How to Bring the Ballot to Aging Americans

Editor’s note: This story has been updated to clarify the position of Syracuse law professor Nina Kohn on the issues of voter access and staff voting assistance in long-term care facilities.

SPRINGFIELD, Va. — Kathleen Henry, 80, wants all her neighbors to vote, even if they can’t drive, read or remember as much anymore.

Soon after the former civics teacher moved to the Greenspring retirement community here in 2003, she took a leading role in running the campus’s polling place and registering voters.

Just this year, Henry said, she’s registered 72 residents as new voters. If a resident doesn’t have an up-to-date government form of identification — as is the case for 18 percent of citizens over 65 — Henry works to bring in a county official to take their picture to comply with Virginia’s voter ID law.

When Election Day rolls around, she and a small group of volunteers set up polling stations in the conference center, a short elevator ride down from the cafeteria and library. The community’s Democratic and Republican clubs post tables with candidate information just outside the voting area. Volunteers shuttle in residents from assisted-living and skilled-nursing facilities. The roughly 2,000 residents of Greenspring, average age 80, are the only voters in this precinct.

“Our motto is if they care enough to come, by golly we’re going to help them vote,” Henry said. “We’ve got it down pretty pat, believe me.”

Now, the gated community about 15 miles southwest of Washington, D.C., boasts some of the highest voter participation rates in Virginia. Turnout for general elections at Greenspring is consistently well above 70 percent, compared with the national average of 55 percent. During the 2004 presidential election, voter turnout here hit 94 percent.

Bringing the ballot to residents of long-term care facilities, many of whom may have impairments that limit their ability to cast a vote independently, is a proven way of increasing voter access, said Jason Karlawish, a professor of medicine, medical ethics and health policy at the University of Pennsylvania who has studied voting and cognitive ability.

“It’s the right thing to do,” Karlawish said. “We have an obligation as a society to allow people to vote.”

But many nursing home residents aren’t as lucky as those at Greenspring. Voting for these seniors depends heavily on state laws — such as early voting, voter ID and same-day registration — and individual long-term care facilities, where staff may or may not be inclined to help residents vote.

Access to the ballot for the 8.4 million residents of long-term care facilities nationwide is an issue of equity, said Nina Kohn, a professor at Syracuse University College of Law.

Running elections the way Greenspring does requires resources and a high degree of volunteer labor, which are more available at a facility where it costs several thousand dollars a month to live than at a nursing home funded by Medicaid, Kohn said.

“Some of these facilities couldn’t have better access,” she said. “At a high-amenity facility, access to voting might be treated as another amenity. ‘We have plays, we have good food, and you can vote here.’ But there are many other facilities that have individuals with similar needs that don’t have polling.”

The lack of ballot access at certain facilities affects specific populations. Nearly two-thirds of publicly funded nursing home residents are women, according to the Centers for Medicare and Medicaid Services. Residents of these facilities, Kohn said, also tend to be poorer than residents of other long-term care facilities.

“We are essentially undermining access to entire interest blocs,” Kohn said.

Barriers to the Ballot

For many residents at publicly funded facilities, absentee ballots may be their only access to voting. Every state will mail an absentee ballot to voters who request one. But relying on absentee ballots brings its own challenges, Kohn said.

In some facilities, residents may not have access to information about candidates and deadlines for requesting a ballot. Ballots may be hard to read and fill out for those with disabilities.

In Louisiana and North Carolina, staff at residential facilities are banned from helping residents vote. And in states where staff can help, ethical questions arise over the independence of residents’ vote, Kohn said.

There is no evidence of systemic voter fraud at nursing homes, Kohn said. “Undoubtedly,” she said, there may have been cases when staff filled out absentee ballots without a resident’s permission and that residents may have been unduly influenced by staff. But, she said, arguing abuse is commonplace or widespread emboldens officials to restrict access to this voting bloc.

Several studies have found that some facilities across the country have screened residents to determine whether they are mentally capable of voting, even if they expressed a desire to vote. In a 2013 study of Virginia long-term care facilities, professor Richard Bonnie at the University of Virginia School of Law found that it’s “commonplace” for staff to disenfranchise residents based on a diagnosis or their perception of a resident’s mental capacity.

A 2011 study by Karlawish found that staff at long-term care facilities are unsure of how to properly assist voters, confused about whether they are legally allowed to judge a person’s capacity to vote, and burdened by the time commitment of helping with the voting process and paperwork.

Ideally, if asked to help, staff should read the ballot out loud to the residents and ask residents to make a choice among candidates, Kohn said. Every resident who expresses a desire to vote should be allowed to vote, she said; there shouldn’t be a litmus test.

At Greenspring, while staff typically help residents just with mobility when it’s time to vote, they will help residents cast an absentee ballot if requested, said Scott Sawicki, director of corporate affairs at Erickson Living, which runs the retirement community. Still, he said, voting is a delicate issue, especially assisting voters who have dementia and other cognitive issues.

“These situations can get very complex,” Sawicki said. “What you consider doing the right thing is a gray area.”

These concerns will grow over the years, as the U.S. population continues to age. According to the U.S. Department of Health and Human Services, the number of long-term care residents is expected to double by 2050.

During the 2016 presidential election, 70 percent of people 65 to 74 years old voted, according to the U.S. Census Bureau. The voter participation rate of those 75 and older reached only 66 percent that year.

Bringing the Vote to Them

The best way to get beyond these barriers is for states and local governments to embrace mobile voting, said Karlawish, the University of Pennsylvania professor.

Mobile polling allows bipartisan pairs of election officials to bring ballots directly to long-term care facilities, where they can assist when needed and register new voters if deadlines allow. This system of voting is allowed in 23 states, but laws vary on whether state or local governments are responsible for administering it.

“We need to maximize the access to the right to vote for all Americans,” Karlawish said, “whether they live at home or in a nursing home.”

State lawmakers recently have proposed to expand voting access for senior citizens and others who may have physical or mental difficulties. Louisiana enacted a law in May that eliminated a requirement that residents of long-term care facilities must prove they have a disability to qualify for assisted early voting. One stalled bill in New York would aid residents of long-term care facilities who need help filling out absentee ballots.

Not every new bill would expand access, however. Under a law enacted in Maine this month, absentee ballots can no longer be given to anyone who has granted power of attorney to another person because of dementia.

Mobile voting is a solution Deb Markowitz embraced as Vermont’s secretary of state from 1999 to 2011.

Mobile polling in Vermont now takes place during the early voting period, which allows officials to visit as many facilities as possible without interrupting Election Day. Despite pushback over the use of limited local election resources, Markowitz, a Democrat, said she made it a priority.

“There shouldn’t be bureaucratic barriers to voting,” she said. “I told election officials to go into the community and see if they could get volunteers to expand mobile voting. They found that easy to do.”

In Multnomah County, Oregon, which encompasses Portland, the county’s elections officials will assist any person who needs help voting, including visiting long-term care facilities to walk residents through ballots.

The county’s director of elections, Tim Scott, begins reaching out to local facilities five months ahead of Election Day to let them know his office will assist anyone who requests help voting. Additionally, his office sends registration cards and election reminders to facilities in the months leading up to voting.

The county’s elections office does not have the resources to visit each site, however, to see if someone needs help, he said. Instead, they rely on voters and facilities to make the initial contact.

“We’re doing our best with what we have,” Scott said. “We’re constrained in resources. We rely a lot on voters finding us.”

To reach more people and care facilities, the county works with the state’s Aging Disability and Veterans Services division and the advocacy group Disability Rights Oregon.

Long-term care facilities have a “fundamental obligation to respect the rights of their residents” and to work with local election officials to make mobile voting the standard, despite the cost, Karlawish said.

Still, the gold standard of Greenspring is far off for many long-term care facilities around the country.

For residents here at Greenspring who can take advantage of the access to voting, like Don Young, it’s immensely appreciated. Young, who leads Greenspring’s Republican Club, is legally blind and wouldn’t be able to drive to another precinct to vote. The vote came to him.

“It really does work for the people here,” he said.