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In the ER? Sign up to vote

Hospitals can play a role in closing the gap in registered voters by offering people a chance to register to vote in places where they disproportionately show up for care: the emergency room.

What if long emergency room wait times, an unfortunate fact of life, could also be a key to increasing voter participation among traditionally underrepresented groups in our electorate? The demographic overlap between those who most use the ER for their health care and those who don’t vote presents a potential opportunity.

In 2014, a US Census Bureau report found that nearly 1 in 4 Americans were not registered to vote. That’s over 51 million potential voting-age adults, or more than the entire population of Spain, who were not registered to vote in the United States.

Voter registration rates in the United States are so disturbingly low in part because citizenship isn’t linked to voting. In many developed nations, including France, Germany, and Sweden, being a citizen means you are automatically registered to vote. US states have only started to move in that direction.


This extra logistical hurdle amounts to what behavioral economists call “sludge,” understood as administrative burdens or frictions that prevent people from doing what they want to do. Even a small amount of sludge can operate as a severe deterrent.

For millions of Americans, the steps needed to understand the process of where and how to become registered, and then doing so, operate as serious barriers to voting.

One consequence is that we end up with stark demographic differences with respect to voter registration.

Consider this: In 2016, a disproportionately large share of all eligible Americans who were not registered were low-income citizens and people of color. Among eligible voters, 31 percent of African-Americans, 43 percent of Hispanics, and just over 43 percent of low-income Americans were not registered to vote in the 2016 presidential election.

A recent survey found that when asked why they had not registered to vote, more than 60 percent of eligible voting-age adults responded that they had simply never been offered the chance to register. And more than one-third of those not registered intended to, but had not gotten around to it or found the process inconvenient.


Hospitals can play a role in closing this gap by offering a large segment of our population a chance to register to vote in places where they disproportionately show up for care: the emergency room.

Emergency rooms care for higher rates of low-income, minority, and uninsured Americans than the average population. In 2016, for example, the annual visit rate among the entire population was 45.8 ER visits per 100 persons. But when stratified among African-American patients, the ER visit rate was almost two times higher at 80 visits per 100 persons. In addition, people without a college education and with lower incomes are especially reliant on the ER for non-emergency care.

While this illustrates a problem in our current medical system, it also introduces a real opportunity to increase voter registration.

Patients coming in for low-acuity complaints are more likely to wait while ER hospital staff care for other patients who are higher in acuity, sometimes waiting up to four to six hours. That time could be leveraged. Why not ask patients if they want to use approximately 90 seconds of their waiting time to register to vote?

There is precedent for doing something like that.

In 2008, the National Association of Community Health Centers ran a voter registration drive in health centers where patients received care. The result was that more than 18,000 low-income and middle-income citizens were added to the official rolls. Another program, conducted in 2012 at two Federally Qualified Health Centers in the Bronx, showed that a large number of voters could be registered easily without requiring significant physician effort, creating undue political influence, or compromising patient-doctor relationships.


Studies have shown that many unregistered voters are highly receptive to the prospect of being offered to register, with one study finding an 89 percent agreement rate among those approached in a hospital waiting room who were asked whether or not they would be open to register to vote.

To be sure, it would be inappropriate for physicians and hospitals to pressure patients in any way. But voter registration initiatives do not pose legal or ethical concerns when they are developed and framed as nonpartisan public service activities. Moreover, hospitals are already initiating efforts to increase voter registration, such as MGH Votes, a campaign launched at Massachusetts General Hospital. In addition, MGH has recently adopted the very initiative that we are recommending here in a program called VotER.

Extending these services to emergency rooms has extraordinary promise, and for one reason above all: It engages Americans who are not registered to vote by meeting them exactly where they are.

Dr. Alister Martin is an emergency physician and faculty at the Center for Social Justice and Health Equity at Massachusetts General Hospital. Cass R. Sunstein is a professor at Harvard Law School.