ISSN 2691-7475 Health Policy Brief September 2020 Better Health, Greater Social Cohesion Linked to Voter Participation Susan H. Babey, Joelle Wolstein, and Shana A. Charles ‘‘ There is evidence that health policies better reflect the needs of the population SUMMARY: This policy brief describes voter registration and participation among California adults, using data from the 2017–2018 California Health Interview Survey (CHIS). Better health status, lower levels of psychological distress, and better access to health care were related to higher levels of voter participation. Higher below the poverty level, who were Latino/a, or who were non-native English speakers but spoke English very well or well were more likely to report a lack of eligibility as the main reason for not being registered to vote. Strategies to increase voter engagement could help ensure that voters better represent the diverse when that levels of voter registration and participation residents of California and could also promote ’’ were reported among those living in policies that better meet the health needs of population votes. neighborhoods perceived as safe and as having these populations. Policymakers, state and local high social cohesion. Among citizens, Asians governments, and community organizations can and those with limited English proficiency help promote voter engagement by providing were more likely to report that they were not civic education paired with preregistration registered to vote because they did not know opportunities in high schools, supporting how or where to register. Individuals who lacked integrated voter engagement efforts, and a high school degree, whose incomes were promoting neighborhood cohesion. V oter participation is an important aspect of civic engagement, and research suggests that a link exists between There are well-documented differences in voter participation, especially by age, race and ethnicity, education, and income.5, 6 Younger civic engagement and health.1 Health may adults and people of color have lower levels affect activities like voting either directly of voter participation. Those with lower (for example, by being a barrier to casting levels of education and lower incomes also a ballot) or indirectly (by contributing to participate less than those with higher levels greater social isolation or reduced interaction of education and income. These groups are with organizations such as churches or underrepresented among voters, making it community groups, which can lead to less likely that their needs will be heard and reduced likelihood of voting).2 In addition, addressed.7 there is evidence that health policies better reflect the needs of the population when that This policy brief uses data from the 2017– population votes.3 Thus, civic and political 2018 California Health Interview Survey participation may indirectly impact health (CHIS) to describe voter engagement (self- by influencing the policies that are enacted, reported voter registration and frequency of which in turn influence health.4 In addition, voting) among California adults, examining socioeconomic barriers such as educational the association of voter engagement with Support for this policy brief attainment can impact both health and the health status, psychological distress, insurance was provided by a grant from The California Endowment. likelihood of voting. coverage, and number of doctor visits in the 2 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1 Self-Reported Voter Registration and Frequency of Voting by Health Indicators, U.S. Citizens Ages 18 and Over, California, 2017–2018 Always Frequently Sometimes Never Total % Registered* Doctor Psycho- Health Status Excellent or very good 40.9% 15.3% 29.0% 3.8% 88.9% Good 37.4% 15.5% 31.8% 3.8% 88.5% Fair or poor 32.7% 14.2% 30.9% 4.7% 82.5% Yes 23.3% 14.1% 37.3% 7.4% 82.1% Past Distress in Past Visit in logical Year No 40.1% 15.2% 29.3% 3.5% 88.2% Yes 40.0% 15.4% 29.5% 3.5% 88.4% Year No 28.0% 13.8% 34.2% 6.4% 82.4% Medicare & supplemental 68.9% 14.3% 12.4% 0.4% 96.0% Type of Insurance Coverage Medicare only 54.3% 18.0% 18.3% 1.2% 91.8% Medicare & Medi-Cal 40.3% 13.2% 27.8% 2.7% 84.0% Employer-based 38.5% 17.2% 32.1% 3.2% 91.0% Medi-Cal 19.7% 10.8% 38.5% 8.0% 77.1% Privately purchased 32.7% 17.8% 31.0% 5.1% 86.6% Other public 26.6% 16.6% 31.2% 6.3% 80.7% Uninsured 20.9% 11.4% 38.4% 6.8% 77.5% 0% 20% 40% 60% 80% 100% ‘‘ *Due to rounding, totals may not match exact sum of percentages. Source: 2017–2018 California Health Interview Survey Voter past year. It also examines variations in voter Those With Worse Health Underrepresented Among Voters engagement indicators by neighborhood registration and characteristics and describes some of the Voter registration and frequency of voting participation reasons reported for not being registered to varied by level of physical and mental health were lower vote. Measures are described in more detail under “Data Source and Methods” at the end (Exhibit 1). Among U.S. citizens, 32.7% of adults who rated their health as fair or poor among adults of this policy brief. Please note that all data reported always voting, compared to 40.9% with worse presented in this brief were collected in 2017 of adults who rated their health as excellent or health. ’’ and 2018, prior to the COVID-19 pandemic. Self-Reported Voter Registration and very good. Among adults who had experienced serious psychological distress in the past year, 23.3% reported always voting, compared to Participation in California 40.1% of those who had not experienced that Among U.S.-born and naturalized citizens distress. Voter registration and participation ages 18 and older in California, 87.5% were also lower among adults with worse reported being registered to vote, and 12.4% access to health care (Exhibit 1). About one- said they were not registered (data not shown). fifth (20.9%) of uninsured adults reported Among registered voters, 44% reported that always voting, compared to more than they always vote in presidential, state, and one-third (38.5%) of those with employer- local elections; 17% said they frequently vote; based insurance and more than half of those 34% reported sometimes voting; and 5% with Medicare (54.3%) or Medicare plus reported that they never vote. supplemental insurance (68.9%). In addition, adults covered by Medi-Cal—a population that includes large proportions of low-income UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Self-Reported Voter Registration and Participation by Neighborhood Characteristics, U.S. Exhibit 2 Citizens Ages 18 and Over, California, 2017–2018 Total % Always Frequently Sometimes Never Registered* Neighborhood Neighborhood High cohesion 49.5% 14.4% 24.6% 2.6% 91.2% Cohesion Moderate 38.8% 15.6% 30.2% 3.6% 88.2% Low cohesion 27.5% 14.8% 35.1% 5.8% 83.2% Feel safe some or none of time 23.2% 14.1% 35.7% 6.9% 79.9% Safety Feel safe most of time 36.1% 15.5% 32.8% 3.6% 88.0% Feel safe all the time 43.0% 15.0% 27.0% 3.6% 88.7% 0% 20% 40% 60% 80% 100% ‘‘ *Due to rounding, totals may not match exact sum of percentages. Source: 2017–2018 California Health Interview Survey adults and those with disabilities—had the Voter Registration and Participation Lower Less than Among Young Adults and Those with lowest proportion (19.7%) among those who reported always voting. Lower Socioeconomic Status (SES) one-quarter Among California adults who are U.S.-born of adults who Voter Engagement Related to Perceptions of Neighborhood Cohesion and Safety or naturalized citizens, self-reported voter perceived their Neighborhood cohesion is an indicator of registration and voter participation varied by age, race/ethnicity, socioeconomic status neighborhoods connectedness and unity among neighbors. It (SES), and English proficiency (data available as mostly is measured by the extent to which people in a neighborhood trust one another, are willing to in online Appendix: https://healthpolicy.ucla.edu/ unsafe reported publications/Documents/Images/VoterParticipation- help others, share values, and get along with that they ’’ Appendix-sep2020.pdf ). The proportions of neighbors. Adults who live in neighborhoods those who reported being registered to vote always voted. with high levels of cohesion reported higher and who said they always voted were lower rates of voter registration and participation among young adults, Asian adults, Latino/a (Exhibit 2). Nearly half (49.5%) of adults adults, African American adults, those with living in neighborhoods with high levels of lower levels of education and income, and cohesion reported always voting, compared those who are non-native English speakers. to just over one-quarter (27.5%) of adults in neighborhoods with low cohesion. More Than 400,000 California Adults Who Are Likely Eligible to Vote Believe They The extent to which people feel safe in their Are Not Eligible neighborhoods can impact community Among U.S. citizens ages 18 and older who residents in a number of ways, including are not registered to vote in California, 14% promoting or hindering civic engagement. said their main reason for not being registered Voter registration and participation were to vote was that they are not eligible, and 5% higher among those living in neighborhoods gave the reason of not knowing how or where they perceived as safe (Exhibit 2). Less than to register. The 14% figure represents an one-quarter of adults who perceived their estimated 442,000 adult citizens who reported neighborhoods as mostly unsafe reported they were not eligible to vote. In California, all that they always voted (23.2%), compared to adult residents can register to vote if they are 36.1% of those who reported feeling safe most citizens, not currently in state or federal prison of the time and 43.0% of those who said they or on parole for the conviction of a felony, or feel safe all the time. 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 3 Percentage Reporting “Not Eligible” as Main Reason Not Registered to Vote by Demographic Characteristics, U.S. Citizens Ages 18 and Over Not Registered to Vote, California, 2017–2018 Gen Z (age 21 and under) 13.4% Millennial (ages 22–37) 12.2% Gen X (ages 38–53) 21.6% Age Boomer (ages 54–72) 11.8% Silent (ages 73+) 3.9% Latino/a 17.9% Asian 9.0% Race/Ethnicity African American 11.9% White 12.2% Two or more 9.4% 400%+ FPL 8.0% 16.0% Income 200%–399% FPL 100%–199% FPL 12.3% 0%–99% FPL 19.9% College grad 9.6% Education Some college 11.6% High school grad 13.2% <High school 20.7% Not well/not at all 15.1% Proficiency English Very well/well 18.4% English only 10.5% 0% 5% 10% 15% 20% 25% ‘‘ Source: 2017–2018 California Health Interview Survey More than have not been declared mentally incompetent. not being registered varied by demographic It is likely that most of these 442,000 characteristics (Exhibit 3). Among citizens 400,000 respondents mistakenly reported ineligibility not registered to vote, the proportions who California to vote and are, in fact, eligible.8 reported not being eligible were particularly adults who are Proportion Reporting Not Being Eligible high among Latino/a adults (17.9%), those with incomes below the poverty line (19.9%), likely eligible to to Vote High Among Non-Native English those without a high school degree (20.7%), vote believe they Speakers and Those With Low SES non-native English speakers (15.1% among ’’ are not eligible. The proportion of adults who reported not being eligible to vote as their main reason for those speaking English “not well/not at all” and 18.4% among those speaking “very UCLA CENTER FOR HEALTH POLICY RESEARCH 5 Percentage Reporting “Don’t Know How or Where to Register” as Main Reason Not Exhibit 4 Registered to Vote by Race and English Proficiency, U.S. Citizens Ages 18 and Over Not Registered to Vote, California, 2017–2018 16% 14.2% 14% 11.7% 12% 10% 8% 6% 5.0% 4.8% 4% 3.3% 2.6% 2% 0% Latino/a Asian White English only Very well/ Not well/ well not at all Race/Ethnicity English Proficiency Note: Sample sizes were too small to present estimates for Source: 2017–2018 California Health Interview Survey other racial/ethnic groups. well/well”), and adults ages 38–53 (Gen X) (21.6%). Percentage Reporting Not Knowing How or Where to Register Was High Among Asians and Non-Native English Speakers Among U.S. citizens not registered to vote, among citizens whose health status was poor, who had experienced psychological distress in the past year, and who had worse access to health care. Voter engagement was also related to neighborhood social characteristics. The proportion of citizens who reported they always vote in local, state, and presidential ‘‘ Asian adults were more than three times as likely as white adults to say Asian adults (11.7%) were more likely than elections was higher among those living in they did not white (2.6%) or Latino/a adults (5.0%) to say they were not registered because they did not neighborhoods where they feel safe all the time than among those in neighborhoods where know how know how or where to register (Exhibit 4). they feel unsafe. The proportion who always or where to Those who speak English “not well” or “not at all” were the most likely to report their reason for not being registered to vote as not knowing vote was also higher among those living in neighborhoods they perceive as having high levels of social cohesion than among those ’’ register. how or where to register (14.2%, compared living in neighborhoods with low cohesion. to 3.3% of native English speakers and 5% of U.S. citizens not registered to vote overall It is important to note that while our findings [data not shown]). provide evidence of relationships between voter engagement and these health indicators, Conclusions and Recommendations the findings do not provide evidence of Millions of Californians who are eligible to the direction of the relationship or the vote are not registered to vote. In addition, mechanisms through which they are related. more than 1 million adults who reported There may be a cycle through which health being registered said they had never voted in and civic engagement influence each other. presidential, state, or local elections. Rates of Our findings suggest that the health of both reported registration and voting were lower individuals and communities is related to 6 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ If certain groups are underrepresented among voters ... the interests voter engagement. Other research suggests that civic engagement impacts health-related policy, and that these policies can affect health. If certain groups are underrepresented among voters and those engaging in other civic activities, the interests of those groups are less likely to be heard and addressed; the In California, 16- and 17-year-olds can preregister to vote. Incorporating civic education into the curriculum and pairing it with opportunities to preregister to vote could increase the proportion of young people who are registered to vote, while also promoting civic knowledge and of those groups result could be policies that put these groups interest in other civic activities at a crucial are less likely at a disadvantage. However, efforts to improve age. In addition, there are disparities in to be heard and civic participation of underrepresented groups civic participation and opportunities to ’’ (such as young adults, people of color, and participate among youth.10 Ensuring quality addressed. those who have health issues) could lead to civics coursework in schools that serve policies that better address the health needs of large numbers of low-income students and these groups. Policies that better address the students of color could help address these health needs of people and their communities disparities. could contribute to improved population and community health, which could in turn •Support integrated voter engagement promote greater civic participation. activities. Integrated voter engagement involves continuous efforts to promote Our findings also indicated that more than participation between elections as well as 400,000 Californians who are citizens reported during elections. Such activities include they are not registered to vote because they voter registration efforts, education of both believe they are not eligible. The following voters and candidates, get-out-the-vote groups were more likely to give not being activities, leadership development, and issue eligible to vote as the main reason for not advocacy.11 These ongoing efforts likely being registered: those who are Latino/a, those build not only voter participation but also without a high school degree, those with civic engagement more broadly. Integrated incomes below the poverty line, and non- voter engagement efforts also may help native English speakers who speak English reach and educate the potential voters well. Asians and non-native English speakers who reported that they do not know how who do not speak English well were more or where to register and who mistakenly likely to report not knowing how or where reported that they are not eligible. to register as the main reason they are not registered to vote. •Promote social cohesion in neighborhoods, as higher levels of social cohesion and Strategies to increase participation in voting perceived neighborhood safety were related and other civic activities, particularly among to higher levels of voter participation. underrepresented groups, could help ensure Neighborhood safety and social cohesion that voters better represent the diverse are interrelated, and improving cohesion is residents of California and could also promote likely to also improve safety. Community policies that better meet the health needs leaders, local governments, and community of these populations. Such strategies could organizations can help build opportunities include: for neighborhood residents to interact and engage, fostering greater cohesion. •Provide civic education paired with In addition, the availability and use of preregistration opportunities in high amenities such as parks and libraries can schools. Youth who participate in civic help promote cohesion. activities are more likely to register, vote, and be civically active as adults.9 UCLA CENTER FOR HEALTH POLICY RESEARCH 7 Data Source and Methods Funder Information This policy brief presents data from the 2017–2018 Support for this policy brief was provided by a grant California Health Interview Survey (CHIS). Data from The California Endowment. presented in this brief were collected from 42,330 adults. Interviews were conducted in English, Spanish, Acknowledgments Chinese (Mandarin and Cantonese), Vietnamese, The authors would like to thank Tiffany Lopes, Korean, and Tagalog. CHIS uses a complex survey Venetia Lai, Elaiza Torralba, and Celeste Maglan design that requires analysts to use complex survey Peralta for their assistance with production and weights to provide accurate variance estimates and dissemination; Julian Aviles for statistical support; statistical testing. All analyses presented in this policy and Andrew Juhnke and Parneet Ghuman for CHIS brief incorporate these survey weights. data access support. As part of a series of questions about voter The authors are grateful to the following reviewers engagement, adults were asked whether they were for their thoughtful and thorough reviews: Mark A. registered to vote. If they were not, they were asked Peterson, PhD, professor of public policy, political the main reason for their not being registered. CHIS science, and law in the Department of Public gives a slightly higher estimate of the proportion of Policy, UCLA Meyer and Renee Luskin School of citizens who are registered to vote than the Report Public Affairs; Chris Ringewald, MA, director of Registration produced by the California Secretary of the Research & Data Analysis Department, of State (87.5% vs. 80.7%, respectively).12 There Advancement Project California; and Steven P. are three likely reasons for this difference: a social Wallace, PhD, associate director of the UCLA desirability bias, in which some respondents reported Center for Health Policy Research and a professor being registered even though they are not; respondents in the Department of Community Health Sciences, believing erroneously that they were registered to UCLA Fielding School of Public Health. vote; and a nonresponse bias, in which people who responded to the survey were actually more likely to Suggested Citation be registered to vote.13 Babey SH, Wolstein J, Charles SA. 2020. Better Health, Greater Social Cohesion Linked to Voter Adults who reported being registered to vote were Participation. Los Angeles, Calif.: UCLA Center for asked whether they vote “always, sometimes, or Health Policy Research. never” in (1) presidential elections, (2) state elections, and (3) local elections. The voter participation/ Endnotes frequency of voting variable was constructed based on 1 Nelson C, Sloan J, Chandra A. 2019. Examining Civic these three voting frequency questions. Perceptions Engagement Links to Health. Santa Monica, Calif.: RAND The California Health of neighborhood safety were based on responses to Corporation. Interview Survey (CHIS) the following question: “Do you feel safe in your 2 Schur L, Shields T, Kruse D, Schriner K. 2002. Enabling covers a wide array of Democracy: Disability and Voter Turnout. Political neighborhood all of the time, most of the time, Research Quarterly 55(1):167-90. health-related topics, some of the time, or none of the time?” For the 3 Navarro V, Shi L. 2001. The Political Context of Social including health insurance neighborhood cohesion measure, respondents were Inequalities and Health. International Journal of Health coverage, health status asked the extent to which they agreed that people in Services 31(1):1-21. and behaviors, and access their neighborhood are willing to help each other, 4 Reeves A, Mackenbach JP. 2019. Can Inequalities in Political Participation Explain Health Inequalities? to health care. It is based get along, and can be trusted (1=strongly disagree, Social Science & Medicine 234 (Aug 1):112371. on interviews conducted 2=disagree, 3=agree, 4=strongly agree). Responses 5 Smets K, Van Ham C. 2013. The Embarrassment of continuously throughout to these questions were averaged and then divided Riches? A Meta-Analysis of Individual-Level Research on the year with respondents into the following categories: low cohesion (<3.0), Voter Turnout. Electoral Studies 32(2):344-59. from more than 20,000 6 Dobard J, Engie K, Ramakrishnan K, Shah S, García moderate cohesion (3.0 to 3.32), and high cohesion Bedolla L. Unequal Voices: Who Speaks for California? Part California households. (3.33 and above). II. Riverside, Calif.: School of Public Policy, University of California, Riverside. https://www.advancementprojectca.org/ CHIS is a collaboration wp-content/uploads/2017/01/Unequal-Voices_PartII.pdf Author Information among the UCLA Center 7 Franko WW. 2013. Political Inequality and State Policy Susan H. Babey, PhD, is a senior research scientist Adoption: Predatory Lending, Children’s Health Care, and for Health Policy Research, at the UCLA Center for Health Policy Research. Minimum Wage. Poverty & Public Policy 5(1): 88-112. California Department of Joelle Wolstein, MPP, PhD, is a research scientist at 8 The CHIS sample does not include those who are Public Health, California incarcerated, and it is unlikely to include adults who the UCLA Center for Health Policy Research. Shana have been declared mentally incompetent. Approximately Department of Health Care A. Charles, MPP, PhD, is an associate professor in 48,000 California adults were on parole for a felony in Services, and the Public the Department of Public Health at California State 2019. https://www.sacbee.com/news/politics-government/capitol- Health Institute. For more alert/article225198485.html University, Fullerton and a faculty associate at the information about CHIS, UCLA Center for Health Policy Research. please visit chis.ucla.edu. UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 9 McFarland DA, Thomas RJ. 2006. Bowling Young: How Youth Voluntary Associations Influence Adult Political Participation. American Sociological Review 71(3):401-25. 10 Babey SH, Wolstein J. 2018. Civic Engagement Among The UCLA Center California High School Teens: Associations With Health for Health Policy Research and Education Outcomes. Los Angeles, Calif.: UCLA is part of the Center for Health Policy Research. UCLA Fielding School of Public Health. 11 Paschall K. 2016. How Integrated Voter Engagement Builds Power and Changes Policy.Washington, D.C.: National Committee for Responsive Philanthropy. 12 California Secretary of State. 2020. Report of Registration, October 1, 2019. Sacramento, Calif. Accessed July 28, 2020. Available at: https://elections. cdn.sos.ca.gov/ror/154day-presprim-2020/historical-reg- stats.pdf. Please note that the CHIS sample does not include adults living in group quarters (e.g., nursing homes, prisons, or dorms). Therefore, estimates of the The analyses, interpretations, conclusions, number and proportion of those eligible to vote and and views expressed in this policy brief are registered to vote may differ slightly from estimates those of the authors and do not necessarily based on actual voter registration records. The 12.4% represent the UCLA Center for Health Policy of adult citizens who reported being not registered to Research, the Regents of the University vote includes less than 0.4% who reported not being of California, or collaborating sure whether they were registered to vote. organizations or funders. 13 Berent MK, Krosnick JA, Lupia A. 2016. Measuring PB2020-6 Voter Registration and Turnout in Surveys: Do Copyright © 2020 by the Regents of the Official Government Records Yield More Accurate University of California. All Rights Reserved. Assessments? Public Opinion Quarterly 80(3):597-621. Editor-in-Chief: Ninez A. Ponce, PhD Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu Read this publication online