Abstract
Introduction:
Emergency voting services are available to hospitalized patients in many states, yet little is known about implementation or participating patients.
Methods:
During the March and November 2024 elections, volunteers at two University of California, San Francisco hospitals collaborated with the San Francisco Department of Elections to offer emergency voting services to 598 patients.
Results:
Among 101 participants, 28.7% were Black, 36.6% experienced housing instability, and 93.1% were publicly insured. Participants overwhelmingly agreed that hospitals should help patients vote.
Discussion:
Findings underscore hospitals’ role in expanding electoral access for underrepresented populations.
Health Equity Implications:
Hospital-based voting may address structural barriers and promote voting among historically underrepresented groups.
Introduction
In the United States (US), voter turnout is disproportionately lower among racial and ethnic minorities 1 and those with chronic health conditions.2,3 Hospital-based voter initiatives may serve as a unique approach for engaging these patient populations. 4 A recent study found that utilization of Vot-ER’s health care-based voter registration tools increased voter turnout among populations underrepresented in US elections. 4 Similar initiatives to register voters in health care settings have also shown success.5–7 However, these efforts have focused on voter registration while strategies to help hospitalized patients cast ballots remain understudied. Most states offer emergency absentee voting on Election Day for hospitalized individuals, 8 yet no study has characterized the sociodemographic and clinical characteristics of hospitalized voters who use these processes.
This study aimed to describe a) a hospital-based emergency voting initiative for Election Day, b) participants’ sociodemographic and clinical characteristics, and c) participants’ previously encountered voting barriers and interests in hospital-based emergency voting.
Methods
For this initiative, volunteer medical providers, staff, and trainees at the University of California, San Francisco (UCSF) collaborated with the San Francisco Department of Elections (DOE) to provide emergency voting services during the March and November 2024 elections. The initiative took place at two academic hospitals: UCSF Parnassus, a quaternary care hospital, and Zuckerberg San Francisco General (ZSFG), a public safety-net hospital. Participants were San Francisco County residents who were eligible to vote in California (i.e., US citizens aged ≥18 years and not serving a sentence for a felony conviction).
Voting outreach occurred at both hospitals’ emergency departments and ZSFG’s inpatient units and on-site skilled nursing facility. Volunteers completed an orientation and worked 4 hour shifts on March 4–5 and November 4–5, 2024.
Patients receiving care at UCSF Parnassus and ZSFG were approached about their plans for voting on the day before Election Day (inpatient units at ZSFG) and on Election Day (emergency departments at both sites and inpatient units at ZSFG). Outreach was limited to this time frame rather than the entire early voting period due to volunteer capacity and unpredictable length of stay. Eligible and interested patients completed a DOE ballot request form and optional survey on their previously encountered voting barriers and interests in hospital-based emergency voting. Completed forms were securely emailed to the DOE, which delivered ballots to the two hospitals every 4 hour on Election Day.
California law allows voters facing a medical emergency or confinement to request emergency ballots and receive voting assistance from any person of their choosing, excluding employers or union representatives.9,10 In addition, California law expressly permits same
Post-initiative, survey results were analyzed, and a retrospective chart review was conducted to assess participants’ sociodemographic and clinical characteristics. This retrospective chart review was approved by the UCSF Institutional Review Board and included a waiver of informed consent.
Results
We approached 255 and 343 patients about obtaining a ballot for the March and November 2024 elections, respectively. Of the 598 patients collectively approached, 97 (16.2%) were ineligible to vote, 186 (31.1%) were uninterested, and 127 (21.2%) had already voted (Table 1). Among survey completers, 22 (21.7%) patients reported not being registered to vote in California. Overall, 101 (16.9%) patients completed ballot request forms, and among those, 67 (66.3%) cast ballots and 34 (33.7%) patients requested but did not ultimately cast them through our initiative due to medical decompensation 8 (7.9%), hospital discharge before ballot delivery 19 (18.8%), loss of interest in voting 4 (4.0%), and requests to drop off the ballots themselves 3 (3.0%). Incomplete ballots were reported and returned to the DOE.
Patient Responses to Optional Voting Experiences Survey
This question was administered to all 255 patients approached in March and 343 patients approached in November.
These questions were optional for patients who signed a ballot request form.
Patients could select multiple responses to this question. Each response was recorded separately in the table.
Patient demographics varied among participants. Twenty-nine (28.7%) patients who completed a ballot request form identified as Black, 24 (23.8%) identified as White, 13 (12.9%) identified as Asian, 1 (1.0%) identified as Native Hawaiian and Pacific Islander, and 24 (23.8%) identified as other. Housing insecurity was common; 37 (36.6%) experienced homelessness or unstable housing (Table 2). Nearly all patients, 94 (93.1%), were publicly insured (Medicaid: 47 [46.5%], Medicare: 10 [9.9%], both: 37 [36.6%]).
Sociodemographic and Clinical Characteristics of Participants
Zuckerberg San Francisco General Hospital.
University of California, San Francisco.
Other languages included Cantonese, Spanish, and Tagalog.
Unstable housing included living outside or in a shelter, temporary housing, hotel, single-room occupancy, or sober living facility.
ZSFG on-site skilled nursing facility was closed in November 2024.
Other services included neurology, neurology intensive care unit, cardiology, general surgery, obstetrics and gynecology, gynecological oncology, and family medicine.
SD, standard deviation.
Among survey respondents (n = 94), the most common voting barriers previously encountered included difficulty registering (n = 12, 12.8%) and physical health (n = 16, 17.0%; Table 1). Notably, most respondents (n = 77, 93.5%) agreed that “Hospitals should increase access to voting for patients before and during election days.”
Discussion
Our study highlighted how a hospital-based emergency voting initiative provided same-day voter registration services and emergency absentee ballots on two Election Days in March and November 2024. Unlike prior health care-based initiatives focused solely on registering voters,4–7 our work helped patients hospitalized or admitted to the emergency department register and cast ballots on Election Day.
We engaged both patients with short- and long-term hospitalizations and those from groups historically underrepresented in the electoral process. Among participants who completed a ballot request form, a high percentage of individuals were Black, experiencing homelessness, or publicly insured—all populations with disproportionately lower voter turnout.1,12 Notably, >20% of participants used the initiative to register to vote, including several first-time voters. In conjunction with our findings, a recent cross-sectional study found that health care-based voter mobilization is particularly useful for reaching more racially and ethnically diverse populations compared with efforts led by political campaigns. 4 Taken together with the findings from our initiative, these results highlight how hospital-based initiatives can help enfranchise underrepresented populations in the electorate. 4
In addition to direct voter engagement, we conducted a survey that identified barriers patients previously faced when trying to vote, including difficulty registering and health-related challenges. Some barriers, such as registration difficulties, may reflect limited awareness of alternative voting options (e.g., online or same-day registration). Given the disproportionate impact of restrictive voting laws on marginalized communities, 13 addressing these challenges is critical. As reflected by our initiative and study results, hospitals can help mitigate these barriers by increasing voting access for individuals receiving inpatient or emergency care on Election Day.
Finally, nearly all survey respondents (93.5%) agreed that hospitals should help patients vote on Election Day. This broad patient support reinforces the imperative for hospitals to expand emergency voting services in the emergency department and inpatient settings.
The success of our initiative was dependent on close collaboration with the San Francisco DOE and support from hospital administration. Future efforts could expand outreach by partnering with multiple county election offices. In addition, although our initiative relied on volunteers, institutionalizing such programs through paid staff or dedicated volunteers may enhance sustainability and enable extension of the outreach period.
Health Equity Implications
Restrictive voting laws have increased in recent years, 14 disproportionately affecting communities already burdened by health inequities—particularly racial and ethnic minorities, 15 individuals with chronic illnesses, 3 and those experiencing housing instability. 16 Medical institutions are increasingly recognizing voting as a social determinant of health,17,18 given its impact on access to medical care, housing, economic stability, and other factors that affect health.19,20 Specifically, voting is associated with better mental health in adolescents, 21 and higher voter turnout has been linked to better physical and mental health outcomes across populations. 22 Ensuring voting access for populations most burdened by health inequities is essential to promoting inclusion in the policy-making processes that shape health outcomes. 23
Expanding voting access must involve a collaborative approach across multiple sectors in society, and hospitals can and should commit to promoting voting access for individuals who are ill and receiving hospital-based care during elections. By offering emergency voting services to patients, hospitals can help ensure that more individuals—especially those often excluded—have their voices and needs represented in the democratic process.
Footnotes
Acknowledgments
The authors would like to thank the San Francisco Department of Elections and their volunteers for their partnership in this initiative.
Authors’ Contributions
T.R.R. was responsible for the conception, design, execution, and drafting of the article. S.R., M.F., and V.L. contributed to data collection and analysis, and article review. Y.P.H. and I.R.G.-G. provided oversight and reviewed and revised the article for critical content.
Human Ethics and Consent to Participate
This retrospective evaluation of de-identified data was approved by the University of California, San Francisco Institutional Review Board and included a waiver of informed consent.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.