Taking Stock of Democracy, Voting, and Health.

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Health is about more than genes and medical care—it is deeply connected to our social and political environment. To understand this environment, I moderated a discussion with three keynote speakers recently during the Dean’s Symposium, “Voting and the Health of Populations: Celebrating the 19^th Amendment Centennial” at the School of Public Health. Hosted in conjunction with the Center for Health Law, Ethics & Human Rights, the event was a vibrant exploration of the link between democratic participation and health, featuring Rachel Levine, Pennsylvania Secretary of Health; Dariely Rodriguez, director of the Economic Justice Project at Lawyers’ Committee for Civil Rights Under Law; and Susannah Wellford, CEO and Founder of Running Start. We explored what the vote means and the work that remains to complete this amendment’s democratic vision.

Ratified on August 26, 1920 after a long and bitter battle over women’s place in America, the 19^th Amendment states: “The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex. Congress shall have power to enforce this article by appropriate legislation.” These two sentences enfranchised nearly 10 million women but only partially fulfilled the vision of first-wave feminists, who sought emancipation from the control of men and the common, intersectional subordination of the time. Men “represented” those considered unable to speak for themselves, including women, children, servants, slaves, and anyone else who was not a propertied white male. In other words, early American democracy suffered a deficit of adequate representation.

Why does this history matter to the public’s health now? In short, because a relationship between health and voting is well documented. Evidence shows that people who are healthy are more likely to vote, and people who vote are more likely to be more socially connected and experience better mental health. For example, recent research illuminates a connection between Medicaid expansion, registering to vote, and voting—patterns that reverse when Medicaid enrollment ends. Women comprise the majority of adult enrollees in Medicaid.

Many challenges remain, such as the persistent mismatch between the demographics of the population and a truly representative government. During the conversation, Wellford remarked that when women run, they win as often as men do, but they run in much lower numbers. Women represent around 51 percent of the US population, yet even after the 2018 “year of the woman,” women comprise a small proportion of Congress (101 out of 435 representatives and 26 out of 100 senators), 29 percent of state legislators, 9 out of 50 governors, and of course 0 presidents or vice presidents. Of the women in office, just over one-third are women of color. In a representative democracy, laws and policies should reflect the priorities of the population. Women and other marginalized groups must run for office and stay in office so they can rise into positions of power. As Wellford also mentioned, more women holding office has a “role model effect” that helps to increase the number of women running and, therefore, winning. Diversity also helps to combat prejudices by indirectly educating those who hold biases, conscious or unconscious.

Another challenge is the after-effects of the Supreme Court’s 2013 decision in Shelby County v. Holder, which renewed state disenfranchisement efforts. Barriers to voting—such as gerrymandering, voter ID laws, documentation of citizenship, purges of voter rolls, and restricted poll access—have grown. Such constraints disproportionately affect women, people of color, low-income and hourly wage earners, and the LGBTQ community. For example, Levine noted that strict voter ID laws are a problem because just one-third of transgender individuals have updated government IDs to reflect their trans status due to the high cost and difficult legal requirements for name and gender changes that many states impose.

It is also important to seek allies and build relationships beyond traditional coalitions. As Rodriguez stated, felon disenfranchisement is a vestige of Jim Crow, and re-enfranchisement conversations must include strategies for preventing historically oppressed populations from being sent to prison in the first place. Incarcerated people experience many health issues that prisons cannot or do not handle, and poor health makes reentry more difficult and leads to greater mortality, for example from overdose. The vote helps to break down barriers to societal and civic reentry, which helps to eliminate cycles of poverty for individuals, and in families and communities.

No one supposed in 1920 that gaining the vote was enough to achieve the first-wave feminists’ vision of true equality, evidenced by the drafting of the Equal Rights Amendment (ERA) shortly after ratification. It took several more decades for women of color to gain the vote through the Voting Rights Act of 1965. As a result, at the 50-year anniversary of the 19th Amendment, second-wave feminists continued to fight for fair access to voting, equal pay, and family equality including control over child bearing and child rearing.

A record number of women are running for president during the 2020 primary election cycle—the ultimate emblem of equality in politics. Yet, women’s health is still a trading card, and they still seek equality in the home and in the workplace. Furthermore, the ERA was ratified recently by the thirty-eighth state (Virginia), but its fate is unclear because Congress placed a time limit on ratification, so litigation has begun. These contemporary barriers to equality may be less formal, but their hidden nature can make them more pernicious.

So what does “the vote” mean? Nothing less than disestablishment of old hierarchies to achieve political, civic, and social equality.

Our health depends on it.

Nicole Huberfeld is a professor of health law, ethics & human rights at the School of Public Health, and a professor of law at the School of Law.