Aletha Maybank, MD, MPH: Good afternoon, everyone. Welcome to the next edition of Prioritizing Equity with the American Medical Association. I am Dr Aletha Maybank, chief health equity officer here at the AMA. We have an exciting show again today.
Before we get into the show, I just want to remind people of some of the resources that we have. We have still our Health Equity Resource Center for COVID-19, which is on our AMA website. And that is where you will actually find all the previous prioritizing equity playlists and all of the folks in conversations that we've had in the past. And for those who also are interested eventually to get credit for participating or watching, we are also working with our educational hub to transform these so that they can be educational tools of which you can get some credit for as well.
And then, also really don't want folks to forget also to check out on the website. We just launched a couple weeks ago, an activity on the website in which you can actually see other health equity initiatives that are happening across the United States and see how other health care, governmental and community-based organizations are working to provide resources, and organizing for minoritized and marginalized communities across the country. We received a lot of inquiry and asks about what are other people doing. And so we thought it would be really great if we could provide some central resource around what other folks are doing all across the country.
So as we move in today, our topic is voting. We are less than 50 days to go before the 2020 presidential election here in this country. We have a recent article. Our Department of Ethics at AMA is quite phenomenal actually, and very great truth-tellers. We had our Dr Audiey Kao, who wrote a piece on the health of We The People, which really talks about and highlights the status of our body politics since COVID and the power of the people, but especially physicians' role to strengthen it.
And so today's discussion will not only focus on the importance of voting, but will also feature two physicians and leaders who are currently finding ways to amplify the importance of voting as it relates to health equity and really cover both the immediate and long-term health equity considerations and its impacts.
So today we have, and returning, because we had Dr Manisha Sharma before, who is a fellow of the American Academy of Family Physicians, but is also co-founder of Vote Health 2020, and at the California Health Care Foundation, she's a leadership fellow. And then we have—hi, Dr Manisha.
Then we have Dr Nathan Chomilo who is a fellow of American Academy of Pediatrics, and he is medical director for the State of Minnesota's Medicaid and Minnesota Care. And currently is interim policy and advocacy work group chair for the American Academy of Pediatrics, Section of Minority Health, Equity, and Inclusion. And AAP, we work very close. We work very closely actually with both of your academies, which is exciting.
All right. So first I'm going to start off with how are you all doing, how I usually start off, where you are in this country and just how are you doing at this point in time during this code response.
So Dr Sharma, would you like to start?
Manisha A. Sharma, MD, FAAFP: Sure. So how am I doing? Well, I think I—the repeating line in my head is, “I'm doing.”
And I think I've had lots of dips and highs and dips and highs throughout this whole entire year. And right now, I think I'm on a upswing in terms of knowing that there's a lot of work to do. There's a lot of ways to really be engaged in our country. I think I'm enraged by some of the things, again, that keep coming up this year, just what's happening in Georgia, just what's happening to women, people of color, our health care coworkers, our patients, our communities. So I think there are days where I feel like the world's burning, and I'm like, “Ahhh.” But then there's other days I'm not going down without a fight. So I think I'm in that space right now. I'm in San Diego at the moment, by the way.
Maybank: Which is a state in which it actually is burning. Unfortunately, right?
Sharma: Burning, literally burning.
Maybank: Literally burning. Thank you for that, Manisha. And I'm probably going to go to first names at this point in time. So Nathan, how about you? Where are you and how are you doing?
Nathan T. Chomilo, MD, FAAP: Yeah. So I'm in clinic, as you can see. I've been wearing scrubs in clinic since this all started. And I have clinic in a suburb just north of Minneapolis. And so, yeah, it's been a little bit of a rough week.
I got COVID tested for the third time since the pandemic because of symptoms and exposures, and thankfully negative, and thankfully family's all healthy. But that's all. It's kind of a stress when you're trying to manage what quarantine might have to look like personally, professionally, and then admits to everything that Manisha has already touched upon, which has been kind of just a slow build over from the time you start to kind of really become aware of how structural racism and inequity works, and wanting to change it, to the exacerbations we've seen in the last several years, in particular, coupled with COVID-19.
So yeah, it's been tough, but I think there's a lot of opportunity to do good, and inspired by people like former representative John Lewis, to make good trouble. So hopefully we can get into some of that today.
Maybank: That's right. So speaking of that and good trouble, and thank you for sharing. So, why should physicians be in good trouble as it relates to voting? We're in this space, so we get it, but not everybody believes that. We've seen plenty of articles, whether they're medical journals and peer review articles. We've seen more public facing articles and popular media, that it's not the role of physicians and med school students, and residents to be engaged, civically in this way. So can you talk about why? Why is it important that we are engaged as a physician community in advocating for voting for ourselves as well as for our patients?
Sharma: Yeah, I can start. So, there's a couple of ways to think about this. One is that this concept of voting as being political is actually a myth, right? Sorry. I'm so sorry. Hold on. Actually, Nathan, you could go ahead. Let me just—
Chomilo: Yeah. So, as Dr Manisha was saying, voting as the concept of it being political, is a myth. It's a part of our civic engagement. It's a part of being in a representative democracy. And as physicians, we certainly have a role both to help inform that process and be civically engaged, but also help empower our patients and communities so that they can be engaged in the process, and that their needs can be heard by their elected leaders.
And so, just the very idea that voting is something taboo has been much more of a cultural shift but not actually based in how our functional representative democracy really works, a healthy representative democracy really works.
Maybank: Thank you. Manisha go ahead.
Sharma: Sorry about that.
Maybank: No worries, all good.
Sharma: …Yeah, I hope, I apologize if I repeat what Nathan may have said but one of the things that I think is really key here is that our friend Daniel Dawes wrote this really great book called Political Determinants of Health, and the first line in the book says, “The care of human life and happiness and not their destruction is the first and only legitimate object of good governments.” Now that was written by Thomas Jefferson at the indoctrination of our country. And as physicians our job is to care for human life. We are there to protect our patients. We're taught to think about bio-psycho-social histories because we're actually taught to think about the things that surround their health. And actually in the integration of health with voting.
And so, the thing is to me this is like we are naturally, doctors are naturally stewards of good governance. We are naturally stewards of good health. And so to me, the whole concept here is that voting, the act of voting is literally a human right. And so, and it's a civic right, it's a civil right as a citizen. So, it's not far removed from each other. I think when you start to politicize the component of what voting is that helps me think through, well I have to ask the question, “Why are you politicizing a human right?”
And so, that to me is really why I think it's really important that physicians, we're natural champions. We have people come to us at their most vulnerable times of their life. They come to us to tell us about everything and anything that's going on with them. And it's not about the disease that they're coming to talk to us about, it's everything that surrounds that. So, I would say that that is exactly why we need to be champions of this work, and it needs to actually be built into our preventive care and how we train and how we are and look at it as preventative care period.
Maybank: Absolutely. When these conversations happen I talk to folks about when narratives and myths get pushed forward, oftentimes there might be another agenda or it's served as a distraction. Because the reality is, is that physicians—and I look at the history of the AMA and who the AMA is at this time—we have always been engaged in the political environment, we're a lobbying body. So clearly physician organizations and associations understand the importance of being an engaged in our democracy and having those relationships but also having power and power to influence and make decisions to improve and develop our health care system. So, we've been engaged in very direct ways in this democracy as physician communities.
Sharma: If I could add one of my favorite quotes is from Alice Walker, and it says, “The most common way people give up their power is by thinking they don't have any.”
And one of the other pieces of this is in physician community it's that there's statistics and there's literature out there that shows that we actually, physicians, we just don't vote. We also vote less than lawyers which is in its own right crazy. And so, I think part of why I think this concept of voting and understanding that our colleagues need to feel like they feel empowered to also go vote. We need to have our patients and communities to feel empowered on voting because voting is the number one thing that allows us to hold democracy accountable period. And that to me is so key to how we think about health. Health is everyone's business, and therefore, we have to hold the health community accountable and that's also part with voting as well.
Maybank: Absolutely. And so, in saying that we have to hold accountability during this time you all are doing and engaged in very key partnerships and to hold the physician community accountable or the health care workforce accountable to voting. And so Nathan, American Academy of Pediatrics has partnered with VotER and can you talk a little bit more about that partnership, why AAP thought it was important to do so at this time and what are the actions and activities that you all are engaged in?
Chomilo: Yeah. Thank you. So the work group that I've been a part of with the section on minority health equity inclusion of the policy and advocacy work group was mulling over multiple different campaigns we could do in 2020 to really get our members involved in advocacy and policy. And we kept coming back to voting and the election being one of the ways whether you're talking about gun violence or climate change and environmental racism. Whether you're talking about access to Medicaid or other ways structural racism works. Really voting is one of the first things you need to be doing to really start impacting long-term and short-term change. And so, we had started to get together this campaign that we were going to do and when we were talking to the AAP governmental staff they were really interested in having health equity become a focus of the Get Out the Vote campaign for the American Academy of Pediatrics when they really learned more about the connection between voting and health equity.
And along the lines of, so there's a component of education there but then there needs to be a component of action as well. And that's where the partnership with VotER really has come up and really helped give us a way to direct our members to tools that can really help engage patients where they are at, give them the information they need to know. Are you registered or not? If you are registered, are you signed up for mail-in voting if that's an option for you and how can you fight to figure that out? And in ways that meet patients through technology or just even a text message. And so, I think that was where the connection came is really what are some of the practical tools that we can give after we've already done some education around why this is important.
Maybank: Thank you. Thanks for that. Manisha, and so you've engaged with VoteHealth, you're co-founder of VoteHealth also working to encourage physicians and the health care workforce to vote as well. Can you talk some about that? And then we'll talk about the connection between the two. But if you could just talk first about VoteHealth and where it came from and why?
Sharma: Yeah. So VoteHealth 2020 is basically we are a bunch of health care providers, physicians mainly, where just like what we're talking about we are very concerned about the fact that voting wasn't a part of our day to day but we were also really concerned that our colleagues weren't voting.
And so I've actually personally been involved in voting period, just in terms of thinking about it and through preventive care. I did a project in the Bronx, and I actually published on the paper, just really thinking about how do you bring it towards FQHCs and just in our milieu. So we basically decided that we wanted, so there's so many people doing such amazing work in the health care workforce on voting. And what we thought was like, “How do we create a movement in a collective?” And being able to bring everybody to the same place, to learn from each other and to expand how to create ways to get people to understand how to make this, sort of socialize this into their milieu wherever they are, in their communities, their churches, their health care centers, their hospitals.
So, that's actually where it really grew organically, and that's how we decided to create VoteHealth 2020. We wanted to create a platform that allowed for an exchange of idea. What we did was we said, “Okay, so in order to do that, we needed to think about the tools,” just like Nathan was mentioning on what VotER did. And what we realized is that not everyone's got access to technology, not everyone's tech savvy. So we were like, “How do you create old school meets new school, right?” And my first career, I was a musician. And so, how did we get people to come to the clubs? Well, we handed them out postcards and flyers. And so what we did was we sort of souped up what we had done in the Bronx actually 10 years ago and souped it up and made it really sexy for 2020, and really created sort of a collage of old school meets new school.
So, as you can see, there's a QR code, that's the new school piece. So, if anybody's watching right now, you can actually really register to vote right now by swinging your camera on the QR code and register. But then we also have flyers, we just hand out to our patients. We have stickers that we put on gas pumps and in the grocery stores, wherever you may be. And so that was really what we wanted to do is create a movement. We know that this election is really important for people, but we actually wanted to make this about past the election. How do you think about local politics, state politics? How do you look at politics and just elections as being your chance at a voice for your community to do better? We just know health disparities echo civic disparities period. The wealthier and healthier get more, and they end up voting more. So now this is a way to create a movement past November, but also for November as well.
Maybank: Great. Nathan, I saw you unmute yourself, do you have something to add?
Chomilo: Yeah, I mean, because I think it really dovetails with how I talk to patients and parents and caregivers of my patients about voting. And there's kind of the two-pronged approach of why it really should be something we're talking about now. One is certainly the acute pandemic and you need to have a plan to vote safely and maintain your health and the health of your household to the best as possible. And then two is that we know that communities where there is more civic engagement, there is more voter participation, they are healthier. And that is thought to be in part because they get more resources, because their elected officials are more responsive to them. And in fact one of the kind of correlations that you can kind of make is we see there's a voting inequity, there's less voter participation, particularly from low income, minority, and other historically under-resourced populations.
And those, when they don't show up to vote, then politicians are less actually responsive to those communities' needs. They are more responsive to those who show up, they're more responsive to the healthy voters, they're more responsive to the wealthy voters. And then those policies that they then champion are reflective of those citizens' needs.
And so there is a political science study that looked and saw that if a state had higher engagement or disproportionate engagement from its wealthy and healthy population to the average wealth and health of the population, then they had actually less investment in things like Medicaid. They had less generous Medicaid programs, less likely to take up ACA expansion. And then when you look at heat maps of where we are seeing COVID break out the worst right now, it's really in many of the states we don't have ACA and many of the states that disproportionately have most of our African American populations. And so there's like a direct connection, both short-term and long-term to having our voting electorate represent our complete country and our complete country's needs instead of just the healthy and the wealthy.
Maybank: Thank you. Very helpful. So to that point, two questions in a way. First, knowing the climate right now, in terms of all the potential barriers to registration as well as availability of polling sites, mail-in issues, what are you all telling the physician and the health care workforce community in terms of messaging to their patients and to one another around these obstacles or navigating through these obstacles that we know are going to exist or that exist actually now?
Chomilo: Yeah. I'll start by saying, I think it kind of first this gets back to one of Manisha's first points is that we need to be prepared to vote ourselves. Right? And so I'm talking to my colleagues, I'm talking to the nurses and rooming staff and others that I work with about, “Do you guys have a plan to vote?” And so I think once we educate ourselves on what our plan is, we have a better idea of how we can educate the patients in our communities and know what are the unique barriers within our community. Right? And so I think that's a really good first step to help both educate ourselves as well as our communities that we're serving.
Sharma: Yeah. I want to add to what Nathan is saying. I think, yeah, so he's right, like first we have to educate ourselves, but I think there's also like an operational and implementational component to this as well. So, one of that is, is that we just need to socialize it. Are you wearing seat belts? Did you get your vaccines? Did you register to vote? That's like in an exam room and that's on the grassroots level of doing that. As you were saying that, to Nathan's point, if I'm talking to my nurses or doctors, saying, “Yeah, do you have a plan to go vote? Did you register?” Registering's the first step. And right now registering deadline, deadlines are actually occurring in the next two to three weeks pretty much across the country. Then it's after registering to vote, “Are you sure you registered to vote? Check your status.”
Then like doing it in two minutes. Like we now have technology to make it so we can even help those folks to do it. Nathan's wearing a VoteER badge, he can literally flash that to his nurse. Right, exactly. He could flash that to his nurse. We have tools on our website that allows for us to have people create it in stickers and all these different things. But that's one piece. The second piece is, is that now it's also talking about administration. So Nathan and I both hold positions of, if you will, power in terms of really being able to influence those who make decisions within our health setup of wherever we are by asking them, “Are you going to excuse people to go and vote?”
And then being able to say, “Hey, CEO or CMO of said place, are you allowing people to go vote?” We are logistically doctors and nurses. We just, because we're not a country that has voting as being a holiday, we logistically just don't have time to go wherever we are. Right?
Sharma: So mail-in ballots become sort of an essential way. I really want us to all stress, like there's ways to do this, especially amongst the pandemic. There's other things also. We can be poll workers. We can help our communities. The poll workers, our average age are 60 and over. All we have to do is call our election board and ask them, “Are you holding a polling site? Where are the polling sites?” And then volunteer as health care workers at those places, so we can ensure that people who are voting that day at a polling site are being safe. There's safety happening within that space. There's a lot of ways that we can start thinking about these things.
One of the things that we do at VoteHealth 2020 is helping people figure a how. Meeting them where they're at and figuring out a how. Sometimes it's just simple as, “What do I tell my patients?” Just like Nathan was saying. “How do I bring it into my physical? How do I this, how do I that?” We are trying to build a movement by helping people see what other people are doing across the country so we can exchange that information and we're the dot connectors to do that.
Maybank: Yes. Nathan, go ahead.
Chomilo: Just wanted to kind of build upon that. There actually is a National Voter Registration Act, 1993, that provides that any venue that provides public assistance, like Medicaid, is empowered to register people to vote. If you are working in a setting where Medicaid enrollees are getting services, you have a right in law to help them register to vote. That's something that you can point to if you start getting any initial pushback.
Then I really liked the piece of talking to our staff and helping figure out ways to make sure that they have the time off that they need because I think that's something that often goes overlooked, thinking about residents and medical students and fellows that you might be in charge of those days and helping facilitate their voting.
Then I think the other piece, sorry, I just had a brain fart. Oh, so, the other piece that you brought up, Aletha, was about the different kinds of barriers to voting. I think in the scripting, it's something that was brought up in one of the webinars that the AEP was how we talk in the presence where there might be people in the households who currently can't vote. I think really being, whether it because they're caught up in the criminal justice system or not. That's why I like asking, “Do you have a plan to vote?” If not, then you can build from there but holding that truth out there too, and knowing that some of these conversations can be uncomfortable, but we have uncomfortable conversations all the time in medicine and this is one that's important for our health as well.
Sharma: Yeah, in fact, I want to add one more thing. Nathan brought up a good point about the National Voter Registration Act. It is the law that actually protects people to do nonpartisan voter registration, but there's also the HERSA and BPHC support, which actually says FQHCs are obligated to do these things, community health centered work, and then there's an IRS code that actually gives you, if you're a 501(c)(3), no matter, it's most teaching hospitals are 501(c)(3)s, and it actually says states you can run nonpartisan voter registration. Whenever there's pushback on it, not being legal, well, that's a myth. Here's the myth busting. These are really key things that people just sort of take no for an answer. I'm encouraging people to not take no for an answer. In a sea of nos, you need one yes and that's all it is. Then go to your government relations folks, go to the folks who know the law, and they can't refute. They cannot deny it.
The other piece I wanted to add to what Nathan was saying also is is that, at the end of the day, that if you believe in the fact that this is good trouble, I'm going to bring up John Lewis. If you believe in the fact that voting is our rights, it's a human right, then there is no way to separate that from health, period. I really want to stress that. All of the physicians that are here today listening, it is really imperative that you understand that you have a voice and you have power and right now, more than anything in, especially in pandemic time, elected officials are listening to us. This is our chance to actually get to push this concept and bring it into our space always.
Maybank: Well, thank you. We're at the end of the show. I knew this was going to be a great conversation. I knew I wasn't going to have to say much either with the two of you, which is wonderful. I just really thank you for your leadership, for the time that you have been able to spend with me today and just encouraging and pushing and busting those myths. I think that that's absolutely critical and allowing us to very much understand that this is a right and that we should be participating in our democracy.
Thank you all again, thank you all who tuned in and join us for the next episode on October 1 that we'll be talking with the Chicago response team that launched racial equity response groups across Chicago. Thanks a lot and see you all soon.
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