Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the Journal's editor in chief, Dr Audiey Kao, with Dr Alister Martin. Dr Martin is an Emergency Medicine Physician and faculty at the Center for Social Justice and Health Equity at Massachusetts General Hospital. He's also Executive Director of VotER, which helps patients get registered to vote. He joined us to talk about the important role of health care professionals and organizations in helping patients get registered to vote, especially during the COVID-19 pandemic. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Alister, thank you for being a guest on Ethics Talk today. [music fades out]
Dr Alister Martin: Thank you for inviting me, Audiey, it's always a pleasure, and I'm very much looking forward to the conversation.
Kao: So, in an election year like no other—
Kao: —the COVID-19 pandemic has disrupted traditional get-out-the-vote activities.
Kao: As a physician on the front lines of this pandemic, you founded an organization called VotER that assists health care professionals and organizations help patients get registered to vote. So, why do you think it's important for clinicians and hospitals to help get patients registered to vote?
Martin: It's a great question, Audiey. Let's start with the basics. COVID-19 has turned voting into a public health issue in 2020. That's the fact. When you think about who the folks are, who do our election administration, these are folks who are out there at the polls, average age of 65 and higher. In a pandemic, these are the individuals you do not want out in an environment where there are long waits and hundreds of people gathered, touching screen, sharing surfaces. That's the first thing. The second is when you look at the data of voter registration rates around the country, in some places they're down as much as 70 percent on the year. And that's because some of these traditional places, like DMVs or voter registration tabling events have all been curtailed because of the restrictions on in-person gatherings or like going to the DMV. One of my family members recently had to go DMV, and they had to create an appointment. When they went, there was no one there. And to sort of think about how the heartbeat of our democracy is the vote, and that's how we help to shape our democracy. It's how we help to shape our health care system. And COVID-19 has really knocked the core of our voter registration apparatus in this country in a significant way.
Martin: It's reduced the ability for folks to register to vote.
And so, to answer your question, why should we care as health care providers and institutions? Well, because who best to talk about public health issues than health care providers, than health institutions? We want to make sure that our patients can vote in a safe and healthy way, and we've got to be committed to that. And the first step along that process is helping folks get registered to vote. And we're seeing across this country at this point over 25,000 doctors, we'll get into, who use VotER, who have the kit or the badge backers in over 200 hospitals and community health centers that use posters and discharge paperwork and other ways to all do this in a nonpartisan way, in a non-interruptive way, in a noncoercive way to help people get registered to vote.
Kao: Yeah. So, can you speak a little bit more about how VotER works and how the response you've gotten from the health community has led to get-out-the-vote registration efforts?
Martin: So, first of all, let's say this is not. It is not health care providers like nurses and doctors walking around ERs with voter registration paperwork and clipboards. We don't have time for that. Our primary mission is the caring for and treating of patients, and that is absolutely the first priority. What it is, is a very low-touch, low-tech way of reminding people, hey, this is something that is probably a good idea to do while you're here, while you're waiting, and something you can do on your own phone.
So, to get into some of the specifics, if you can imagine this for a second. You're at your primary care doctor's office, and you're sitting down in the waiting room. And over your left shoulder, you see a large poster that says, “Our health clinic can now help you get registered to vote. Text this message or use this QR code to register yourself.” And so, you turn around, and you zap the QR code or you send a text message. And you get on your phone, a link, to use the Secretary of State website in that state to register to vote. You can also, if you're interested, get your mail-in ballot. So, that's one way that VotER works.
Another way that VotER works is we've got health care providers, like I mentioned, about 25,000 at this point, who have one of these, which is a healthy democracy kit. This is my badge that I'll wear tomorrow when I go into the ED.
Martin: Often patients ask me, “Hey, Doc, why does your badge say ‘Vote’ on it?”
Martin: “Well, it says ‘Vote’ on it because if you're interested, you can check your voter registration, or you can register to vote or get your mail-in ballot. Just use this QR code or use that text message. And so, often that's sort of the way that we position it, we ask our providers to bring it up. Sometimes I bring it up, and I say, “Do you have a plan to vote, if you're able to, in this election?” And a lot of folks say, “Yeah, I'm planning on voting.” And I say, “Okay, great. Do you know if you're registered?” And a lot of times folks say, “Yeah. Of course, I'm registered.” And I say, “Okay, great. Do you want to check while you're here? It takes two minutes. You do it on your own phone.” And the response has largely been positive. Out of the 25,000 people that use VotER or hospitals that use some of the posters, we've not heard any negative experiences from patients, which is really great. And I think that just belies the nature of this as being a, on surface, I think a lot of folks think it's a controversial issue. But when you really think about it, registering your vote is probably one of the most American and fundamental things that we can do as citizens in this country.
Kao: Well, it sounds like you've made this process as easy as possible for physicians and nurses. That being said, have you had some resistance among your colleagues in terms of them spending time or having to engage in whatever level of training one needs to engage in, to help patients get registered to vote, especially during a pandemic and all that needs to be done to help patients from just a medical health care standpoint?
Martin: It's another really, really good question. You know, what I often hear from folks who are on the fence is, “I don't want to learn about voter registration and all the things that are involved in that.” My answer is, “Neither do I, [laughs] to be quite honest!”
Martin: We have a job. We have a skill set. We are experts in what we do. We do not need to be voter registration experts. And so, what we've done with VotER is we've partnered with a really incredible group called VoteRiders, and they manage a hotline. It's 24/7, either a phone or a text message hotline, depending on what the patient likes. And that hotline, actually can jump in if a patient has any trouble, if they have questions, if they feel like their ID is not up to date or if they just moved. Or like I had recently, I had a guy who, to escape the pandemic, he flew out to St. Kitts in the Bahamas and decided to come back two or three weeks ago. And he saw my badge. He asked me, “Doc, what's up with that badge?” I said, “Well, it can help folks get registered to vote. Are you interested?” And he said, “Well, I'm not sure, actually, because I've been in St. Kitts for six months. Can I still register? Can I still vote? I don't know where my residence is. I'm not sure how that works.” I said, “You know what? I don't know either. But here is the hotline that you can use. They'll take care of it. I got to go see another patient.”
Martin: And so, I circled back. It turns out that he could register to vote because his residence was still in Boston. And I just checked because I wanted to know. I didn't have to. So, that's an example of that.
Kao: Yeah. So, if I can move on and ask you about clinics and hospitals, including those that provide care to many undocumented immigrants.
Kao: These clinics and hospitals may have concerns that voter registration efforts can create an unwelcoming environment for patients who are not eligible to vote. So, what do you say to these health care organizations that are concerned about stigmatizing individuals and communities around eligibility to vote?
Martin: We struggled with this for a lot at the initial stages about a year and a half ago when we were doing some of this initial planning. And what I'll say is two things. The first is that one of the models that we really thought about very hard early on, here at Mass General and some of the other initial pilot sites, was a mandatory process where, when you came in, Audiey, to the E.R., to the community health center, the triage person or the admin person who's getting you your hospital bracelet and does the registration for the E.R. also mandatorily asks you, “And by the way, if you're interested, you can register to vote here. Let me send you a link.” And that was one of the initial models that we were sort of playing with and we ideated around.
Martin: And then we very quickly stumbled on, and we got some really good feedback, from some of our patients and some of the folks that we're using in our initial focus groups around the fact that it could be exactly as you described, stigmatizing. And so, that's why we did not decide to go down that path. Instead, what we have is a system where, if the patient wants to engage, they can engage, right? If they want to use the posters to register themselves, it's them that's doing their voter registration. There's absolutely no mandate for them to use it, to do it. It's just another thing that's there for the patient.
So, I think that the core of who is doing the voter registration being stuck onto the patient, being sort of shifted from the provider, from the hospital onto the patient, it's just their decision to do it or not is really, really, really, really critical.
Now, point number two is, your question's a very good one. Well, does posters or the idea of voter registration in an institution in of itself stigmatize or create a problem for undocumented folks, well, I would ask a question in reverse, which is, well, when you go to the DMV, when we talk about voter registration at the DMV and there's signage, the signage, there's someone who asks you actually mandatorily, right, when you're at the DMV, when you're getting your driver's license. Does that stigmatize folks, or does that create a place where folks don't want to use the DMV if they're undocumented? And I would say I think we need more data to sort of figure out if it's actually true that posters and other resources that are available for people optionally, does that actually hurt the undocumented population? And so, I think it's something we should absolutely look further into. But I think what our own sort of internal planning process revealed was that we can't have mandatory systems. We can't be asking everybody who comes into these hospitals and E.R.s, “Are you registered to vote or not? Do you want to register,” because of your reason, your point exactly.
Kao: Yeah. Well, I appreciate your evidence-based approach to addressing these issues, because I think that's a very prudent and appropriate one. So finally, as we near the end of our conversation, as you alluded to earlier in our conversation, COVID-19 has dramatically exposed the disproportionate health impact, public policy failures on disenfranchised communities. And separate from registering or getting registered to vote, who we ultimately elect to represent us will largely determine the direction of public policy. In other words, elections have consequences. It's also commonplace for a patient to ask a physician, “What would you do if you were me, Doc?” So, how should clinicians respond when they are asked, “Who would you vote for if you were me?”
Martin: The first and most important thing that we communicate to every single doctor, nurse, PA, MP, medical student who uses VotER or every health institution that decides to partner with VotER is the importance of nonpartisanship, the importance of not using these materials for campaigns or candidates or for any particular policy position or ballot measure. This is simply about registering to vote, and that's where the line ends. When you look at the law first of all, the 1993 National Voter Registration Act stipulated that hospitals are allowed to register people to vote. In fact, any institution that gives public assistance is allowed and encouraged to register people to vote, but they must do so in a nonpartisan way. So, it's principally important that everyone sort of understands that from get, from jump, from the beginning.
Now, to answer your question directly around sort of how I respond or how we teach our providers to respond when the question comes up of, “Okay, no. But seriously, Doc, who are you voting for?” What we say is a couple of different things. The first, you know, “As your doctor, I cannot tell you who to vote for. But what I can tell you is that it's incredibly important for you to use your voice. 80 percent of your health is due to what we call the social determinants of health, and only 20 percent is actually sort of what's happening in this roof and in between these walls of this exam room. And so, in order for us to make you healthier, we need to be doing all we can to vote for the policies and for the positions that make the social determinants of health in your environment, your lived experience, healthier for you.” And so, in short, we tell our docs to say, “We can't tell you who to vote for, but what's important is voting. It does not matter who you vote for. It does not matter which position you take or what stance you have on that ballot measure. I'm going to take care of you no matter what.” And that's really, really important.
The second thing that I often get fond of saying is patients will ask, “Doc, who you voting for?” And I say, “I'm voting for you! I'm voting for you. I am voting to make sure that my voice is heard to create a healthier health care system and a more fair and just health policy apparatus that can take care of patients. And you should be part of that process, too.” So, those are the two typical responses.
The third, when I really just want to get out of there, I say, “Well, you know what? There's a very good nonpartisan resource called VOTE411. They can give you some information on the candidates. And from there, I think it's up to you to make your own decision. Talk to friends and family about it.” So, those are three responses that we typically give.
Kao: Yeah. So, on that note, I want to thank Dr Alister Martin for sharing his insights and passions about voting with our audience today. Alister, thank you again for being a guest on Ethics Talk.
Martin: Thank you, Audiey. This is amazing. Please continue to keep ethics at the forefront of these conversations and your important voice in space. So, thank you for doing what you're doing.
Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. And finally, to our viewing audience, we are only a few weeks or so away from Election Day. For those who still have not registered to vote, you may still have time. And I encourage you to visit vote.gov or vote.org and find out how to get registered in your state. And to everyone still planning to vote, educate yourself about public policy positions espoused by candidates before casting your vote. Be safe and be well. We'll see you next time on Ethics Talk. [bright theme music plays]
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