Upstream Advocacy: Family Medicine Promotion of Voting

When I was growing up, my parents role-modeled voting every election in November. As Vietnamese refugees who fled their homeland when it fell to Communism, they took their American right to vote seriously, teaching their children to value this opportunity to choose their leaders.

As I advanced in my medical training and observed patients deciding how to spend their money among rent, food, and medication, I realized that social determinants influenced health outcomes, and civic engagement could impact legislators and policy. Because family physicians see patients in different settings and life stages, we can advocate for policies that improve community health by promoting voting.

Because elected leaders develop legislation that impacts health care access and services, voting is essential. One important example of how the legislative branch of the American government affects health is the Affordable Care Act (ACA), which has defined essential benefits, prevented discrimination against people with preexisting conditions from having insurance, and reduced the number of uninsured. However, state-elected officials prevented the full enactment of the ACA by challenging the expansion of Medicaid. Due to a ruling by the Supreme Court justices that the executive branch nominated and the legislative branch confirmed, states did not have to expand Medicaid coverage as part of the ACA. To date, 10 states have opted out. ¹ Recent studies have unequivocally demonstrated the profound impact of Medicaid expansion on public health. This expansion is associated with reduced cancer mortality, improved diabetes self-management, and decreased postpartum hospitalizations, underscoring the critical role of policy decisions in shaping health outcomes. ^2- 4

Another significant example of legislators’ impact on health care access is reproductive health. After the Texas state legislature passed abortion restrictions that went into effect on September 1, 2021, infant mortality in Texas increased with a disproportionate impact on children of color. ⁵ States that restricted abortion coverage to federal minimum requirements had a higher median rate of adolescent births, preterm births, short interpregnancy interval births, and low-weight births than states that provided comprehensive abortion coverage. ⁶

Additionally, reproductive health policy impacts physicians in training. Because trainees are often of reproductive age, they are considering abortion access for their patients, themselves, and their loved ones in residency application decisions. ^{7, 8} States with abortion bans have observed decreases in residency applicants. ^{9, 10} Because about 66% of family physicians practice in the state where they complete residency, ¹¹ an applicant decrease could worsen physician-to-patient ratios, particularly in states already facing health disparities.

Although many physicians agree that participating in civic engagement is an essential aspect of professionalism, ^12-15 they are less likely to vote than the general population. ^{16, 17} Researchers have hypothesized that this could be due to physicians viewing clinical work as having great social focus and satisfaction, time pressures, medical school selection of individuals less inclined toward civic participation, and medical training leading to the perception of voting in conflict with professional duties. ¹⁶ Family physicians and educators can facilitate civic engagement and help patients and communities be healthy by supporting voter registration and turnout within their own networks.

People who vote report better subjective health. ¹⁸ However, only 37% of adult citizens voted in the United States in 2018, 2020, and 2022. ¹⁹ In a scoping review, Brown et al described the relationship between voting and health, finding that those with worse health tend to vote less frequently and that differences in voter participation due to social, economic, and health inequities significantly affect electoral outcomes. ²⁰ People who are White and those on the higher end of the socioeconomic scale are more likely to vote and have better health than those who are not White and at the lower end of this scale. ^{19, 20}

Studies have examined the relationship between health disparity and voting. In Brazil, improving voting technology promoted the enfranchisement mainly of less-educated voters. This improvement was associated with increased health spending, which increased prenatal visits and reduced the number of low-weight births by less educated mothers. ²¹ Recently, researchers found that the passage of the Voting Rights Act in 1965 was associated with significant reductions in Black infant deaths in Southern counties. ²² Thus, family physicians interested in improving public health and health equity should encourage eligible patients to vote.

Family physicians and educators can promote civic engagement in many ways. First, they can support nonpartisan voter registration efforts. This support could involve organizing voter registration during trainee orientations, before or after classes or didactics, and during grand rounds when learners and faculty are on-site. Promoting civic engagement also could include organizing voter registration within health care facilities. ^{23, 24, 25} Any office providing public assistance, such as Medicaid services, can offer nonpartisan voter registration services under Section 7 of the National Voting Rights Act (NVRA). ^{26, 27} Resources are available through nonprofit, nonpartisan organizations such as the Civic Health Alliance (https://www.civichealthalliance.org) and Vot-ER (https://vot-er.org). Registering people to vote in health care-based settings can reach a younger and more ethnically diverse population than those who report contact from political campaigns. ²⁸

Second, family physicians and educators can support voter outreach. As election dates grow closer, voter registration efforts can provide information about election dates and absentee ballots, reminding people about early voting, absentee voting, and election day. Department chairs and deans can encourage people to vote. Graduate medical education faculty can ensure that residents have time off and patient care coverage to vote. These steps can reinforce lessons on civic health as a nonmedical driver of health and advocate for policies that strengthen opportunities for everyone to live healthy lives. 

Third, family physicians and educators can support voter protection. Health care workers are community members who often have jobs with paid leave, so organizations could provide staff with paid leave to work at polling locations. Municipalities need poll workers to enfranchise voters. The more fully staffed and functioning locations there are, the more convenient options voters have and the shorter the wait for in-person voting. Other options to protect voter enfranchisement include volunteering for voter protection hotlines or poll watching to ensure citizens can vote without interference.

Family physicians and educators are trusted messengers who can promote civic engagement through nonpartisan voter registration, outreach, and protection in clinical learning environments. Regardless of political affiliation, voting is an upstream way to influence policy that works toward reducing health disparities and improving health equity. Against this backdrop, I will continue my parents’ legacy by registering learners and patients, reminding people about election dates, and voting early. Advocating for healthy people and communities through civic engagement is essential to our professional commitment as family physicians.