured poignantly by Jon Favreau, former speechwriter to President Obama, “democracy is fragile and belongs to those who show up.”
With this in mind, what can we as medical students, physicians, and allied healthcare professionals—no doubt part of the “intellectual elite”—do to heal the personal and societal wounds from this election? How can we ensure, going forward, that the values to which we adhere remain secure? Answers to these questions will likely require significant reflection, but we believe that democracy is at its best, and most equitable, when all voices are heard. Therefore, we suggest that there is meaningful and feasible action that we can take today. We can help our patients register to vote.
Voter Registration in a Healthcare Setting is Meaningful
Since the pioneering work of Rudolf Virchow in the 19th century, generations of physicians have sought to improve the social factors that cause illness among their patients. This advocacy has led to, among many others, the provision of safe drinking water, widespread access to vaccines, and campaigns to reduce cigarette smoking. More recently, physicians have focused their attention on the so-called “social determinants” of health—factors like housing instability, poor nutrition, and occupational exposures. The number and scope of interventions designed to improve social determinants have expanded dramatically, and in an effort to focus physicians on the most impactful projects, Russel Gruen and colleagues developed a novel framework. Put forth in a 2004 special communication in JAMA, they delineated between professional obligations—which address social issues that both directly cause illness and are amenable to change—and professional ambitions—which tackle the broader social factors that indirectly affect health2. Professional obligations must come first in any provider’s agenda, but ambitions too should be championed. Voting, of course, does not directly cure disease, but it can empower citizens to influence society around them. A vote for any candidate or platform propels a particular healthcare agenda, whether it defends or denies women’s’ reproductive rights, raises or lowers the price of prescription drugs, or expands or narrows access to healthcare. Our system is most equitable when all voices are heard, and regardless of one’s own political stance, promoting voter registration is a worthy aspiration.
Voter registration in the U.S. is indeed problematic. Driven by low overall rates of registration, turnout for American elections is lower than in almost every other developed country around the world3. Additionally, wide discrepancies in voter turnout exist across demographic groups. For example, in 2012, Asians and Latino Americans voted at a 20% lower rate than whites or blacks. Poorer and less-educated citizens turned out at roughly half the rate of their more affluent peers, and similarly low levels of voting were observed among Americans with disabilities and unstable housing opportunities4. While not yet fully characterized, the results from this month’s election are likely to show a familiar trend.
The same demographics least likely to vote are also those with the poorest health in our society. Failing to vote, of course, does not lead to poor health, but the two are certainly related.
A 2001 study found a striking connection between voter participation and self-reported levels of health. Stated simply, citizens in states with the greatest voting disparities between rich and poor tended to rate their health poorly, whereas citizens of more equitable voting states rated their health better. This difference remained significant even after controlling for baseline levels of wealth and income inequality5. The connection between a state’s voter turnout and overall health seems peculiar, but Kim Qualie Hill, a professor of political science from Texas A&M University, and his colleagues posited one explanation. In an article published in the American Journal of Political Science, they found that electorates that contained fewer low-income voters tended to have less generous social welfare systems6. They reasoned that administrations enact legislation that favors their electoral coalitions, and that higher-class interests—overrepresented in such blocs—are often at odds with policies benefitting the poor. These findings suggest that, by failing to vote, society’s most disenfranchised citizens are forgoing a powerful opportunity to improve their conditions, health among them.
Voter Registration in a Healthcare Setting is Feasible
In the clinic patients come first, and while many healthcare providers aspire to make sweeping improvements in socioeconomic inequalities, time is increasingly constrained. So how can busy practitioners find time to address professional ambitions like voter registration? Luckily, recent experiences inform a practical path forward.
Studies have shown that many unregistered voters simply lack the initiative, time, or understanding to navigate the registration process, but are receptive to assistance. Citing the National Voter Registration Act of 1993—which encourages providers of public assistance, like Medicaid services, to build voter registration capacity—the National Association of Community Health Centers ran a voter registration drive in 2008. Through their efforts more than 18,000 low- and middle- income citizens were added to the official rolls. Another program, conducted in 2012 at two Federally Qualified Health Centers in the Bronx, showed that a large number of voters could be registered easily without requiring significant physician effort, compromising patient-doctor relationships, or creating undue political influence7. Patients were simply asked about their voter registration status while waiting to see their doctor. If they were unregistered but interested in voting, clinic staff provided them with voter registration cards and answered any of their questions. Completed forms were then mailed to the Board of Elections. In all, each registration took as little as 5 minutes to accomplish.
It is important to note that it would be inappropriate for physicians, with their institutional and professional power, to coerce their patients to adopt specific political beliefs or actions. However, these studies showed that when performed as a nonpartisan public service, either by clinic employees or physicians themselves, voter registration drives do not pose legal or ethical concerns. While it is unclear how many of these patients subsequently cast a ballot in an election, registering to vote represents a substantial step in the right direction.
Now is the time for healthcare providers to facilitate voter registration among their patients. We are poised at an uncertain time in the course of our democracy, and recent events have put the future direction of healthcare into question. President-Elect Trump vowed during his campaign to repeal the Affordable Care Act—an idea likely to be welcomed in the GOP-controlled congress. Additionally, roll out of the Medicare Access and CHIP Reauthorization Act is set to begin in 2017, and the tenor in Washington will likely play a major role in how the law is instituted. Although the legislative agenda over the next 4 years remains unclear, it seems likely that millions of Americans are in jeopardy of losing access to affordable, high-quality medical care. However, if it is the will of the voters, future laws might be enacted to strengthen our healthcare system. Whatever direction, everyone should have a say in their health.
The success of a democracy, by definition, depends on the engagement of its participants. Healthcare providers, by virtue of serving all patients, are uniquely poised in society to understand the diverse needs of a diverse populace. Physicians already counsel their patients to quit smoking, adjust their diets, and apply sunscreen, and I strongly believe that registering to vote should join this list of prescriptions. This simple act can enable patients from every socioeconomic and ethnic background to fight, in a small but absolute manner, for the rights that they believe in. Healthcare and otherwise.
1. McDonald, MP. 2016 November General Election Turnout Rates. United States Election Project. http://www.electproject.org/home/voter-turnout/voter-turnout-data accessed November 14, 2016.
2. Gruen RL, Pearson SD, Brennan TA. Physician-Citizens—Public Roles and Professional Obligations. JAMA. 2004; 291: 94-98.
3. Desilver D, U.S. Voter Turnout Trails Most Developed Countries. Pew Research Center. August 2, 2016. http://www.pewresearch.org/fact-tank/2016/08/02/u-s-voter-turnout-trails-most-developed-countries/ accessed November 14, 2016.
4. Perez V. Representational Bias in the 2012 Electorate. Project Vote. 2015
5. Blakely TA, Kennedy BP, Kawachi I. Socioeconomic Inequality in Voting Participation and Self-Rated Health. Am J Public Health. 2001; 91: 99-104
6. Hill KQ, Leighley JE, Hinton-Andersson A. Lower-Class Mobilization and Policy Linkage in the U.S. States. Am J of Political Science. 1995; 39: 75-86
7. Liggett A, Sharma M, Nakamura Y, Villar R, Selwyn P. Results of a Voter Registration Project at 2 Family Medicine Residency Clinics in the Bronx, New York. Ann Fam Med. 2014; 12: 466-469