Health & Democracy Index

Methods

This analysis compares 12 public health indicators and voter turnout to the Cost of Voting Index for U.S. states for the 2020 general election. All indicators and measures were selected based on an analysis of published literature linking civic participation and health. First published in 2021, the Health & Democracy Index was updated in October 2023 to include the most current available data for the selected health indicators (described below).

Civic Participation

Cost of Voting in the American States: 2020

The Cost of Voting Index (COVI) was developed by political science researchers at Northern Illinois University and was first published in 2016 as an analysis of the relative cost of voting in presidential election cycles from 1996-2016. The cost of voting refers to the time and effort associated with casting a vote and is intended to characterize the overall electoral climate in each state or, in other words, the extent to which each state embraces inclusivity in the electoral process versus restriction or exclusion.

The 2020 COVI is constructed from nine issue areas, including:

• Registration deadlines
• Registration restrictions, such as no online voter registration
• Registration drive restrictions, such as training required by the state
• Pre-registration laws for 16 and 17 year olds
• Automatic voter registration
• Voting inconvenience, such as excuse required to vote absentee
• Voter ID laws
• Poll hours
• Early voting

When the Health & Democracy Index was first published, it used the 2020 COVI. Subsequent research has shown a strong association between the COVI in an election year and health outcomes in the following year. Therefore, this updated analysis maintains the 2020 COVI but uses 2021 health data where available.

Voter turnout

This is one of the most common measures of civic engagement in the literature reviewed. It is the percent of eligible voters who cast a vote in a given election. This matters because participation in elections shapes policy. This analysis uses turnout data from the most recent general election in 2020, as reported by the non-partisan U.S. Elections Project.

Health Outcomes

The public health indicators selected include individual health measures as well as factors that influence health outcomes, also known as determinants of health. Indicators are only included if there is an evidence-based link between an indicator and civic engagement (most commonly measured as voter turnout). The 12 indicators are described below. The data have been standardized for graphical representation.

Individual and Community Health

• Self-rated health. 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.
• Self-rated mental health. This is the average number of poor mental health days reported in the last 30 days. People with poor mental health are less likely to vote. Lower is better.
• Adults receiving disability benefits. This is the percentage of adults 18-64 receiving Social Security Disability Insurance (SSDI) payments. This tells us about economic stability for workers with disabilities and also helps us understand labor force participation rates in each state. People with disabilities tend to vote at lower rates than people without disabilities. Lower is better.
• Premature mortality. This analysis uses a state ranking based on years of potential life lost (YPLL) before age 75. Many premature deaths are preventable. People of color are at higher risk for premature death, and there is some evidence linking this to lost votes over time resulting in significant voting disparities. Lower is better (1 is the best, 50 is the worst).
• Infant mortality. This is the rate of infants dying within the first year of life. It is a common measure of public health worldwide, and tells us about access to and quality of healthcare in a community. Lower is better.
• Chronic disease prevalence. This analysis uses the percentage of adults who report having 3 or more chronic conditions. People with chronic conditions may vote at lower rates than people without chronic conditions. Having multiple chronic conditions also affects the risk of mortality. Lower is better.
• Active physicians per capita. This is the total number of active physicians of all types per 100,000 population. It tells us about access to health care in a population. People who are healthier are more likely to vote, and access to care is one way that people can obtain and maintain good health. Higher is better.
• Uninsured. This is the percentage of people reporting not having health insurance coverage. Lack of coverage is associated with increased risk of chronic disease and mortality and delayed access to care. Lower is better.
• Overall health. This is a composite measure of weighted z-scores for each state calculated by America’s Health Rankings, and is a relative measure of population health in each state. Better health is associated with higher voter participation. Higher is better.

Other Factors

• Poverty. This analysis uses the percent of households below the federal poverty line. This matters because people with lower incomes vote at lower rates than people with higher incomes, and experience worse health outcomes across a number of health indicators. Lower is better.
• Community and Family Safety.  This analysis uses a state ranking that is a composite of several measures related to social and economic factors that influence community and family safety, including economic resources and violence. This matters because people who live in neighborhoods with greater safety are more engaged in their community and vote at higher rates. Lower is better (1 is the best, 50 is the worst).
• Gini index. This is a commonly used measure of income inequality. It tells us the extent to which the income distribution in a given area does not show perfect equality, and it matters because greater economic inclusion leads to greater economic growth and stability. Lower is better.

Indicators and Data Sources

• Voter Turnout (2020 General Election)—The United States Elections Project
• State-level voting policies—The National Conference of State Legislatures
• Self-rated Health, Self-rated Mental Health / poor mental health days, Uninsured Rate (All data from 2021, previously 2019)-Behavioral Risk Factor Surveillance System (BRFSS)
• Overall Health, Multiple Chronic Conditions, Premature Mortality, Community and Family Safety (All data from 2021, previously 2019)-America's Health Rankings
• Active Physicians per 100,000 population (2020, previously 2018)—Association of American Medical Colleges (AAMC), State Physician Workforce Data Report
• Infant Mortality (2020, previously 2018)—National Vital Statistics Reports (CDC)
• Annual Statistical Report on the Social Security Disability Insurance Program (2021, previously 2019)—Social Security Administration, Office of Retirement and Disability Policy
• Gini Index of Income Inequality (2021, 1-year estimate, previously 2019)—U.S. Census Bureau (Table B19083)

Limitations

The Index helps illustrate the ways in which inclusive voting policies and public health outcomes are linked, but it is important to note that these links are correlational and that the findings do not prove a direct causal relationship between specific voting policies and specific health outcomes. While the correlational relationship is strong, more research is needed on the specific causal links between civic engagement and public health.

Further, this research is ongoing and can be expanded. The Index currently includes health indicators that were selected based on a review of research exploring the connection between these indicators and civic engagement. With more research, additional health indicators may be included in the future, including metrics related to other social and political determinants of health.

In addition, data for race and ethnicity are not currently included because of the variation in the ways these data are collected via different instruments and across states, including lack of standard categories across data sources. The research team is continuing to collect and analyze these data for inclusion in the future..

Finally, data from the BRFSS for 2019 did not include some data points for New Jersey, which did not meet the requirements for inclusion in the annual aggregate data set. Data from the BRFSS for 2021 does not include some data points for Florida, which did not meet the requirements for inclusion in the annual aggregate data set. Data for the District of Columbia and U.S. territories, which are not ranked in the Cost of Voting Index, are not currently included in this analysis.

Additional References and Resources

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2. Blakely TA, Kennedy BP, & Kawachi I. (2001). Socioeconomic inequality in voting participation and self-rated health. American Journal of Public Health. 91(1):99-104.
3. Brians, CL & Grofman, B. (2002). Election Day Registration’s Effect on U.S. Voter Turnout. Social Science Quarterly. 82(Mar.): 170–183.
4. Brown CL, Raza D, & Pinto AD. (2020). Voting, health and interventions in healthcare settings: a scoping review. Public Health Reviews. 41, 16.
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6. Civic Engagement and Population Health Initiative. (2021). Compendium on Civic Engagement and Population Health. University of California, Riverside Center for Social Innovation, the University of Wisconsin Population Health Institute, and the Robert Wood Johnson Foundation.
7. Dawes, DE & Williams, DR. (2020). The Political Determinants of Health. Johns Hopkins University Press.
8. Dubowitz T, Nelson C, Weilant S, Sloan J, Bogart A, Miller C, & Chandra A. 2020. Factors related to health civic engagement: results from the 2018 National Survey of Health Attitudes to understand progress towards a Culture of Health. BMC Public Health. May 7, 2020; 20(1):635.
9. Kim S, Kim CY, & You MS. (2015). Civic participation and self-rated health: a cross-national multi-level analysis using the world value survey. Journal of Preventive Medicine & Public Health. 48(1): 18–27.
10. Lyon G. The Conditional Effects of Health on Voter Turnout. (2021). Journal of Health Politics, Policy and Law. 46(3): 409–433.
11. Mattila M, Soderlund P, Wass H, & Rapeli L. Healthy voting: The effect of self-reported health on turnout in 30 countries (2013). Electoral Studies, 32(4): 886-89.
12. Nelson C, Sloan J, & Chandra A. (2019). Examining Civic Engagement Links to Health. RAND Social and Economic Well-Being. (California: RAND Corporation: Santa Monica California).
13. Rodriguez JM, Geronimus AT, Bound J, & Dorling D. (2015). Black lives matter: Differential mortality and the racial composition of the U.S. electorate, 1970–2004. Social Science & Medicine. Vol. 136-137: 193-199.
14. Schraufnagel S, Pomante II MJ, & Li Q. (2020). Cost of Voting in the American States: 2020. Election Law Journal: Rules, Politics, and Policy. 19(4): 503-509.
15. Street A., Murray TA, Blitzer J., & Patel RS. (2017). Estimating Voter Registration Deadline Effects with Web Search Data: Political Analysis. Political Analysis. 23:225–241
16. U.S. Department of Health and Human Services, Office of Disease Prevention and Population health, Civic Participation. Healthy People 2020, Social Determinants of Health, Interventions and Resources. Site last updated June 23, 2021.