Health & Democracy Index

When communities vote they influence policy decisions that have a big effect on their health.

This analysis compares 12 public health indicators and voter turnout to the restrictiveness of voting policies in each state.

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Overall Findings: More Voting Access, Better Health Outcomes

States with more inclusive voting policies and greater levels of civic participation are healthier.

Less Voting Access, Worse Health Outcomes

States with exclusionary voting laws and lower levels of civic participation are less healthy.

What Changed? After 2020, in general, public health indicators showed improvement across the board.

Most notably, every single state showed an improvement in Self-Rated Health, and a majority of states (32) showed an improvement in Mental Health. All but one state showed a decline in the percent uninsured.

The Connection: Voting Policy & Public Health

Voting policies shape our ability to participate in elections and be represented on decisions important to us as individuals and communities. States that make elections more accessible through policies like automatic and same day registration, non-strict voter ID requirements, felon re-enfranchisement and mail voting options enjoy higher levels of voter participation and stronger public health outcomes. States that have more barriers to voting—and lower rates of voter participation—have worse public health outcomes.

Why this matters: communities with more inclusive voting policies enjoy greater social cohesion, improved community conditions, and better health.

Inclusive Registration: Includes automatic voter registration, same day, and election day registration

Vote at Home: Includes all mail elections and states with no-excuse absentee voting

Restrictive Voter ID: States that require additional documentation at the polls, such as photo ID, even after voters have already established their eligibility.

Voting Rights Restoration: Includes states where rights are not lost after a felony conviction or rights are restored post-incarceration.

Healthy People Vote: Voting Takes Time, Focus and Energy

When people feel healthier and more connected to their neighbors they feel valued and are more likely to vote and engage in other aspects of community life. Being healthy means people can physically vote and have the time and energy to follow voting processes and make voting decisions. Policies that make voting locations more accessible and allow voting from home help people with health challenges cast ballots.

Barriers Harm Health: Voting Disparities and Health Disparities are Linked

Some of the same barriers to health are barriers to voting, including structural inequities in transportation, language access, broadband access, and accessible spaces. Communities that face these barriers may have a lack of social inclusion, reduced sense of belonging, and less access to health resources, which are all associated with worse health outcomes, from higher infant mortality rates to greater risk of chronic disease.

These barriers can become a self-reinforcing feedback loop: people who are experiencing poor health are less likely to vote, and people who don’t vote are more likely to report that they have poor health. This tends to impact people with low incomes and lower education levels, and people of color more than other population groups. The practical result is an underrepresentation of these communities in important policy decisions that shape health and wellbeing.

Thankfully, higher levels of civic participation can mitigate these disparities. For instance, rates of infant mortality are higher among Black and American Indian communities than white communities, but this disparity shrinks for all racial and ethnic groups in states that have better civic health and voter participation.

Looking at the States: Colorado has inclusive policies and strong public health outcomes.

  • Automatic voter registration
  • Vote by Mail
  • Non-restrictive Voter ID
  • Voting Rights Restoration

Explore state-by-state results on civic participation and public health.

Looking at the States: Tennessee has exclusive policies and relatively weak public health outcomes.

  • Restrictive voter registration
  • Restrictive voter ID
  • Felon disenfranchisement
  • Limited vote by mail

Explore state-by-state results on civic participation and public health.

Policy Action:Closing the Gap

Leaders can close the civic participation with more inclusive rules and policies, for instance, with automatic voter registration at the DMV, through Medicaid sign-ups and other services. There is a growing commitment to strengthen civic health and voter participation as evidenced by recent positions taken by multiple public health organizations:

American Medical Association: Support for Safe and Equitable Access to Voting

American Public Health Association: Advancing Health Equity through Protecting and Promoting Access to Voting

Society for Public Health Education: Voter Registration and Participation Resolution

County Health Rankings & Roadmaps: 2023 National Findings Report Cultivating Civic Infrastructure and Participation for Healthier Communities

Healthy People 2030: Increase the proportion of the voting-age citizens who vote — SDOH‑07

Explore:

Select a public health metric to see how it correlates to voting access across states.

This is the percentage of adults reporting that their health is good or better when asked “How is your general health?” People who report fair or poor health are less likely to vote, but people who have good or better health are more likely to vote. Higher is better.

See this information in an interactive table.

Explore:

See state-by-state results on civic participation and public health.

See this data in an interactive table.

What We Can Do

These findings underscore the importance of promoting a healthy and inclusive democracy to assure the conditions for all people to be healthy.

Policymakers can promote health and wellbeing by making it easier for voters to register or update their registration through a variety of programs and services. Additionally, building upon the adoption of voter participation as a core objective in Healthy People 2030, state and local health departments can include civic and voter participation in their health improvement plans and in their health education and outreach campaigns.

Individuals can promote health in their community by ensuring they participate in every election, and help others register to vote and cast ballots.

Institutions can also promote local, state and national health goals, remind people of upcoming elections, promote the relationship between health and voting, and join partnerships and programs to promote civic participation.

Learn more about our recommended policies.

Conclusion: The Link Between Public Health and Civic Participation

There are many aspects of public health policy that are directly linked to civic participation. For instance, in some states, voters have been able to adopt Medicaid expansion by ballot initiative. At the local level, voters also have significant input on spending and programs for green spaces, schools, public transit and other infrastructure that improves public health.

More broadly, voting is an important way that we build social inclusion and belonging as communities. Elections are the largest public events we hold nationally. Higher rates of community participation and social contact are linked to higher rates of civic participation and better public health outcomes.

Further, laws that make voting accessible make voting easier for people with different abilities. This includes accounting for the location and physical accessibility of polling sites and equipment, language, and assistance with casting a ballot.

For more information, please see Methods for this analysis, including additional references and resources. This data is also available in a detailed, interactive table.

AL

  • Voter Turnout 62%
  • Cost of Voting Index 39 / 50
  • Premature Mortality 48 / 50
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AK

  • Voter Turnout 68%
  • Cost of Voting Index 36 / 50
  • Premature Mortality 37 / 50
  • More Detail

AZ

  • Voter Turnout 69%
  • Cost of Voting Index 30 / 50
  • Premature Mortality 24 / 50
  • More Detail

AR

  • Voter Turnout 57%
  • Cost of Voting Index 42 / 50
  • Premature Mortality 44 / 50
  • More Detail

CA

  • Voter Turnout 69%
  • Cost of Voting Index 10 / 50
  • Premature Mortality 1 / 50
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CO

  • Voter Turnout 78%
  • Cost of Voting Index 7 / 50
  • Premature Mortality 11 / 50
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CT

  • Voter Turnout 71%
  • Cost of Voting Index 20 / 50
  • Premature Mortality 7 / 50
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DE

  • Voter Turnout 70%
  • Cost of Voting Index 33 / 50
  • Premature Mortality 36 / 50
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FL

  • Voter Turnout 72%
  • Cost of Voting Index 40 / 50
  • Premature Mortality 27 / 50
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GA

  • Voter Turnout 68%
  • Cost of Voting Index 49 / 50
  • Premature Mortality 35 / 50
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HI

  • Voter Turnout 56%
  • Cost of Voting Index 6 / 50
  • Premature Mortality 9 / 50
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ID

  • Voter Turnout 68%
  • Cost of Voting Index 18 / 50
  • Premature Mortality 10 / 50
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IL

  • Voter Turnout 66%
  • Cost of Voting Index 4 / 50
  • Premature Mortality 20 / 50
  • More Detail

IN

  • Voter Turnout 62%
  • Cost of Voting Index 41 / 50
  • Premature Mortality 38 / 50
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IA

  • Voter Turnout 73%
  • Cost of Voting Index 24 / 50
  • Premature Mortality 19 / 50
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KS

  • Voter Turnout 66%
  • Cost of Voting Index 38 / 50
  • Premature Mortality 26 / 50
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KY

  • Voter Turnout 65%
  • Cost of Voting Index 43 / 50
  • Premature Mortality 45 / 50
  • More Detail

LA

  • Voter Turnout 64%
  • Cost of Voting Index 27 / 50
  • Premature Mortality 47 / 50
  • More Detail

ME

  • Voter Turnout 76%
  • Cost of Voting Index 14 / 50
  • Premature Mortality 23 / 50
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MD

  • Voter Turnout 70%
  • Cost of Voting Index 5 / 50
  • Premature Mortality 29 / 50
  • More Detail

MA

  • Voter Turnout 71%
  • Cost of Voting Index 11 / 50
  • Premature Mortality 4 / 50
  • More Detail

MI

  • Voter Turnout 74%
  • Cost of Voting Index 13 / 50
  • Premature Mortality 32 / 50
  • More Detail

MN

  • Voter Turnout 80%
  • Cost of Voting Index 15 / 50
  • Premature Mortality 2 / 50
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MS

  • Voter Turnout 60%
  • Cost of Voting Index 47 / 50
  • Premature Mortality 49 / 50
  • More Detail

MO

  • Voter Turnout 66%
  • Cost of Voting Index 48 / 50
  • Premature Mortality 40 / 50
  • More Detail

MT

  • Voter Turnout 73%
  • Cost of Voting Index 21 / 50
  • Premature Mortality 28 / 50
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NE

  • Voter Turnout 70%
  • Cost of Voting Index 22 / 50
  • Premature Mortality 15 / 50
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NV

  • Voter Turnout 66%
  • Cost of Voting Index 28 / 50
  • Premature Mortality 25 / 50
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NH

  • Voter Turnout 75%
  • Cost of Voting Index 45 / 50
  • Premature Mortality 16 / 50
  • More Detail

NJ

  • Voter Turnout 72%
  • Cost of Voting Index 16 / 50
  • Premature Mortality 8 / 50
  • More Detail

NM

  • Voter Turnout 61%
  • Cost of Voting Index 31 / 50
  • Premature Mortality 43 / 50
  • More Detail

NY

  • Voter Turnout 61%
  • Cost of Voting Index 17 / 50
  • Premature Mortality 3 / 50
  • More Detail

NC

  • Voter Turnout 73%
  • Cost of Voting Index 23 / 50
  • Premature Mortality 34 / 50
  • More Detail

ND

  • Voter Turnout 63%
  • Cost of Voting Index 8 / 50
  • Premature Mortality 22 / 50
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OH

  • Voter Turnout 67%
  • Cost of Voting Index 34 / 50
  • Premature Mortality 39 / 50
  • More Detail

OK

  • Voter Turnout 55%
  • Cost of Voting Index 37 / 50
  • Premature Mortality 42 / 50
  • More Detail

OR

  • Voter Turnout 76%
  • Cost of Voting Index 1 / 50
  • Premature Mortality 12 / 50
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PA

  • Voter Turnout 70%
  • Cost of Voting Index 32 / 50
  • Premature Mortality 30 / 50
  • More Detail

RI

  • Voter Turnout 63%
  • Cost of Voting Index 19 / 50
  • Premature Mortality 13 / 50
  • More Detail

SC

  • Voter Turnout 66%
  • Cost of Voting Index 44 / 50
  • Premature Mortality 41 / 50
  • More Detail

SD

  • Voter Turnout 66%
  • Cost of Voting Index 29 / 50
  • Premature Mortality 31 / 50
  • More Detail

TN

  • Voter Turnout 60%
  • Cost of Voting Index 46 / 50
  • Premature Mortality 46 / 50
  • More Detail

TX

  • Voter Turnout 61%
  • Cost of Voting Index 50 / 50
  • Premature Mortality 21 / 50
  • More Detail

UT

  • Voter Turnout 69%
  • Cost of Voting Index 3 / 50
  • Premature Mortality 6 / 50
  • More Detail

VT

  • Voter Turnout 72%
  • Cost of Voting Index 9 / 50
  • Premature Mortality 14 / 50
  • More Detail

VA

  • Voter Turnout 73%
  • Cost of Voting Index 12 / 50
  • Premature Mortality 18 / 50
  • More Detail

WV

  • Voter Turnout 57%
  • Cost of Voting Index 35 / 50
  • Premature Mortality 50 / 50
  • More Detail

WI

  • Voter Turnout 75%
  • Cost of Voting Index 25 / 50
  • Premature Mortality 17 / 50
  • More Detail

WY

  • Voter Turnout 65%
  • Cost of Voting Index 26 / 50
  • Premature Mortality 33 / 50
  • More Detail