In this Dec. 5, 2022 edition of the Prioritizing Equity series, building on recently adopted AMA policy about voting as a social determinant of health, tune in for an invaluable conversation on how voting and health are related and practical tools for physicians and their institutions to support voting.

 

 

  • Aliya Bhatia, MPP—executive director of Vote ER and Civic Health Month
  • Russia Chavis Cardenas, MPP—public policy strategist and advisor, director of Strategy and Partnerships at Civic Health Alliance
  • Anna Sicilia, DO, MPH—candidate at Philadelphia College of Osteopathic Medicine and Thomas Jefferson University; Vote ER Civic Health fellow
  • Stella Safo, MD, MPH—co-founder of Civic Health Alliance Group
  • William Jordan, MD—director of Health Equity Policy at the AMA Center for Health Equity

Dr. Jordan: Hello everyone. Welcome to Prioritizing Equity. I am Bill Jordan, director of Health Equity Policy at the American Medical Association Center for Health Equity. Thank you for joining us for a new episode of the Prioritizing Equity series. We will be discussing the new policies around voting adopted by the AMA over the past two years, and as we move through another election season, we are very lucky to welcome two nonpartisan organizations who are leading the conversation on how voting and health are related and provide some practical tools for physicians and their institutions to support voting. This is a panel discussion followed by questions from the audience. I'll start by introducing our panelists and then we will get started. I have with me today Dr. Stella Safo, who is an HIV primary care physician and founder of Just Equity for Health, a health care improvement company.

In 2021, Dr. Safo and three other physician leads co-founded the Civic Health Alliance, which promotes civic engagement within health care. Next, we have Russia Chavis Cardenas, a public policy strategist and advisor, currently serving as the director of Strategy and Partnerships at Civic Health Alliance. Russia is a seasoned public policy professional who centers community voice and is focused on experience-improved health and well-being, focused on advancing civic engagement so communities of color can experience improved health and well-being. Then we have Aliya Bhatia, who is executive director of Vote ER and Civic Health Month. Aliya works with health professionals across the U.S. to bring voter registration into health care settings including emergency rooms, hospitals and community health centers.

And last but not least, we have Anna Sicilia, a DO-MPH candidate at Philadelphia College of Osteopathic Medicine and Thomas Jefferson University, and a Vote ER Civic Health fellow. Anna helped author the recent AMA resolution “Voting as a social determinant,” adopted in June 2022, and also continues advocacy work on voting and voter registration at her medical school and public health master’s program. With that brief introduction, we'll jump right into our panel. I was personally really happy to see the AMA adopting policy in 2022 supporting democracy as the child of a Hungarian-Jewish refugee who survived two different ways of authoritarianism before coming to the United States. For me, some of the most inspiring stories in our country are about expanding and protecting voting rights. I was hoping that each of you could expand a little on how you came to this work about voting and health.

Dr. Safo: I'd be happy to start. As Bill mentioned, I'm Stella Safo, and for me, this work was really grounded in my work as a medical doctor. One of the things that I think has been most devastating to see is there's a movement in medicine to really think about redesigning our health care delivery system to meet the needs of really high quality at cost, so this idea of value-based medicine and population health. And one of the things that's just been hard to witness as someone who's been in the room helping to design these care models both for industry as well as for health systems is just the lack of a patient voice or end user voice at that initial design table, so for example, we'll be talking about a hypertension model and we'll build the whole thing and then roll it out and then wonder why people are like, “Well this doesn't really work for me, or this part of this doesn't acknowledge the fact that I can't even buy a blood pressure machine,” or whatever it may be.

And it made me think a lot about whose voices are represented, and where and how their voices are represented, so when COVID hit—and COVID is kind of everyone's villain origin story in some ways these days—we saw what happened in the ways that public policy was being decided, in the ways that materials were being allocated to different patient populations. And again, there was what I had seen in my kind of professional work of the lack of the voices of those who are most impacted and who were most impacted at that time by transmission, and infection and mortality rates. And it really made me want to think through within health care this connectivity between having a voice, so kind of thinking through civic engagement and what that meant and improvements in health care. And it was so clear to me as someone who's always been a little bit loud as a clinician, that health care is a very, very quiet profession where we tend to be very conservative, we tend to be very careful that we never want to be seen as being political or anything like that.

But that just means that our voice has in some ways disappeared by really kind of calling for our patients and our peers to be able to have the kind of power and strength of voice to be able to advocate for the health needs that they have, so for me, this was really just seeing what was happening within the corporate movers population in health management, lack of patient voices and then the devastation of COVID-19. And that led us to create Vote Health 2020 and then that became Civic Health Alliance. Maybe I'll popcorn it over to Aliya for you to kind of give the story for Vote ER.

Bhatia: Thank you, Stella. It is an honor to be here with all of you, an honor for our collaboration with the Civic Health Alliance and with kind of the incredible work that the AMA is doing on this front. My background is more in the other social determinants of health, primarily in education and housing. And as a born and bred Atlanta Georgian, one of the things that I got to do as part of a leadership program, in December 2019, was I got to go on a ride-along with our emergency medical services and I went on this ride-along throughout metro Atlanta and saw where EMTs and ambulances were working with families and communities. And so much of what I saw was incredibly overwhelming. I was seeing all these social determinants pop up here and there, how the EMTs were responding to issues of homelessness. They were often responding to issues where a change in insurance had created an emergent situation. They were responding to situations of food insecurity.

And at the end of this ride-along, I turn to the manager and I say, “If I give you a magic wand, you only get to change one thing because we got to prioritize in this role, things are expensive to do, we got to set our priorities. What's the one thing that you do before that magic wand disappears?” And his answer really surprised me. I thought he was going to say education because that was my background, so I had that type of bias. And instead, he said, “Aliya, if I could only change one thing, I wish all my patients voted. If all my patients voted, then our local elected officials would invest in job training, affordable housing, they would make sure there was a grocery store in every neighborhood. And when I needed to get somebody an ambulance, I would have the funds to do so.” And it was not long after that, that I heard about this broader movement around civic health and had the opportunity to join Vote ER and work with incredible folks like Stella and Russia and Anna since then. So, I'll popcorn it over to Russia.

Chavis Cardenas: Hi, thank you Aliya. My story, Bill, to answer the question that brings me to health. It ties into what Stella and Aliya just mentioned, and I'd really like to share a present-date story of how why I'm here and why I'm engaged in the public policy work that sits at the intersection of voting and health, particularly as it relates to marginalized communities. And I'm going to walk you through this story and we're going to get to the bottom line. So recently, as we know, California is the nation's preeminent global goods movement gateway, and it hosts the ports of Los Angeles and Long Beach. In October 2020, Governor Newsom in California adopted an executive order to ease the backlogs experience in the goods movement and supply chain due to COVID-19 and changes in consumer demand.

In that executive order, Governor Newsom required state departments to expedite the lease of vacant state land and private land for the storage of cargo containers. You're like, where are we going? How is this health? We're getting there. As a result, 11 of those cargo storage sites have been located in South Los Angeles. One of those cargo sites is directly adjacent and are butting up against residents' backyards, and it is emitting diesel fuel particulate matter directly into the homes of families living in those dwellings. Diesel exhaust is known to contribute to a range of health problems and long-term exposure to diesel exhaust poses the highest cancer risk of any toxic air contaminant. According to the LA County Census Report, 95% of the residents in the Westmont-West Athens community in South LA are Black and Hispanic.

Additionally, we know based off of the county primary 2020 election that we had earlier this year, that there are 6.6 million persons eligible to vote in California, in this part of California. 5.6 million persons registered. Only 1.6 million voted, meaning 24% of the eligible voters turned out in our primary election and cast ballots. And I hypothesized that if we extrapolate those figures down to the Westmont-West Athens community, that we'd probably find fewer ballots cast in that based off of the total number of eligible voters. So this governor's policy decision, which is seemingly unrelated to health, has created an environmental and health justice issue for Black and Hispanic residents of South Los Angeles.

This is a quintessential explanation, an example and a story that I'm living with and I deal with on a daily that of why I'm involved in the public policy work that lives at this intersection of health and voting because as an organized and civically engaged community inclusive, and particularly inclusive, of health professionals and health systems organizations, we can galvanize resources to affect change. That's where I'm at. That’s how I get here. And I'd like to use that example to show that there is a sincere meaning behind that health in all policies approach. And I think this was a lens that we got it wrong here in this state and now we have to work to correct it. And I think Anna has something to say about how we could correct it, so I'll popcorn it over to you.

Sicilia: Well, hi everyone. My name is Anna Sicilia. I’m a medical student. I also finished up my MPH last year. What brings me to this work I really want to say overall is my patients. And then as a med student, sometimes we say that sounds cliche, but it's really about them. And I think what sparked me thinking about this was my work before medical school. I was a clinical research coordinator, and I had a chance to speak with patients, and as a coordinator, we get to spend a little bit more time. And we got on the conversation with one of my patients, we'll call him Mr. K for his anonymity here and he has diabetes. And when I started working with him, he had a very stable level, and then all of a sudden, his levels really got out of control, not out of control but just were elevating. You could see that his diabetes was uncontrolled.

And we talked about why this was and it led to me learning that he couldn't afford his insulin. He was actually rationing his insulin—and as a result—he wasn't able to take care of his diabetes. And when I think about that, and I wanted, at the time I was younger, and I wanted to provide a solution and I couldn't provide it. I just provided comfort in that space. And as I've kind of continued to work with patients, I realized by the power of one's voice, especially in the scheme of voting. And so, I wanted to say, wanted to kind of be able to provide solutions and this was one of the ways I could by offering patients the registration to vote, so when I learned about that, I obviously hopped on the train because I wanted to help people. And so, this kind of led me to this work and I've really got a chance, especially with getting my MPH to learn not only at an individual patient-provider interaction but also on a grander bigger picture how this can really make a difference.

Dr. Jordan: Thank you Anna and the whole panel for sharing those personal stories. As you know, the AMA adopted policy in 2022 recognizing voting as a social determinant of health. And I'd like each of you to delve a little bit more into talking about the connection between voting and health as you started in the last question and particularly how it shows up among historically minoritized and marginalized groups. Maybe we'll start where we left off with Anna with the story of how this resolution was adopted by the AMA.

Sicilia: Absolutely, so I was first like an honor and a great opportunity to be part of the amazing resolution team. There was about four of us, part of the core team—writing team—and each one was just a pleasure to work with; they were awesome and I'm happy to be kind of representing our story here. As a part of the process, we looked at the peer review literature on the intersection between voting and health, and we really used that as a way to kind of move the needle forward and get this resolution seen by the AMA. And there was a lot of evidence showing the impact. One of the things, and when we look at it, there's about, I think, about 25 plus whereas clauses, which is basically the bullet points that support the resolved, which lead to being what's actually included in the AMA policy.

And one of the ones that really stood out for me was the historical nature of when someone votes the impact it can have because that's just tangible: you vote, you see the impact. And in our research, we found that the Women’s Suffrage Movement, once women were allowed to vote, that led to an increase in funding for women programming and led to an actually decrease in child mortality by eight to 15% in the U.S. And another example is the removal of health literacy in 1965, which actually expanded the number of Black voters who could vote. And then it increased the funding in areas of largely Black communities and shifted the pattern of voting so that those communities could really benefit from policy.

And so, when we were going up, obviously we were nervous because we had to speak in front of a big crowd, not a regular basis thing for mebut at any rate, I was—when you work really hard on something and you see the amount of support of the people who stand up, it almost takes your breath away. We had the American College of Physicians, the American College of Emergency Physicians, the American Psychiatric Association, the American Women's Medical Association, they were all standing up at the mic and providing support on this. And it was just really powerful to see all medicine coming together to kind of move the needle and make a big difference.

Bhatia: I'm happy to pepper in a couple of other studies on this front and I'll raise two that really sit with me. Again, a lot of my background is more on the social determinant side, so I'm particularly interested in how resources get moved into particular places. And one thing you may know about the U.S. is that our voting systems are different in every state. And so, it can be a little harder to look at some of the causal patterns, but there are countries around the world where the voting systems are the same across the country. And that creates a really interesting opportunity. And one of those is Brazil.

And at the point at which Brazil moved from paper ballots to electronic ballots, it actually created a huge shift similar to kind of how Anna was describing some of the shifts that happened around women's suffrage, some shifts that happen in the U.S. around civil rights. This shift from a written ballot where you had to write down the name of the candidate you were voting for to one where you could press a button on a screen where you saw their face. You didn't necessarily have to know from a literacy standpoint how to fully write out the name and increase the number of votes counted in Brazil by 10% but because only some places could get that technology first.

You can look at the difference in funding for public health between the communities that got that first and got it eight years later. And it turns out that there was a 33%, one-third increase in public health funding between the communities that got that new technology first and were able to count 10% more of their ballots first. The same types of ballots that Russia is probably seeing in the communities where now diesel is being going to their communities. Like similar type of effect there. And if you look in the U.S., there's a University of California professor who did as best as he could to get the similar level of causal study here in the U.S. and found that when a more diverse group of people vote in a city or county election and when a larger number of people vote, that it increases the investments in social services like housing, public health, education by a third.

And so, we really see this impact on investments and just yesterday in the New York Times, the former New York City commissioner, health commissioner wrote at the end of an op-ed about declining life expectancy in the U.S. that his sweeping prescription would be that everybody should vote, that all parents should vote. And so, I thought that was a really timely note coinciding with the end of civic health month, so that's some studies to add to the mix.

Chavis Cardenas: Aliya, to answer that question, I think mine dovetails well. What I would say is there's like a benefit in ease, in automation. That's a little bit of what you were talking about in that Brazil example is that they provided an easier and a more accessible way for residents in Brazil to vote. What we've seen and what we do know is that historically we've seen that there is the ease and access of voter registration and automation have increased the number of individuals who are registered to vote, that's exactly what you said in Brazil. And as a result of some advocacy that we've seen led by the League of Traveling Women, League of Women voters in California, we saw the National Motor Voter Registration Act in MVRA known as motor voter, what we call, with transition in California a few years ago from an opt-in registration to now an opt-out registration, meaning that when we walk to the DMV and I fill out my driver's license application for the first time I get in the system before I was like, opt-in, do you want to register the vote?

Folks sometimes will leave a blank, now it's changed and it's automated. As soon as you submit that, it's saying we're going to send this, do you want to opt-out of that? And we have seen the number of voter registrations increase in California, of course, they verify that with the local election officials. This goes through the Secretary of State just to ensure that the voter roles are clear. But one of those examples of how do we create ease into the process is a big thing that we should be thinking about. And given this example, I think that health systems leadership can consider these types of approaches when thinking about how they want to incorporate ease and automation into their own voter engagement practices. And there's another approach that I would, it's really new that I think is going to be exciting to watch out that comes out this October is recently, about a year ago, a little more than a year ago, President Biden issued an executive order, Executive Order 14019.

And in that order, he's requiring federal agencies to serve as a model employer by encouraging them to facilitate employee civic participation. An outcome of that is that they're supposed to submit their strategic plans on how do they do this to Susan Rice, who's the assistant to the president for domestic policy. Those strategic plans are coming out October 2022. Health systems who are interested in this work can look at those plans to see if they can glean any strategies that these federal agencies are using to increase ease of automation into their own practices. And I think the third and final thing that I would say, Bill, is that we know that many unregistered voters want to be met where they're at and with a trusted messenger.

And oftentimes that trusted messenger is their health care provider and their medical professionals that they work with. So, doctors and medical students who are working in their clinical and academic settings and particularly those who are working in settings where voter turnout is traditionally lower, like those who are working with younger patients or college-aged student-patients or communities of color, they can get connected to some of the automated tools that are out there. There's a ton out there, some from the people on this panel, some that are not and then thinking of ways to incorporate that into their daily practices. Those are all ways I think that would help kind of weave this gap and address some of those things that you were talking about in those op-eds, was we just want to see increased folks voting so that we can have fewer health disparities across the nation.

Dr. Safo: So well said. I don't want to take up too much time and add in too much more, but I think one of the kind of easy things to go to is just to remember that the impact of social determinants of health issues like housing, the kind of effects from the criminal justice system, employment, et cetera, all of those things have more of an impact on those directly marginalized populations. And all of those things are things that you cannot treat, you cannot handle within health systems alone. Those happen outside of the hospital walls, right? And the only kind of lever that we have to be able to impact and control those really end up going oftentimes through our elected officials. That is the most kind of apolitical reality that one can speak to if we care about the reality that in certain cities people are dying from gun violence or that people will start to die from lack of access to reproductive rights.

All of these things that we really, we know are going to directly impact the patients that show up in our emergency rooms and our urgent care centers are often decided before patients even come into our clinic walls—so for me—the kind of connectivity between voting and health is so clear around social determinants of health, which ends up impacting a strictly marginalized populations more. And then there's just interesting data. Some of it kind of studied and some of it self-reported, but in 2020, a systemic review—excuse me—systematic review took a look at a couple of studies that attached voting to health and found that individuals who tended to vote also tended to have better health care outcomes around chronic illness management.

And the reason why this matters in the U.S. is that, currently, I believe the number is over 55% of Americans over the age of 50 have at least one medical condition, one chronic medical condition and almost 30% have at least two. And so, if you think about what could be associated with this and how to impact that it matters that there is that association that's been studied between voting and health. The other thing that I find really interesting is just even the way people feel about their health. One study by Blakely looked at 260,000 individuals in the U.S. and asked individuals who voted about their kind of assessment of their overall health and those who were more likely to vote were found to have a positive overall health assessment as well. So these kind of realities I think are not just from the point that we've all discussed that my colleagues have really spoken to really clearly about impacting the social determinants, but it's also on the actual clinical and quality health outcomes as well.

Dr. Jordan: Thank you. It definitely sounds like voting and health are tangled branches of the same tree. As many of you mentioned historically minoritized and marginalized groups can face unique barriers to voting, and unfortunately, doctors are notoriously busy and vote at lower rates than the general population and than other professions. The AMA adopted policy in 2021 about making safe voting easier during the pandemic and also policies in 2022 about the health impact of voter disenfranchisement and how to make voting easier for the medical community. When we were working at the same health system together years ago, Dr. Manisha Sharma launched voter registration at the primary care sites where we worked and that mainly served communities of color. I'm wondering if … Russia gave an example of the motor voter kind of example. I'm wondering what else you all think that doctors and medical students can and should do in their clinical and academic settings to support clinicians, learners and patients in voting, particularly in places where there have historically been barriers, and also speak to any obstacles that institutions might face perceived or real.

Dr. Safo: I think the biggest kind of takeaway is ease and Russia really spoke to that really clearly. We get the outcomes from these systems because of the way that we've designed the systems. And so, when clinicians and patients really are so overwhelmed with navigating a really burdensome health care system, there's little time to think about other things and yet there are spaces and time within the clinical settings where you can really push people to register if they voted, make sure that they are registered, that they can check their registration status. And these are things like putting up flyers with QR codes in your waiting room or having your doctor just say to you; I think Russia or someone else mentioned—the trust that people have in the health care system, which matters at a time when a lot of people have lost trust in all kinds of public institutions, right?

Having your clinician say to you, “Hey, are you registered to vote? Do you have a plan to get out there and vote? How's everything kind of all set for you?” All of those things are shown to really help people feel like, “Okay, well this matters.” Others that I care about are doing it. And so, in as much I think as our audience members can really have a takeaway, the ease matters so much. And I know Vote ER was created with that in mind; Civic Health Alliance is created with the same thing in mind of how can we do the work and create the tools and the resources that are all nonpartisan and bring them to you. And all you have to do is either put them up, share them with colleagues so that people can really, again, when they're engaged in this health care system, have an easy way to at least vote, but also think about other forms of civic engagement.

Sicilia: Absolutely. I think I'm kind of going from the medical student perspective when I think about doing this and when I've done this in clinic, it's nice because we get to spend a lot of time with patients and it's the fortunate opportunity where we get to—interns may get six, seven patients on an inpatient team. As a med student, especially in our early first few months, we only get one or two initially to start, and obviously, that builds up but we get to spend time and we get to know them. And in building those deep relationships with patients, we have the opportunity to ask this question and work and see what barriers they face as well. And also use that as a learning opportunity. So, when I think about what students can do, just wearing the badge, even having the lanyard, I've gotten even asked by attendings, what is that?

Or even patients, what is that? And because they see you every day, they see you wear the same thing every day and they see the same four walls every day, so what else is new? And that becomes the lanyard, so it's been a great opportunity. And I've had a patient, actually, about a few weeks ago I would say, I asked her if she was registered to vote as a part of an initial outpatient intake. This was the first time she was at the office, and I just casually asked her and she said, “No, I'm not registered yet.” We got her registered. And she at the end of it thanked me for asking. And I thought, I was like, oh. I was in a way … I think it's important work, but then when it's acknowledged and recognized in real-time as a patient thanking you for asking that question because it was the ease, the automation, the trust we were able to build with the patient, it was just a great and rewarding experience, so definitely as providers we can all kind of move this needle as well.

Dr. Safo: And Bill, maybe one more thing that we would add. Just strategically, a lot of times folks feel like they have to go to the highest ranks of the health system to have any of these programs take off. And I will say that one of the things that we've really enjoyed doing as a grassroots organization is working directly with the individual med students or with the individual clinicians. Because what happens is exactly what Anna described of a groundswell of momentum that then brings on leadership. If your entire medical school class is like, “Can we take on voter registration tables as something that we do in our clinics,” or if your clinicians are coming to you and saying, “We want to do this,” it's a lot harder to allow the inertia of our big bureaucratic systems to take over.

I really just want to plug the power of the individuals. We're going to talk in a little bit about the power of the institutions, which I think for listeners on this call is really where most of our minds go. But the power of the individuals, I think within health care to move a lot of this forward, and a lot of the work that all of us have done is really relied on individuals saying we want to do this in our health system. And then others coming on board.

Bhatia: I will just add Bill mentioned the incredible trailblazing work of Dr. Manisha Sharma, and one of the things we really love are the Civic Health Alliance's compilation of the resources that came out of being—that trailblazing work means that we have really, really strong guides for how health institutions can think about this, how they can think about the federal framework for it. All the different sort of requirements frankly of organizations under the National Voter Registration Act and how those requirements around voting and voter access apply down to health organizations.

Dr. Jordan: Thank you. I know you alluded to it in your most recent remarks but I think there's often, as you mentioned, kind of bureaucratic hurdles. A lot of us work at large institutions, they can be slow-moving at times. What are the barriers that these institutions might perceive whether it's not knowing the ins and outs of the laws around this or just not feeling like they have the resources to prioritize this, and what do you think institutions really can do and should do to really engage in this work?

Dr. Safo: I'm happy to speak to our resources and then I'd love to turn it over to others to talk about the barriers because I think it's really helpful as you're advocating to know what you're kind of up against. One of the biggest things that we hear that we have heard is a fear that somehow bringing in voter registration within health care settings is actually illegal or is something that's going to get the health care system into trouble. And it's really unfortunate because in some ways it's almost as though things have become so politicized that if you were just to say, “I want to help you register,” that somehow that seems to have a political bent to it and that's just not the case. And so, one of the kinds of biggest things that we've heard from institutions and people in institutions who want to do this work is, my institution says that this is going to be seen as political, so we can't do it.

And our kind of response to that always is actually there are laws—and there's precedents—and I think I'm sure Russia could speak to this for days, there's policy in place that actually really supports health care settings being in the role of serving at least as voter registration sites. And the key here is that all of this has to be nonpartisan. And so, there's an IRS code 501, for 501(c)(3), that if you are a public non-profit organization, that you are encouraged to actually set up voter registration drives. And the National Voter Registration Act actually has a portion in it that encourages all non-governmental, non-profit entities to register folks to vote. And if you're a federally qualified health center who has Medicaid-eligible employees and recipients, patient recipients within your clinic that you actually are there, there's an actual requirement that you should go through the due diligence to make sure that you can be a registration site. And that kind of requirement is a little bit more lax if you only have those folks as volunteers.

So, we actually have a one-pager that has all of this there. We print it out, we have people send it over to their leadership just to say, here's what we know to be true, here's the law and it supports us doing this in a nonpartisan way, which is obviously the only way that we would want to do it within the health care setting, so that's probably the biggest barrier that I've heard for institutions. And again, we come ready with the kind of language and the resources to really be able to speak to that.

Bhatia: Yeah, I love that. I love that one-pager from the Civic Health Alliance. We actually have had a chance over the last eight months or so to work directly with Health and Human Services on voter access and health spaces. And they have now put out, for federally qualified health centers, a summary of the laws and rules around this. Because as Stella mentioned, it's weird because on the one hand, the law is so encouraging of this work, and also, organizations may have a perception that they have to clear some hurdles to do it. And so, HHS actually put out a direct guidance list. If you're a federally qualified health center, here's what voter access looks like for you. Another barrier that we sometimes hear about is the incredible weight that health organizations and health professionals are carrying right now and the time impact of it. And so, one thing that I think both Civic Health Alliance and Vote ER are always doing is looking at new and innovative models.

And one of the ones that we're really excited about—one of our partners in Philadelphia is Einstein Healthcare and they use a system called Phreesia for patient intake. And we've worked with Einstein and Phreesia so that as part of the intake process, you receive a nudge about voter registration straight through that. And that way for that particular part of Einstein that has implemented this in that way, there's no time needed by the health professional in order to implement that, so we try and make sure in all of our work that we're thinking about streamlining in the ways that Russia has mentioned and thinking about new ways to reduce the barriers on individual health professionals.

Chavis Cardenas: I think the one thing I would go back to is if we're thinking about this, the federal agencies are in the same situation right now, with that Biden executive order that I was referring to, so they're also in the exact same scenario of the conversation that we're having right now and thinking of ways for them to serve as those models for employers and facilitating employees civic participation, so as a new tool that's coming out, I really encourage you guys to look at those strategic plans that are coming out in October because there's going to probably be some pretty cookie cutter strategies that are going to be there that we could uplift and plug and play into the health care setting.

The benefit there, and why I'm pressing that one is because those are going to already be vetted from an executive branch attorney and all the legal ramifications that are a part of that, and federal agencies have to be nonpartisan. And so, they're going to be doing all of that work. And so, sometimes I think it will be a benefit instead of creating everything from the ground up to look to see what's that low-hanging fruit that's in those plans that are going to come out, to see what can we implement on our side that can replicate that.

Dr. Safo: Can I add just one more thing that I think you really have touched upon with those comments, Russia, which is that one other barrier that we get is a fear of being the first. And so, health systems don't want to be seen as kind of putting their heads out there and doing something really different from other health systems, so I know within Civic Health Alliance we do this, and Vote ER has almost been the prototype of doing this, of creating the feeling of a movement and being able to say, “Oh, you know who else is doing this?” So, in New York, we are our health systems. We have a ton of health systems, they're all super competitive, so we can say, “Sinai, who else is doing this? Montefiore is actually doing this and here's how they have it set up. Dr. Manisha Sharma set it up in Montefiore.” And that actually has been something that's helped us.

Very similar to what Russia's saying about using these plans, these strategic plans, using these prototypes, I think is really being able to share which other health systems are engaged in this work. And it's why it matters when Anna was talking about these resolutions and just the precedent that it's setting is that we have to create a culture and a feeling that this is where we're going, this is what's happening, this is where we're moving to. Versus I think what has happened historically, which is that you're an outlier if you're talking this way or wanting to do this work. And so, I think each of you again on the call is just so important for this because the normalizing of this, I think is what's going to really lead us to success.

Dr. Jordan: Thank you. I mean, I definitely hear what everybody's saying in terms of getting our large institutions that we work at to go from no to yes, and to come around to engaging in this work. Do you all have other examples of how institutions like once you've brought them on board, how they should be engaging in this work, whether it's a health system, a physician network, a clinic or an academic institution?

Dr. Safo: Aliya, do you want to go first or do you want me to go?

Bhatia: Sure. I'm happy to kick us off there. Yeah, lots of great examples. One example being Penn Medicine really does a lot of this work through medical students and really having their medical students be the energy around a lot of their work around voter registration. Penn Medicine is the defending champion right now of the healthy democracy campaign for the last two years. There's a Georgia team that is currently winning, so I'm excited to see how it pans out. Another really great and inspiring example is, in a different type of setting, is UltiMed in Southern California. They have put together a five-touch model where every patient gets asked five times, five different points around voter access and voter registration, and then they even turn their clinical sites into polling locations. And it had just huge, huge impacts on their community. So at Vote ER, we have about 500 different hospitals involved in the work, and a hundred or so sort of health organizations and other types of spaces involved in the work. And we're just really excited for all the different models that they're coming up with.

Dr. Safo: And I'll speak on behalf of Russia and myself for Civic Health Alliance. We have work that has gone into creating a compact, which is a sort of strategic plan that we're asking health systems to use. And so, the idea behind this has been that very similar to what Aliya just mentioned, there are sites that are doing this, but a lot of times health systems will say, “Well, I don't know how to start.” And so we met in the spring of 2022 with 16 civic engagement leaders, health system leaders and we really designed out and understood what are the barriers to doing this work well within health systems—and how do we do it and what are some of the examples we can pull from, so groups like UltiMed were represented, patient voting, other groups within the health care and kind of civic engagement space share their kind of best insights and some, I think real building blocks were created.

That's now in a 10-page document that'll be coming out at the end of this month, it being September. It'll be coming out at the end of this month. And we're really excited to share it with you because what it says is it gives the kind of foundational background that we've all talked about here and then it starts to get into the actual bread and butter. What can you do? It's really practical things like creating the type of strategic investment from your system that'll allow you to give your staff time off when it's on Election Day to go and vote. Or that automates, let's say, when your new residents and fellows come on-site, automates them being able to get registered, and all kinds of other ideas. It's sort of a menu, but it also creates this space that says, and what else can you do that's really customized to your site?

And so we're really excited to share that when that comes out, we'll be bothering Bill and others to please share it with you as widely as we can because we really think that part of what is happening again is that there's a little bit of an overwhelmed sense that health systems have given us coming out of COVID and everything that's happening that to add something else like, oh, and now help your population to vote, seems super daunting. And so, to set these roadmaps and to set the precedent—and to make it part of the culture is something that we're very, very committed to. Again, the Civic Health compact is what we really want to be focusing on and that you'll be seeing more of this fall.

Dr. Jordan: Great, thank you. I think that's a good segue to talk about what other resources your organizations have to offer to support doctors and medical students in doing this work and how they can access them, so if you can share with us a little bit on that?

Bhatia: Stella, you want to kick this one off and then I can go?

Dr. Safo: I would say, Russia if you want to take off the RX Vote and talk a bit about that, that'd be great.

Chavis Cardenas: Yeah, I can do the RX Vote. So, at Civic Health Alliance we have an RX Vote campaign that we have on our website that you can use it. It's just you click in your QR code and you go through the steps—and it says your name, your date of birth, your location. And then it will do either two things. One, bounce back to your location to see if you're already registered to vote in that location, so it's verifying registration. If you're not registered to vote, then it takes you automatically through the process just to register on-site. I think Anna's used something very similar and you go through the process and then it gets you to register to vote. We also have prescription card pads that you can have in your office and serve it out like a prescription. This is your prescription to register to vote and it'll have the QR code on there. We have lanyards as part of the campaign and other materials that we can provide you access to if you want to use them to have into your own care setting.

Bhatia: And at Vote ER, in addition to similar individual tools, we're really excited about something that's right around the corner on September 20, National Voter Registration Day. And in 2020 we worked with several—Penn Medicine and Einstein in particular—to send network-wide entire staff emails around voter registration. We actually modeled it off of the California Secretary of State's email template that had been highly successful. And so, I'll drop in the chat where you can access that. And we have this year already, Stanford Health, Penn Medicine, Atrium Health already committed to sending these across their networks. And you have to remember that many health institutions and hospitals are some of the biggest employers in their community. And the range of people who are touched by that employment space includes some folks who we can maybe in our minds imagine but some folks who are just across the entire spectrum of society are going to be touched by a note like that. And so, the resource that right now we're really thinking about at Vote ER is how can we get more major health institutions to engage their entire community around voting on National Voter Registration Day.

Dr. Jordan: I'm so grateful for all the resources you're offering. I think as the last question, I would just say with today's audience of professional societies across the country; I was hoping you can close with a few thoughts on how professional societies can support doctors and medical students in doing this work.

Dr. Safo: I just want to shout out what the AMA is doing. I think the AMA has really gone above and beyond. There's always more that you guys can do and we're going to be the first to tell you that, but it matters that the AMA shows up in support of the work that we're doing, hosts things like this that lets us come and talk about it. In 2020, they were doing things with us when we're just little old Vote ER, so I would say elevating and recognizing these efforts is just one, two and three of what you can do. And then also, I think the second thing that I would add is that, again, the normalizing of what we're discussing is something that is surprising to me like we're going backwards. It used to be a few years ago you could talk about voter registration within health centers and people weren't kind of so nervous.

Because of the political environment that we're in, people are nervous. And so, I think that this particular role the professional bodies can play in bringing so many individuals together is to kind of take that leadership role of saying, “We're doing this, we support this, we support these organizations, we support the principles that are laid out,” really goes a long way when you're thinking about the kind of political environment that we are finding ourselves in. And so, working in partnership, elevating this work and then helping to normalize the importance of this work is something that I think AMA has done really well and I hope other professional societies will continue to do.

Sicilia: Absolutely. And I think the other thing is, the first of all, when I started med school was the first time I ever heard of the word "resolution.” And I think it's a unique opportunity for a student like myself and of my colleagues to also be able to say something that means that's meaningful and that we can think for change on a larger level. And one thing that working on the AMA resolution has taught me is that it's not only the AMA that has resolutions; it’s other professional societies that have them as well. So for me, I would realize that I could take this to my own medical body, the AOA. And so, I have a group of colleagues who are also working on an AOA resolution, which really aligns with, in osteopathic medicine we have one of the core tenants is body, mind and spirit.

And the idea that, you know, you nourish those and that impacts someone's health and voting is just one way to nourish one's body, mind and spirit and the whole body as a unit, so we're taking that concept and because it's true, to the AOA and hopefully passing a resolution in that professional society as well. It's this whole opportunity and working in this space is realized the power of one person's voice. And I'm looking at everyone on the call here; just by us being there and the work we've done, and you guys have done has led, has trailblazed the way for me to be able to step in and do work. And to see a lot of women on this panel, it's really powerful, so I also want to acknowledge that as well. One voice can make a really big difference, and I think as sitting on professional societies and working with those on professional societies, taking one thing you learn and saying it can make a big impact.

Dr. Jordan: Thank you. Well, I'm so grateful to all of you for your leadership on this and for being here today and sharing with us.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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