LWVUS Submits Comments to HHS on Healthy People 2030 Objectives

LWVUS submitted public comments to the US Department of Health and Human Services (HHS) on the proposed Healthy People 2030 objectives. The League articulated why the objective to increase the proportion of the voting-age citizens who vote as a social determinant of health should be updated from a research objective to a core objective.

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December 2, 2022 

Paul Reed 
Deputy Assistant Secretary for Health and Director, Office of Disease Prevention and Health Promotion, RADM, US Public Health Service 
US Department of Health and Human Services 
Washington, DC 

Re: 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 

On behalf of the League of Women Voters of the United States (LWVUS), we write in response to the Department of Health and Human Services’ (HHS) Solicitation of Comments on Proposed Healthy People 2030 Objectives: Social Determinants of Health-NEW-07: Increase the proportion of the voting-age citizens who vote.  

The League is a century-seasoned, nonpartisan, nonprofit organization committed to protecting every person’s freedom to vote. We are a grassroots group comprised of more than 500,000 members and supporters across more than 750 local and state Leagues nationwide. The League focuses on advocacy, education, litigation, and organizing to achieve our mission to empower voters and defend democracy. Through our sister organization, the League of Women Voters Education Fund, we run Vote411.org, a one-stop shop for voter information, voter registration, and nonpartisan voter guides. 

The Healthy People framework is a roadmap for achieving national-level health goals over a 10-year span. The setting, measuring, and tracking progress on these goals advises health improvement planning across federal agencies. The objectives of Healthy People also inform the goal-setting process and priorities at state- and local-level health agencies and nonprofit hospital systems. We are pleased by the Office of Disease Prevention and Health Promotion’s (ODPHP) interest in promoting voter participation to a core objective in Healthy People 2030 and urge ODPHP to transition the measure from a research objective to a core objective as soon as possible. 

Evidence Included in This Comment 

In the following comments, we have included sources to support evidence. We request that the full text of our statement, and of the evidence and authority cited, including citations and corresponding links, be incorporated into the formal administrative record for purposes of the Administrative Procedure Act.  

Core Objective Criteria 

Voter Participation is of National Importance 

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 with more accessible voting policies and higher levels of civic participation are healthier across multiple public health measures. High levels of civic participation – including voter participation – help ensure that people in communities are connected, improving neighborhood cohesion, health outcomes, and community resilience. Voters show better future mental and physical health than non-voters, even after adjusting for various other factors. For communities in which voter turnout is historically lower, like Black, Latino, Asian American, Pacific Islander, and American Indian people, voter participation can be a game changer.

The 2020 election is an excellent example of how states implemented policies and programs that led to more inclusive access to voting opportunities, such as expanding and promoting mail voting and early voting options. Although the comprehensive policies resulted in historic voter turnout, approximately one-third of eligible Americans still did not cast a ballot. Additionally, disparities in voter turnout persist despite overall increases in voter participation.

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 crucial indicator of social cohesion and contributes to community social capital, we need to 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, and recognize the importance of voting as a matter of public health and equity.

Effective, Evidence-based Interventions to Improve Voter Participation 

Establishing evidence-based strategies to increase voter participation has been a focus of political scientists for decades. There is a growing body of evidence about policies and practices that can either bolster or hinder voter participation. Increasing voter turnout requires 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 the 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. An analysis driven by Healthy Democracy Healthy People in 2021 uses the COVI rankings to illustrate that various policies granting greater access to the ballot are positively associated with individual and community-level health indicators.

1. Addressing Structural and Systemic Barriers to Voting 
Policies such as increasing access to mail voting; increasing the window for early voting; expanding available polling locations and hours of operation to accommodate nontraditional schedules; and ending restrictive voter identification policies would go a long way toward ensuring community members have a direct say on policy decisions that affect their health. Voter identification laws have been shown to suppress voters from racial and ethnic minorities in both primary and general elections. Additionally, policies that disenfranchise people with felony convictions deny the right to vote to an estimated 4.6 million Americans who are currently or formerly incarcerated. These policies disproportionately affect Black Americans. Currently, only two states and the District of Columbia allow people with felony convictions to vote, including while incarcerated.

Structural barriers to political participation and power keep communities most impacted by inequities from effectively influencing critical decision-making processes. To address these disparities, Healthy People must focus on improving voter participation and access over the next decade. 

2. Enabling Inclusive Voter Registration

The most common reasons people do not vote are not being registered and needing to understand how to navigate the voting process. Eligible people are successfully registered to vote when they are offered active voter registration services. This includes being asked if they want to vote or 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.”  

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 interacting 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 the first step in increasing voter participation. According to the Brennan Center for Justice, states that have enacted AVR saw up to a 94% increase in voter registrations. 

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 and contact information for local elections offices, as well as by educating them on how to exercise their voting options. Additionally, states can ensure voters have more opportunities to register to vote by enacting same-day and Election Day voter registration policies. 

Reliable, Nationally Representative Data Source 

Public data on elections are readily available from four federally managed databases: The Current Population Survey (CPS), the US Census Bureau, the US Bureau of Labor Statistics, and the Election Administration and Voting Survey (EAVS). These data sources meet the two 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 two additional data points beyond the baseline during the decade.   

The CPS, the US Census Bureau, and the US Bureau of Labor Statistics are data sources HHS is using to measure the proportion of voting-age citizens who vote. The CPS election data has been included in the November supplement of election years since 1964. Therefore, it includes rich historical data. 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 is that they rely on self-report and proxy-reported data, which is known to inflate voter participation rates compared to actual ballots counted. Additionally, while these datasets include state-level metrics, they need 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 on voter registration, election infrastructure, and voter participation. This dataset can help ensure accurate voter turnout reports 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. One limitation of the EAVS is that it does not include population estimates such as age, sex, race, or ethnicity for those who voted. To ensure the most accurate voting data is used, Healthy People 2030 can combine population estimates from the CPS, US Census Bureau, and the US 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. 

These data sources meet the two criteria for inclusion as a core objective in Healthy People 2030. The EAVS includes baseline data from 2016, 2018, and 2020 and will soon have 2022 data available, with most counties consistently submitting the survey instrument. The CPS, US Census Bureau, and the US Bureau of Labor Statistics all include annual questions in their national population surveys about voter participation. 

Data to Help Address Disparities and Achieve Health Equity 

Over the last few decades, 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 formed through policies. Policy campaigns that address health outcomes and social determinants of health require managing the political environment. Within a fully functioning democracy, policy decisions are directly and indirectly determined through elections. Decisions made now 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. Black, Latino, and American Indian voters face heightened barriers when voting and participating in our democracy as they are more likely to experience longer polling lines, are disproportionately burdened by stringent voter identification laws, 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. Additionally, 15% of Black voters and 14% of Latino voters had trouble finding their polling locations compared to only 5% of white voters.  

Voters with disabilities face numerous challenges to voting. Americans with disabilities were 7% less likely to vote than people without disabilities in the 2020 election, even after adjusting for age. In 2020, voters with disabilities were also nearly twice as likely as nondisabled voters to experience problems when voting, and one in nine voters with disabilities faced barriers accessing the ballot box. During the 2020 election, people with vision and cognitive impairments were especially likely to face obstacles, accounting for roughly 7 million and 13.1 million eligible voters, respectively.

Recommendation 

The League of Women Voters of the United States encourages Healthy People 2030 to transition voter participation rates to a core objective. The above evidence demonstrates that voter participation meets the criteria for inclusion as a core objective in the Healthy People framework. 

Sincerely, 

Virginia Kase Solomón 

CEO