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The act of voting is at the heart of a healthy democracy. A growing body of research is building the case that voting also plays an important role in physical health – which affects who votes.

Experts on this back-and-forth say the connections are a weave of cultural, political and other factors that studies are just starting to unravel. But it's far from a fringe concept. Groups such as the American Medical Association, ·¬ÇÑÊÓƵ and American College of Physicians have endorsed the idea that voting plays a role in health, making voting access something that health care professionals should be addressing.

"I think there's a clarity that's growing" about the connections, said Dr. Anita Chandra, vice president and director of RAND Social and Economic Well-Being, which is based in Arlington, Virginia. Chandra co-wrote a on how civic engagement, which includes activities such voting and volunteering, is linked with physical and mental health and overall well-being.

Just a decade ago, the idea of linking voting and health was controversial, said Chandra, whose background is in public health and child development. Today, she said, voting and other forms of civic engagement are increasingly seen as an essential element of health.

Researchers describe the process as a kind of loop: Health can affect someone's ability to vote. Voting has a direct effect on public policy. That, in turn, influences people's health.

"It's not just about making sure people who are not in optimal health are engaged and voting," Chandra said, but how voting affects things such as access to parks, construction of safe sidewalks and other public policies that affect health.

In one historical example, after women in the U.S. won the right to vote in 1920, elected officials enacted public health measures championed by women, and child deaths fell by 20,000 a year, according to a in the Quarterly Journal of Economics.

Dr. Ross Arena, a professor who is head of the department of physical therapy at the University of Illinois Chicago, has co-written several studies that look at connections between regional culture, voting and health.

One study, published in in August, found that counties with low voter turnout fared worse on a health index that included items such as physical activity, mental health, heart disease and whether a person currently smoked. The findings suggest "poor health may be a powerful contributor to lower participation in the voting process," Arena and his colleagues wrote.

Other factors that influence voter participation include age, race, education and income, as does access to voting methods, which varies by state.

Another article, published in in 2023, found that better access to voting correlated with better health as measured by an index of 12 factors such as premature mortality, infant mortality, active physicians and poverty.

Dr. Julianna Pacheco, a professor of political science at the University of Iowa in Iowa City, said that while the connections between voting and health are "pretty clear," there are also nuances.

"If a person has physical limitations, it might be harder to get to the polls and especially burdensome to navigate the process of obtaining an absentee ballot," depending on where they live. "For a person who is depressed, politics may not be something that is on their minds, and it may be extra difficult to learn about the candidates in a way to inform the vote."

While some researchers have found that early civic engagement is associated with less depression later in life, Pacheco's has shown how depression is linked to a lower likelihood of voting later in adulthood. Her research also found that poor self-rated health at the end of adolescence is associated with a lower chance of someone voting in their first election.

Work by Pacheco and her colleagues shows that being in an educated family might mitigate the effect of poor health on voting among young people. suggests poor health depresses turnout among low-income voters but not wealthier ones.

The correlations vary by disease. One , published in the Journal of Health Politics, Policy and Law, looked at data from eight states in the 2008 election and found that people with cancer were more likely to vote than their peers without cancer, whereas people with heart disease were less likely to vote than those without heart problems.

"Different health issues sometimes create community," Chandra said, and some of those communities might be more supportive of political activity.

That sense of community, whether around a health condition or something broader, can be another piece of the puzzle in how voting contributes to health. Social isolation is a well-established risk factor for poor heart health and other problems. But voting, Chandra said, is an act of participation that provides a sense of connection as well as a "sense of agency" that a person has a voice.

Some researchers have suggested that if unhealthy people don't have access to the polls, it could lead to a "health bias" in public policy, favoring the needs of healthier people.

The U.S. Office of Disease Prevention and Health Promotion includes increasing voter participation among the objectives of its Healthy 2030 project, a collection of data-driven goals aimed at improving public health.

While recent national elections have had the highest turnout in decades, a 2023 report found that only 66% of those eligible voted in the 2020 presidential election and only 46% turned out for the 2022 midterms. In the nation's largest cities, is even lower – a median 20% for municipal elections, according to researchers at Portland State University.

Arena is among those who say health care professionals at all levels have an important role to play in boosting voter access. "It should be considered part of your professional responsibility to advocate for voting rights and access to voting," he said.

One effort to register people in waiting areas at two Bronx clinics in New York City during a 12-week period in 2012 successfully registered 114 people – 89% of those who were eligible. The effort was written about in the .

Arena and Pacheco noted the success of nonpartisan efforts that give physicians and nurses badges with QR codes that link patients to voter registration information or let them request absentee ballots as local laws allow.

"A lot of people do not vote simply because nobody asks them to," said Pacheco, who said federal law gives community health care centers the discretion to support nonpartisan voter registration efforts.

Some politicians consider such efforts to be partisan. But the showed that the strength of the connection between poor health and low voter turnout was similar in Democratic and Republican regions. That suggests the influence of health on participation transcends political affiliation.

"The correlations are pretty consistent," he said. And once anyone has poor health, it could be a barrier to voting "no matter what your ideology."

Arena's long-term goal in exploring the connections is to find ways to reach people who, for partisan or cultural reasons, have tuned out messages about public health. "We're not resonating with big parts of the country," he said.

But, he said, "if, in fact, political ideology impacts health decisions, and poor health impacts voter turnout, then there's an opportunity to have a bi-directional conversation. It's my responsibility as a health professional to start thinking about how to improve voter access, and hey, let's talk about how your culture and political ideology impact your health care decisions."

Chandra also said the discussion about voting and health shouldn't be partisan.

"Unfortunately, it, at times, has become one," she said, "but it really shouldn't be."

To her, the focus should be on improving lives by helping people engage with their communities. "If we're trying to enhance life expectancy, enhance life satisfaction, enhance optimism and reduce the diseases of despair, then I would say engagement as a general principle is certainly nonpartisan."