Clinicians Can Help Inpatients Vote on Election Day

Tara Haelle

November 02, 2018

With Election Day just around the corner, an "explosion" of early voting is contributing to record-high voter turnout for a midterm year in states like Texas, Arkansas, and Florida. But millions of people still plan to vote on Election Day — and statistically, some of them will inevitably end up unexpectedly hospitalized on the day they planned to go to the polls.

Though helping patients vote may not seem a top priority to those providing healthcare, some physicians argue that such aid is a key component to holistic care.

"Facilitating the process for hospitalized patients to vote can increase their agency and amplify their voices and concerns," write James McKenzie, MD, and Jennifer Okwerekwu, MD, and colleagues in a study published October 31 in the Journal of the American Academy of Psychiatry and the Law.

McKenzie and Okwerekwu, both psychiatry residents at Harvard Medical School in Boston and the Cambridge Health Alliance in Massachusetts, spearheaded an initiative in their small community hospital to ensure that patients from any department had the opportunity to vote in the 2016 presidential election if they wanted to.

"Some people are misinformed that if you have a disability, you're not able to vote," McKenzie told Medscape Medical News, but federal law says otherwise. "You really have to be really severely incapacitated to not be able to vote. The vast majority of people meet the standard for capacity to vote."

Data are scarce on how many people experience short-term, unplanned hospital stays in the days leading up to and including Election Day, but an estimated 7% of the population is hospitalized each year, according to the Centers for Disease Control and Prevention. Some proportion of that number will inevitably include people whose hospitalizations were unplanned and include an election day.

Yet the issue of hospitalized individuals' voting rights is a relatively "invisible" one, Okwerekwu said, because most people simply don't think about it and those who do are confined to institutions with less of a voice.

"Hospitals are some of the largest institutions in the country, and you don't think about the ways in which your freedoms are not fully able to be exercised when you're in these institutions," Okwerekwu told Medscape Medical News. "Hospitalizations can be short, but that can be a critical five days if it overlaps with an election."

Some people have the knowledge and wherewithal to know their rights and seek help if they unexpectedly end up in the hospital on Election Day.

"I've gotten a call from a woman who was on her way to the hospital because she went into labor on Election Day and she was afraid she wasn't going to get to vote," said Michelle Bishop, MSW, a voting rights specialist with the National Disability Rights Network in Washington, DC, recounting to Medscape Medical News her experience working with a voter protection hotline. "She was determined she was going to have her baby and cast her ballot on Election Day."

But that's not necessarily typical, Bishop said. Many people are not aware of their right to vote even when in the hospital, and few would think to plan for it ahead of time.

"Nobody is walking around thinking, 'I'm going to vote on Tuesday, but will I still be able to vote if I get hit by a bus today?' "

"It Allowed Us to Make Sure Their Voices Were Heard"

For Okwerekwu, a naturalized US citizen whose family moved from Nigeria to Ireland to the United Kingdom before settling in the United States, helping ensure hospitalized patients were able to vote arose from a deep sense of civic responsibility. Her residency began in the summer of 2016, a chaotic time when young black men were being shot by police, the Pulse nightclub mass shooting occurred, immigration issues dominated the headlines, and "Trump was being Trump," she said. It was depressing, she said, leading her to think about the identity of America as a nation and what she stood for.

Add to that the juxtaposition of her "multiple minority identities" as a black female immigrant and her privilege as a Harvard-trained physician, and she felt obligated to help but uncertain how.

"I'm a doctor, people say I have power, but I felt very powerless, and that sentiment was echoed by a number of my co-residents," she said. Then she turned to the safety-net hospital where she worked.

"At Cambridge Hospital, we serve people from all walks of life, especially those who are disenfranchised," including refugees, people without insurance, and non-English speakers, she said. "We saw the impact of the world we live in and the toxic stressors on the patients we serve every day, and there was this overwhelming feeling of powerlessness in myself and my patients. As the elections were coming up, we recognized that this is one venue where everyone eligible to vote can have a voice."

Okwerekwu and McKenzie first researched state voting laws online to learn how patients could vote if they had missed the deadline for an absentee ballot. The two created flyers and visited each hospital department to educate patients and enlist the staff in learning which patients might want help voting via a proxy. Some patients asked a family member or friend to help once they learned they could, but about a dozen patients accepted McKenzie's and Okwerekwu's help.

"A lot of our patients are socially isolated and don't have the means to ask a friend or family member to get to the polls, so it allowed us to pick up the slack to make sure their voices were heard," Okwerekwu said. "It wasn't about having a specific voice be heard but that those voices are heard in general."

After some local press covered their project, the two heard from a handful of individuals at other medical centers who wanted to learn more about their work, though they don't know if those people did anything similar. They also heard from a few patients.

"One woman who had a heart attack was devastated because she wasn't able to vote," Okwerekwu said. "She wrote me and asked how to do it, and I emailed her, and her son was able to help her."

Hospitals' Responsibility to Help Patients Vote

The combined impact of four federal voting laws essentially make it a hospital's responsibility to help any inpatients who want to vote to do so, McKenzie said. These include the Voting Rights Act of 1965, the Americans with Disabilities Act of 1990, the National Voter Registration Act of 1993, and the Help America Vote Act of 2002.

"No specific part says, 'hospitals have to facilitate voting,' so they're not breaking any laws by not informing patients or making it easier, but they do break the law whenever a patient asks and is told that they can't vote for any reason," McKenzie told Medscape Medical News.

The most common examples of this stonewalling include being told there are no resources to help a patient vote or a misunderstanding of voter eligibility for mentally disabled patients, he said. The Voting Rights Act's second provision explicitly ensures that a person with mental disabilities, including mental illness, be allowed to vote without having to complete a test that isn't required of all voters.

The federal court ruling Doe v. Rowe in Maine in 2001 further affirmed that people can be deemed incompetent to vote only if they "lack the capacity to understand the nature and effect of voting such that they cannot make an individual choice."

Bishop said she believes the onus should be on local election officials to ensure hospitalized patients have an opportunity to vote, but she has heard anecdotally of hospitals that make an effort to check with patients and see if anyone needs help voting.

One such hospital is Providence Holy Cross Medical Center, located just outside Los Angeles, in Mission Hills, California.

"We practice something called whole person care, which means we see our patients as people, not as medical conditions, and tend to all of our patients' needs, beyond their medical ones," said Marwa Kilani, MD, medical director of palliative care at Providence Holy Cross. "Being hospitalized on a holiday or an important day like Election Day can be stressful for patients, and we want to do what we can to alleviate that stress. If it's important to our patients, it's important to us."

Kilani's institution has hospital volunteers who find out which patients expect to be hospitalized on Election Day, whether from surgery or illness, and get provisional ballots for them.

"If a patient is admitted on Election Day and expresses an interest in voting, volunteers work with the care team to see who would like a ballot," Kilani said. "The volunteers are responsible for returning the ballots. It's really that simple."

She has not heard any concerns from the medical staff about the program, and patients regularly express appreciation that the hospital is asking and helping.

How to Help

For clinicians who want to help, there are resources available, such as the website The project, which provides state-by-state information and materials, is the brainchild of Kelly Wong, MD, an emergency medicine resident at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, and Alison Hayward, MD, MPH, an attending physician in the emergency department at Rhode Island Hospital and assistant professor at the Warren Alpert Medical School.

According to the website, Wong first saw the need in 2016, when patients expressed disappointment that they wouldn't be able to participate in the presidential election.

"I didn't know then what I know now: hospitalized patients have the right and ability to vote," she says on the site.

For his part, McKenzie emphasizes that physicians or hospital staff interested in helping patients vote must first familiarize themselves with their state's election laws, ideally reaching out to the local election commission for guidance. Different states have different laws governing absentee voting and deadlines, proxy voting, and voter ID requirements, for example.

McKenzie also cautioned others to be prepared to encounter ignorance or sometimes even obstruction.

"Some states make it pretty hard to vote, and some states go out of their way to make it easy," he said. "All states have to have some mechanism for this, but whether it's going to be intuitive and the people at the voting commission are going to be familiar with it or not, there's probably going to be a huge range."

That said, he and Okwerekwu began their efforts only a week or two before the 2016 election and managed to reach all the hospital's departments.

"A couple of people were relieved because they were worried they weren't going to be able to get out in time to vote but had kept it to themselves and were disappointed, and then someone came by to offer to pick up a ballot for them," he said.

They also have not heard any negative responses from other physicians. "It's been 100% supportive and encouraging from our colleagues," he said, though he acknowledged that a small handful of people in units without any trainees seem to feel burdened by McKenzie's request to talk to patients about whether any wanted to vote.

 "If we didn't have any personal contact with the staff on those units, there was a sense this was extra work we were asking people to do," he said.

McKenzie has also heard from some physicians who worry that, given the concerns about voter suppression and voter fraud, even trying to help patients vote could be viewed suspiciously.

"Any action that is trying to get more people to vote nowadays can be framed as an effort to skew things," he acknowledged, but he counters that they frame their efforts as focused on caring for people's health.

"Social inclusion is an important part of mental health," McKenzie said. "That's hopefully beyond politics and a deeper calling of healthcare."

Beyond those concerns, however, is the reality of how important the opportunity is for any American, especially those with disabilities, Bishop said.

"Voting is the most fundamental right that we have. All of our other rights depend on our vote," Bishop told Medscape Medical News. "We can't shut people with disabilities out of their opportunity to have a say in the matters that have a really drastic impact on their lives."

She continued, "Whether or not you happen to be hospitalized on any given day doesn't change the fact that you're an American and that you have a say in your government."

Those fundamentals are what inspired Okwerekwu as well.

"Knowing that your vote counted is a way of affirming your humanity in a way. It affirms your importance in the community and your place as a stakeholder, someone whose concerns are valid," Okwerekwu said. "It was a lot of work, but to be able to do that for people was awesome."

None of those interviewed have disclosed any relevant financial relationships. No external funding for the study was noted.

J Am Acad Psychiatry Law. 2018 October 31. Full text

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