Overview
Barriers to voting are barriers to health. A new proposal before the U.S. Election Assistance Commission would require documentary proof of citizenship to register for federal elections — blocking millions of eligible voters without improving election security. Evidence shows restrictive voting laws harm public health and deepen inequities. A healthy democracy is essential for a healthy nation.
Civic participation is a determinant of health. When access to the ballot is constrained, communities lose the ability to influence the systems that shape their well-being. Barriers to voting are therefore barriers to health, and they fall hardest on those already marginalized. The U.S. Election Assistance Commission (EAC) is reviewing a proposal from the America First Legal Foundation that would require voters to provide documentary proof of citizenship when registering for federal elections. Such a requirement would block millions of eligible Americans from registering, despite overwhelming evidence that noncitizen voting in federal elections is extraordinarily rare. A 2024 audit in Georgia identified only 20 potential noncitizen registrants out of 8.2 million voters, representing just 0.000002 percent of the electorate. In our public comment, the Network for Public Health Law urged the Commission to reject the proposal.
We don’t need to look far to see the impact of bureaucracy masquerading as security; it harms the very people our systems are meant to serve. When the federal government imposed similar rules for Medicaid under the Deficit Reduction Act of 2005, many eligible citizens lost or delayed access to health coverage because they could not easily produce documents such as birth certificates or passports. The Government Accountability Office found that Kansas denied nearly 20,000 residents, largely children and families, Medicaid coverage for failing to provide documentation, even though officials knew the majority were eligible. In Oregon, stricter documentation rules delayed prenatal care for pregnant women, increasing the risk of preventable complications. These measures didn’t prevent fraud; they increased costs and denied critical services to people who needed them. The same dynamics would likely occur if documentary proof of citizenship were required for voter registration.
The Institute for Responsive Government has contributed important policy analysis on this issue. Their research shows that documentation requirements disproportionately burden people already facing barriers to obtaining identity papers, including people who have changed their names after marriage, rural residents who live far from ID offices, people with lower incomes, and communities of color. These groups are also more likely to experience health disparities, meaning that policies restricting civic participation compound existing inequities. The Institute’s work demonstrates that secure and inclusive election systems can be achieved through modernization rather than exclusion. States that use automatic or same-day voter registration and data-matching with federal agencies have improved both efficiency and election integrity without burdening voters.
This intersection of public health and democracy is not theoretical. The Health and Democracy Index shows that states with inclusive voting laws have better overall health outcomes, including lower rates of chronic disease and higher life expectancy. Civic participation affects health because it shapes the laws that govern social determinants such as housing, education, and access to medical care. When people can vote, they have a voice in the policies that influence the environments in which they live and work. When their access to the ballot is restricted, they lose that power.
Barriers to voting are, in effect, barriers to health equity. Communities that are underrepresented in the political process are often the same ones facing limited access to health services, environmental hazards, and economic instability. Restrictive voting policies reinforce these disparities by excluding people from democratic decisions that could influence the systems hurting them. Conversely, efforts to expand voting access through longer voting hours, mail-in ballots, multilingual materials, and accessible polling locations, are investments in public health.
Ensuring the integrity of elections is vital, but integrity is not achieved by making it harder for citizens to participate. Evidence from the health sector shows that documentary proof requirements waste resources and exclude eligible individuals without improving accuracy or security. The federal voter registration form already includes a legally binding attestation of citizenship under penalty of perjury, which is both effective and consistent with federal law.
A healthy population depends on a healthy democracy; the right to vote is a determinant of health. Public health practitioners, policymakers, advocates, and election officials share a responsibility to ensure that the systems governing civic participation are accessible and equitable. The EAC must reject the proposed rule requiring documentary proof of citizenship and affirm its commitment to a fair and inclusive electoral process. Protecting the right to vote strengthens both our democracy and the nation’s collective well-being.
This post was written by Quang “Q” Dang, J.D., Executive Director, Network for Public Health Law
The Network promotes public health and health equity through non-partisan educational resources and technical assistance. These materials provided are provided solely for educational purposes and do not constitute legal advice. The Network’s provision of these materials does not create an attorney-client relationship with you or any other person and is subject to the Network’s Disclaimer.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.
