Subject: Written Comments on Proposed Healthy People 2030
Objectives: Social Determinants of Health-NEW-07: Increase the proportion of the voting age citizens who vote.
Comment Reference: 87 FR 64240
Submitted by the Minnesota Public Health Association (MPHA) in response to the Department of Health and Human Services’ (HHS) Solicitation of Written Comments on Proposed Healthy People 2030 Objectives: Social Determinants of Health-NEW-07: Increase the proportion of the voting age citizens who vote.
MPHA was established in 1907 and is a volunteer-driven membership organization for over 350 public health professionals throughout the state of Minnesota. We represent a wide variety of public health disciplines from across the state. Our mission is to create a healthier Minnesota through effective public health practice and engaged citizens. Our vision is to be an active, independent voice for public health in Minnesota.
MPHA recognizes the positive relationship between civic engagement and mental health, healthy behaviors and well-being. We understand that when more people are engaged in the democratic process, people and communities are healthier and that civic and voter participation contributes directly and indirectly to community health. We believe that to promote health and advance health equity it is vital to assure inclusive democratic processes and participation in the electoral system.
The Healthy People framework is a roadmap for achieving national-level health goals over 10- year spans. Setting, measuring, and tracking progress on these goals informs health improvement planning across federal agencies. Healthy People goals also inform the process of setting health goals and priorities at state and local level health agencies and non-profit hospital systems. MPHA supports the inclusion of voter participation to a core objective in Healthy People 2030. We urge you to transition the measure from a research objective to a core objective as soon as possible.
The evidence summarized below demonstrates that voter participation (the proportion of the voting age citizens who vote) meets the criteria for inclusion as a core objective in the Healthy People framework:
Evidence Included in This Comment
- Have a reliable, nationally representative data source with baseline data no older than 2015;
- Have at least 2 additional data points beyond the baseline during the decade;
- Have effective, evidence-based interventions available to achieve the objective;
- Be of national importance; and
- Have data to help address disparities and achieve health equity.
HHS should consider all citations supporting evidence and authority included in this comment as part of the formal administrative record for purposes of the Administrative Procedure Act. Throughout the comments that follow, we have included citations to supporting evidence, including links. We direct HHS to each citation and corresponding links and we request that the full text of the evidence and authority cited, along with the full text of our comment, be incorporated into the formal administrative record for purposes of the Administrative Procedure Act.
Core Objective Criteria
Reliable, Nationally Representative Data Source
Public data on elections are readily available from four federally managed databases: Current Population Survey (CPS), U.S. Census Bureau, the U.S. Bureau of Labor Statistics, and the Election Administration and Voting Survey (EAVS). All of these data sources meet the two data criteria for inclusion as a core objective in Healthy People 2030. They all have reliable, nationally representative data with baseline data no older than 2015 and have at least 2 additional data points beyond the baseline during the decade.
The Current Population Survey (CPS), U.S. Census Bureau, and the U.S. Bureau of Labor Statistics are data sources HHS is using to measure the proportion of the voting age citizens who vote. The primary strength of these data points is the ability to make conclusions about disparities in voter participation based on race, gender, disability status, income, and other characteristics discussed in the survey instruments. One weakness of these data sets are that they rely on self-report and proxy-reported data1 which is known to inflate the voter participation rates as compared to actual ballots counted.2 Additionally, while these datasets include state level metrics they do not include representative samples for many counties. Instead of solely relying on these self-reported measures, we propose using additional sources to determine a more accurate representation of voter participation across the country.
The EAVS is a national survey of county election offices conducted after general elections. The survey includes election office reports of voter registration, election infrastructure, and voter participation.3 The inclusion of this dataset can help ensure accurate reports of voter turnout are included in Healthy People 2030 tracking. Similarly, accurate statewide turnout results for both voting age (VAP) and voting eligible (VEP) populations are provided each election cycle by the US Elections Project, directed by Michael McDonald at the University of Florida.4 One limitation of the EAVS is that it does not include any population estimates such as age, sex, race, or ethnicity for those who voted.5 To ensure the most accurate voting data is used, Healthy People 2030 can combine population estimates from The CPS, U.S. Census Bureau, and the U.S. Bureau of Labor Statistics to determine weights for relevant demographic data with the county elections reports from the EAVS and statewide turnout from US Elections Project.
All of these data sources meet the two data criteria for inclusion as a core objective in Healthy People 2030. The EAVS includes baseline data from 2016, 2018, 2020, and soon will have 2022 data available with most counties across the country consistently submitting the survey instrument. The CPS, U.S. Census Bureau, the U.S. Bureau of Labor Statistics, all include annual questions in their national population surveys about voter participation.
Effective, Evidence-based Interventions to Improve Voter Participation
There is a growing body of evidence about policies and practices that can both bolster or hinder voter participation. Despite record voter turnout in the 2020 election, approximately one-third of eligible Americans did not cast a ballot.6 Increasing voter turnout requires both inclusive policies and robust community efforts to educate and mobilize eligible voters ahead of each election.
Policies that enable voter participation are described in the Cost of Voting Index (COVI), developed by political science researchers at Northern Illinois University in 2016. The COVI analyzes the relative “cost” of voting in each state in terms of time and effort associated with casting a vote. States with a lower COVI Index have less restrictive voting policies and are associated with increased voter participation.7 An analysis driven by the Healthy Democracy Healthy People in 2021 uses the COVI rankings to illustrate that diverse policies granting greater access to the ballot are positively associated with individual and community level health indicators.8
1. Addressing Structural and Systemic Barriers to Voting
Policies such as increasing access to mail voting (which historically has not impacted partisan vote share);9
increasing the window for early voting; expanding available polling locations and hours of operation to accommodate nontraditional schedules;10,11,12
and ending restrictive voter identification policies13
would go a long way toward ensuring community members have a direct say on policy decisions that affect their health. Additionally, being more inclusive with policies such as restoring the right to vote for those who are (or have previously been) incarcerated–14
an estimated 6.1 million Americans are denied their voting rights due to policies that disenfranchise people with felony charges. These policies disproportionately affect Black Americans.15
Currently, only two states and Washington, D.C. allow people with felony convictions to vote, even while incarcerated.16
Additionally, voter identification laws have shown to suppress voters from racial and ethnic minorities in both primary and general elections.17
2. Enabling Inclusive Voter Registration
The most common reasons people do not vote is not being registered and not understanding how to navigate the voting process.18-19 Eligible people are successfully registered to vote when they are offered active voter registration services.20 This includes being asked if they want to vote or to update their registration, receiving assistance as they complete the voter registration process, and ideally having their completed registration application collected and transmitted to the appropriate election officials or, if that is impractical, receiving a stamped envelope in which they can submit their voter registration application. Government agencies can aid in active voter registration efforts by accepting designation as voter-registration agencies under the National Voter Registration Act of 1993 (NVRA). Section 7 of the NVRA requires that:
“Any office in a covered State that provides either public assistance or state-funded programs primarily engaged in providing services to persons with disabilities must offer voter-registration services. Armed Forces recruitment offices must also provide voter registration services. In addition, a State must designate other offices in the State as voter-registration agencies.”21
One way the voter registration process can be streamlined is through Automatic Voter Registration (AVR) programs. AVR allows eligible voters to be automatically registered when they interact with the state Department of Motor Vehicles (DMV) through data sharing between the DMV and the state’s voter registration system. AVR removes barriers to registration for eligible voters, which is a first step in increasing voter participation. According to the Brennan Center for Justice, states that have enacted AVR saw up to a 94 percent increase in voter registrations.22
AVR is not appropriate in all settings. When AVR is not plausible or appropriate, community health programs and state agencies can ensure that members of the public can update their voter registration by including voter registration in all external operations by providing the necessary paperwork, contact information for local elections offices and educating them on how to exercise their voting options. Additionally, states can make sure voters have more opportunities to register to vote by enacting policies like same-day and Election Day voter registration.
3. National Importance of Voter Participation
Improving voter participation is crucial for advancing health and racial equity. Research has shown that civic and voter participation is strongly associated with health outcomes: states and countries that have more accessible voting policies and higher levels of civic participation are healthier across multiple public health measures.23 High levels of civic participation– including voter participation– help ensure that people in communities are connected to each other, improving neighborhood cohesion, health outcomes and community resilience.24 Voters show better future mental and physical health compared with non-voters, even after adjusting for a range of other factors.25
Ahead of the 2020 elections, states implemented policies and programs that led to more inclusive access to voting opportunities. These included expanding and promoting mail voting and early voting options.26 This resulted in historical voter turnout rates with 159 million people voting.27 Despite record voter turnout in the 2020 election, approximately one-third of eligible Americans still did not cast a ballot.28 Additionally, disparities in voter turnout persist despite overall increases in voter participation.29 Historically, voter turnout is lower for Black, Latino, Asian American, Pacific Islander, and American Indian people than for their white counterparts, as well as for younger voters and voters with lower education levels.30,31,32,33
Measuring voter turnout as a core objective in the Healthy People framework is key to better tracking inequities in civic and voter participation and identifying actions and policies that will improve participation and health outcomes. While we know that voter participation is a key indicator of social cohesion and contributes to community social capital,34 we do not effectively track and aspire to improve voter participation in public health research and practice. To effectively advance health equity, Healthy People must acknowledge the deep history of structural racism, ableism, and xenophobia that has been used to systematically restrict voter access. Healthy People must recognize the importance of voting as a matter of public health and equity.35
Importance of data to help address disparities and achieve health equity. Public health research and efforts to address disparities and advance health equity have focused on the social determinants of health and on increasing access to quality health services among marginalized populations. The social determinants of health differ from the social needs of individuals and instead exist at the population or community level. They are impacted through policies.36 Policy campaigns that aim to address health outcomes and social determinants of health require addressing the political environment. Within a fully functioning democracy, policy decisions are directly and indirectly determined through elections. Decisions made directly through elections include policies that communities vote on through ballot initiatives and referendums. People also decide on policy indirectly by delegating power to elected representatives who make policy through legislative and formal decision-making processes. However, despite community efforts to build power and influence decision making to advance health and racial equity, there continue to be intentional efforts to limit civic and voter participation that lead to ongoing health inequities.
As discussed earlier, research shows that states with better access to voting have better health. Additionally, those states that have less restrictive access to voting see disparities shrink for maternal mortality.37 Black, Latino and American Indian voters face heightened barriers when it comes to voting and participating in our democracy. Black, Latino, and American Indian voters are more likely to experience longer polling lines,38,39 are disproportionately burdened by stringent voter identification laws,40 and have fewer polling locations per capita than their white counterparts. American Indian voters face unique barriers to mail voting on reservations due to non-traditional addresses, homelessness, overcrowding, language barriers, and lack of broadband access and use of PO boxes.41 Additionally, 15 percent of Black voters and 14 percent of Latino voters had trouble finding their polling locations compared to only five percent of white voters.42
Voters with disabilities face numerous challenges to voting. Americans with disabilities were 7 percentage points less likely to vote than people without disabilities in the 2020 election even after adjusting for age.43 In 2020 voters with disabilities were also nearly twice as likely as nondisabled voters to experience problems when voting, and 1 in 9 voters with disabilities faced barriers accessing the ballot box.44 People with vision and cognitive impairments were especially likely to face obstacles during the 2020 election, which accounts for roughly 7 million eligible voters and 13.1 million eligible voters, respectively.45
These structural barriers to political participation and power keep communities most impacted by inequities out of effectively influencing critical decision-making processes. In order to address these disparities, Healthy People must focus on improving voter participation and access over the next decade.
The Minnesota Public Health Association encourages Healthy People 2030 to transition voter participation rates to a core objective. The evidence discussed above clearly demonstrates voter participation meets the criteria for inclusion as a core objective in the Healthy People framework.
1. IPUMS. Voting and registration supplement sample notes. IPUMS CPS. Available at: https://cps.ipums.org/cps/voter_sample_notes.shtml. Accessed November 4, 2022.
2. Tittle CR, Hill RJ. The accuracy of self-reported data and prediction of political activity. Public Opinion Quarterly. 1967;31(1):103-106. http://www.jstor.org/stable/2746888
3. EAVS faq. U.S. Election Assistance Commission. Available at: https://www.eac.gov/research-and-data/eavsfaqs#What-is-the-Election-Administration-and-Voting-Survey. Accessed November 4, 2022.
4. US Elections Project. Available at: https://www.electproject.org/election-data/voter-turnout-data Accessed November 10, 2022.
5. EAVS faq. U.S. Election Assistance Commission. Available at: https://www.eac.gov/research-and-data/eavsfaqs#What-is-the-Election-Administration-and-Voting-Survey. Accessed November 4, 2022.
6. US Elections Project. 2020 November General Election Turnout Rates. 2020. Available at: http://www.electproject.org/2020g. Accessed November 4, 2022.
7. Schraufnagel S, Pomante II MJ, Li Q. Cost of voting in the American States: 2020. Election Law Journal: Rules, Politics, and Policy. 2020;19(4):503-509. doi:10.1089/elj.2020.0666
8. Health & Democracy Index. https://democracyindex.hdhp.us/.
9. Thompson DM, Wu JA, Yoder J, Hall AB. Universal vote by mail has no impact on partisan turnout or vote share. Proceedings of the National Academy of Sciences. 2020;117(25):14052-14056. DOI: 10.1073/pneas.2007249117.
10. Dionne Jr. EJ, Rapoport M. A dozen ways to increase voting in the United States: Voting. Carnegie Corporation of New York. https://www.carnegie.org/our-work/article/dozen-ways-increase-voting-united-states/. September 12, 2022. Accessed November 7, 2022.
11. Newkirk II VR. What early voting in North Carolina actually reveals. The Atlantic. November 8, 2016. Available at: https://www.theatlantic.com/politics/archive/2016/11/north-carolina-early-voting/506963/ Accessed November 7, 2022.
12. The Leadership Conference Education Fund. The Great Poll Closure; 2016. Available at: http://civilrightsdocs.info/pdf/reports/2016/poll-closure-report-web.pdf.
13. Alvarez RM, Bailey D, Katz JN. The effect of voter identification laws on turnout. California Institute of Technology Social Science. 2008; Working Paper No.1267R; doi:10.2139/ssrn.1084598
14. Uggen C, Larson R, Shannon S, and Stewart R. Locked Out 2022: Estimates of People Denied Voting Rights. The Sentencing Project. Oct 25,2022. Available at: https://www.sentencingproject.org/publications/locked-out-2022- estimates-of-people-denied-voting-rights/.
15. Hunter D. Restoring the right to vote is a pathway to better health – a look at felon re-enfranchisement and the 2020 Election. The Network for Public Health Law. 2020. Available at: https://www.networkforphl.org/newsinsights/restoring-the-right-to-vote-is-a-pathway-to-better-health-a-look-at-felon-re-enfranchisement-and-the-2020- election/. Accessed November 4, 2022.
16. National Conference of State Legislatures. Felon voting rights. 2021. Available at: https://www.ncsl.org/research/elections-and-campaigns/felon-voting-rights.aspx. Accessed November 4, 2022.
17. Hajnal Z, Lajevardi N, Nielson L. Voter identification laws and the suppression of minority votes. Journal of Politics. 2017;79(2),363–379. https://doi.org/10.1086/688343
18. Flaxman S, Gaskins-Nathan K. The Untold Story of American Non-Voters. The Knight Foundation; 2016:68. Available at: https://knightfoundation.org/wp-content/uploads/2020/02/The-100-Million-Project_KF_Report_2020.pdf
19. Montanaro D. Poll: Despite Record Turnout, 80 Million Americans Didn't Vote. Here's Why. NPR. December 15, 2020. Available at: https://www.npr.org/2020/12/15/945031391/poll-despite-record-turnout-80-million-americansdidnt-vote-heres-why Accessed November 4, 2022.
20. The Leadership Conference on Civil and Human Rights. The Leadership Conference Urges Strong Implementation of Executive Order Promoting Voting Access. May 26, 2022. Available at: https://civilrightsdocs.info/pdf/policy/letters/2022/05262022LCCHR%20VR%20EO%20Letter.pdf. Accessed November 4, 2022
21. The United States Department of Justice. The National Voter Registration Act of 1993 (NVRA). Available at: https://www.justice.gov/crt/national-voter-registration-act-1993-nvra
22. Morris K, Dunphy P. AVR Impact on State Voter Registration. Brennan Center. 2019. Available at: https://www.brennancenter.org/our-work/research-reports/avr-impact-state-voter-registration Accessed November 3, 2022.
23. Nelson C, Sloan J, Chandra A. Examining Civic Engagement Links to Health: Findings from the Literature and Implications for a Culture of Health. RAND Corporation; 2019. Available at: https://www.rand.org/pubs/research_reports/RR3163.html
25. Ballard PJ, Hoyt LT, Pachucki MC. Impacts of adolescent and young adult civic engagement on health and socioeconomic status in adulthood. Child Dev. 2018;00(0):1–17. Available at: http://doi.wiley.com/10.1111/cdev.12998.
26. DeSilver, Drew. Turnout Soared in 2020 as Nearly Two-Thirds of Eligible U.S. Voters Cast Ballots for President. Pew Research Center, 28 Jan. 2021. Available at: https://pewrsr.ch/3oAN3MB. Accessed November 4, 2022.
27. Frey WH. Turnout in 2020 election spiked among both Democratic and Republican voting groups, New Census Data shows. Brookings. March 9, 2022. Available at: https://www.brookings.edu/research/turnout-in-2020-spikedamong-both-democratic-and-republican-voting-groups-new-census-data-shows/. Accessed November 4, 2022.
28. US Elections Project. 2020 November General Election Turnout Rates. 2020. Available at: http://www.electproject.org/2020g. Accessed November 4, 2022.
30. Ray R, Whitlock M. Setting the record straight on black voter turnout. Brookings. Available at: https://www.brookings.edu/blog/how-we-rise/2019/09/12/setting-the-record-straight-on-black-voter-turnout/. September 12, 2019. Accessed November 10, 2022.
31. Joint Center for Political and Economic Studies. 50 years of the Voting Rights Act: the state of race in politics. 2015. Available at: https://jointcenter.org/50-years-of-the-voting-rights-act-2/. Accessed November 4, 2022.
32. Alexander D. Why young people don’t vote, and why 2020 might be different. Johns Hopkins University. 2020. Available at: https://hub.jhu.edu/2020/10/20/mobilizing-youth-voters-scott-warren/. Accessed November 4, 2022.
33. Wang T. Ensuring Access to the Ballot for American Indians & Alaska Natives: New Solutions to Strengthen American Democracy. New York, NY: Demos; 2012. Figure 1. Available at: https://www.demos.org/sites/default/files/publications/IHS%20Report-Demos.pdf. Accessed November 4, 2022.
34. National Research Council. Civic Engagement and Social Cohesion: Measuring Dimensions of Social Capital to Inform Policy. Washington, DC: The National Academies Press; 2014. https://doi.org/10.17226/18831.
35. Anderson C, Durbin RJ. One Person, No Vote: How Voter Suppression Is Destroying Our Democracy. New York: Bloomsbury Publishing; 2019.
36. Hacker K, Houry D. Social needs and Social Determinants: The role of the Centers for Disease Control and Prevention and Public Health. Public Health Reports. 2022;137(6):1049-1052. doi:10.1177/00333549221120244
37. Health & Democracy Index. https://democracyindex.hdhp.us/.
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39. Klain H, Morris K, Ayala R, Feldman M. Waiting to vote: racial disparities in Election Day experiences. Brennan Center for Justice. 2020. Available at: https://www.brennancenter.org/our-work/research-reports/waiting-vote. Accessed November 4, 2022.
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41. Native American Rights Fund. Vote by mail in Native American communities. Available at: https://www.narf.org/vote-by-mail/. Accessed November 4, 2022.
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