Voting Policy and Health: Evidence as a Call to Action for Health Professionals, Organizations, and Institutions

Political scientists have long studied the relationship between healthy people and voter participation, finding that people with better health outcomes are more civically engaged.¹ However, more recently, researchers in both political science and public health have begun to analyze the related connection between underlying voting policies and health outcomes. Simply put, do communities have better health outcomes in states with less restrictive voting policies? And is the opposite also true – do communities have worse health outcomes in states with more restrictive voting policies?

These studies have found a correlation between state voting policies that either promote or hinder participation and a variety of health outcomes, including health insurance access, COVID outcomes, overall health, working-age mortality, life expectancy, and infant mortality. This literature review discusses recent evidence on the relationship between electoral policy and health outcomes. This growing understanding suggests that an inclusive and representative democracy might be an important contributor to public health.

In light of this evidence, this review also offers actionable ways health professionals can be champions for an inclusive and representative democracy. Leading health organizations and institutions such as Healthy People 2030,² the American Public Health Association,³ the American Medical Association,⁴ and County Health Rankings & Roadmaps have already recognized⁵ voter access as a pathway for advancing health equity. As these organizations have recognized, health systems, institutions, and organizations are uniquely positioned to highlight this link, facilitate further research into this question, and engage communities that often face barriers in the voting process.

Evidence

Research on the connection between voting policies and health outcomes has developed substantially over the past four years.

In 2021, an article in the medical journal The Lancet by Pabayo, Liu, Grinshteyn, Cook, & Muennig first explored the connection between policy and health outcomes. Their study found that in states with more restrictive voting policies, people with lower incomes, racial minorities, and young people were also less likely to have health insurance.⁶ The study also found that insurance rates for wealthier, white, and older populations did not vary across states. These findings provide evidence that communities most impacted by restrictive voting policies – lower income individuals, racial minorities, and young populations – also have less access to care. The study used the Cost of Voting Index (COVI)⁷ to measure electoral restrictions and survey data to measure individual health insurance access.

While these findings suggest that addressing barriers to voting could be associated with lowering uninsured rates, the study was limited in a few key ways. The study only identifies a correlation and does not establish a causal link between voting restrictions and lower insurance rates for the most heavily impacted populations. Additionally, the researchers used telephone survey data for health insurance rates, which can pose issues with response bias, as the population answering phone calls may not be fully representative. This survey data also did not include questions about people’s voting behavior, so it was not possible, for example, to assess if a state’s voting policies impacted individual voting behaviors related to healthcare, such as voting for governments that make health insurance more accessible. While these limitations are important to understand, these findings represented the first real attempt to unpack the relationship between policies that make it easier to vote and health insurance access.

In 2022, several of the same authors further explored this question about the relationship between voting policies and health outcomes. Pabayo, Grinshteyn, Steele et al., analyzed the association between state voting policies and COVID-19 case and mortality rates at the county level.⁸ This study found that the relative restrictiveness of electoral policies in a state was correlated with higher county COVID-19 cases and mortality rates from January 2020 to March 2021 – the period before vaccines were readily available. Additionally, the researchers found that lower income communities faced more barriers to voting than higher income communities and experienced a larger burden of the pandemic in terms of COVID-19 death rates.

The study controlled for a wide range of factors such as the county’s political leanings, median income, age, and population density. The study did not explore the related connection with race, and the researchers also cited the need for racial data for COVID outcomes to better explore this relationship.

In 2023, Schraufnagle likewise found a consistent relationship between state electoral policies and state health over the last twenty-five years.⁹ Relying on the America’s Health Rankings (AHR)¹⁰ state composite score to measure overall state health and the COVI to measure electoral access, the research found that as state COVI scores changed over time there were corresponding changes in state health scores in the AHR. This study provides further evidence that state electoral policies are associated with community health and that this relationship is stable across time.

Unlike the previous studies which are focused on a single point in time, this study looked at results over time, adopting a longitudinal approach. However, even with a longitudinal time-series approach, the author was unable to unpack competing theoretical arguments to determine a causal pathway between health outcomes and voting policies. The author suggested future research should examine this relationship across a single state that had increased the relative cost of voting over the last several years and could use additional methodologies that examine in more detail the voting policies and health outcomes in a particular state.

Looking more broadly beyond the connection between voting policies and health outcomes, a 2022 study by Pacheco and LaCombe looked at the related role of state institutions and population health.¹¹ They defined two categories of state institutions, those that promote political accountability and those that promote checks and balances. Institutions that promote political accountability were defined as campaign finance laws, laws that make it easier to register and vote during elections, laws that make it easier for citizens to communicate their preferences like ballot initiatives and referenda, and staffing, pay, and resources that enable legislators to learn about the conditions in their districts. Institutions that enable a system of checks and balances were defined as consensus-oriented institutions like the level of professionalism of state legislatures which either enables or hinders the body’s ability to propose, pass, and enact new legislation without external influences.

Hypothesizing that states with greater political accountability and checks and balances would enact laws that are responsive to community health needs, the study compared state institutional and electoral data from 1975 to 2016 across all 50 states to infant mortality rates, life expectancy, and midlife all-cause mortality. The study found that states with institutions that promote political accountability are associated with lower infant mortality rates than states with institutions that do not promote political accountability. Similarly, states with institutions that promote checks and balances are associated with longer life expectancies than states with institutions that do not promote checks and balances. While voter access is not a central focus of this paper, the findings showed that political accountability, which included several indicators of voter access, was associated with population health at the state level. However, the study was not able to fully account for other explanatory variables, such as party control and policy liberalism, which could potentially explain both observed outcomes.

The most recent paper to confirm the link between voting access and health outcomes is Rushovich et al.’s 2024 study on the impact of the Voting Rights Act of 1965 (VRA) on infant mortality rates.¹² This study makes the strongest causal argument that voting rights have a clear connection to health and racial equity. Between 1965 and 2013, the VRA required certain “covered” counties with a history of discrimination to submit all electoral changes to the Department of Justice or a federal court for “preclearance” approval before these changes could take effect. A comparison of infant mortality rates between covered and uncovered jurisdictions found that counties covered by the preclearance clause of the VRA experienced an average 11.4% decrease in Black infant deaths beyond those experienced by counties not covered by the VRA. Additionally, the study found that there were 20% fewer Black infant deaths than would have been expected in the absence of the VRA. However, VRA coverage did not impact white infant death rates.

The study was limited by the assumption that the underlying population in the observed counties did not change across the study period (1965-2021), but this was controlled for using population counts as a variable. The study was also limited by the accuracy of infant death records which have been shown to be undercounted for Black infants and rural and impoverished areas. Additionally, a potential alternative explanation is that hospital systems were desegregated in 1966, one year after the passage of the VRA. The researchers included a variable to indicate whether a county had at least one desegregated hospital to control for this limitation. In addition, the long time period included in this study is another limitation. It is unknown if the relevant portion of the VRA, which was enacted in 1965 and struck down by the Supreme Court in 2013, would still affect all groups equally in the study’s post-treatment time-period (2014-2021). Nevertheless, while the study has some important limitations, it does appear to show that the VRA produced improvements in health outcomes for Black Americans and underscores the importance of better understanding how contemporary changes to electoral policies are related to health and racial equity.

What Health Professionals Can Do

With this growing body of research in mind, policymakers and individuals working in the health sector should consider several common sense actions to further develop the link between increased voter access and improved health outcomes.

1. Public health researchers must continue to study the relationship between electoral policies and health outcomes. Future research should continue to unpack this relationship by using quantitative and qualitative measures, focusing on states that have made changes to their electoral policies, and disaggregating data across racial groups.
2. Governmental health institutions can make this research easier by accurately measuring voter registration and participation in state health assessments and health impact reports, using the principles of Healthy People 2030,¹³ a data-driven federal campaign to improve health outcomes. For example, the 2024 Minnesota State Health Assessment includes data on voter participation, highlighting that while the state has high statewide voter participation, gaps still exist across age, income, geography, and racial minorities — groups that also experience the greatest health inequities. By incorporating voting into these public health databases, this data makes it easier for public health researchers to study the relationship between health outcomes and electoral policies. This data also showcases that there is more that can be done to encourage inclusive civic and voter participation, providing evidence to future electoral reforms.
3. Health professionals and their organizations can support community driven efforts to change electoral policies to automatically register eligible people to vote¹⁴ and to make casting a ballot easier. Relying on the evidence discussed, health professionals can serve as trusted messengers on health outcomes and point to the potential link between democracy and health through letters to lawmakers and providing testimony in hearings.

<sup>1. Nelson, C., Sloan, J., & Chandra, A. (2019a). Examining Civic Engagement Links to Health: Findings from the Literature and Implications for a Culture of Health. RAND Corporation.
2. Department of Health and Human Services Office of Disease Prevention and Health Promotion. (2023, June 27). SDOH-R02 Recategorized to Healthy People 2030 Core Objective – News & Events | health.gov. Health.gov. https://www.health.gov/news/202306/sdoh-r02-recategorized-healthy-people-2030-core-objective#:~:text=The%20Healthy%20People%20initiative%20has
3. American Public Health Association. (2022). Advancing Health Equity through Protecting and Promoting Access to Voting. Www.apha.org.
https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2023/01/18/Access-to-Voting
4. American Medical Association. (2022). Policy Finder | AMA. Policysearch.ama-Assn.org. https://policysearch.ama-assn.org/policyfinder/detail/voting?uri=%2FAMADoc%2FHOD.xml-h-440.805.xml
5. University of Wisconsin’s Population Health Institute. (2023). 2023 County Health Rankings National Findings Report. County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/reports/2023-county-health-rankings-national-findings-report
6. Pabayo, R., Liu, S. Y., Grinshteyn, E., Cook, D. M., & Muennig, P. (2021). Barriers to Voting and Access to Health Insurance Among US Adults: A Cross-Sectional Study. The Lancet Regional Health – Americas, 2, 100026. https://doi.org/10.1016/j.lana.2021.100026
7. The Cost of Voting Index (COVI; Schraufnagel & Pomante, 2020) has recently become a focus of researchers aiming to better understand how election policies at the state level are associated with population health. The COVI, originally established in 1996, measures the relative restrictiveness of state voting laws and policies using a principle component analysis (PCA). PCA is a method of transforming a large set of variables (such as state election policies) into a smaller one (such as an index score or ranking). The 2020 COVI uses nine components covering policies related to registering to vote and casting a ballot. All of these components are combined into a single index score and states are then ranked from easiest to vote (1, Oregon) to hardest to vote (50, Texas).
8. Pabayo, R., Grinshteyn, E., Steele, B., Cook, D. M., Muennig, P., & Liu, S. Y. (2022). The relationship between voting restrictions and COVID-19 case and mortality rates between US counties. PLOS ONE, 17(6), e0267738. https://doi.org/10.1371/journal.pone.0267738
9. ​​Schraufnagel, S. (2023). Voting Restrictions and Public Health: An Analysis of State Variation 1996–2020. State and Local Government Review. https://doi.org/10.1177/0160323×231202421
10. AHR is the longest running analysis of health in the United States, analyzing over 280 unique measures from more than 80 public data sources. The AHR’s composite score is a ranking determined by a combination of the health measures and, similar to the COVI, states are ranked from healthiest to least healthy.
11. Pacheco, J., & LaCombe, S. (2022). The Link between Democratic Institutions and Population Health in the American States. Journal of Health Politics, Policy and Law. https://doi.org/10.1215/03616878-9978103
12. Rushovich, T., Nethery, R. C., White, A., & Krieger, N. (2024). 1965 US Voting Rights Act Impact on Black and Black Versus White Infant Death Rates in Jim Crow States, 1959–1980 and 2017–2021. American Journal of Public Health, e1–e9. https://doi.org/10.2105/ajph.2023.307518
13. Department of Health and Human Services Office of Disease Prevention and Health Promotion. (2023, June 27). SDOH-R02 Recategorized to Healthy People 2030 Core Objective – News & Events | health.gov. Health.gov. https://www.health.gov/news/202306/sdoh-r02-recategorized-healthy-people-2030-core-objective#:~:text=The%20Healthy%20People%20initiative%20has
14. Institute for Responsive Government. (n.d.). Automatic Voter Registration. Institute for Responsive Government. Retrieved September 19, 2024, from https://responsivegov.org/automatic-voter-registration/</sup>