LWVUS Urges Voter Registration Opportunity on HealthCare.gov

LWVUS joined coalition partners in submitting comments to federal agencies in support of adding an opportunity to register to vote in the HealthCare.gov's health coverage application- specifically the placement of this information in the determination of eligibility for benefits section.

August 14, 2024

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Agency Information Collection Activities: Submission for OMB Review; Comment Request

Dear Administrator Brooks-LaSure, 

On behalf of The Leadership Conference on Civil and Human Rights, Dēmos, and the 43 undersigned organizations, we submit these comments in response to the comment request by the Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS), regarding Submission for OMB Review of Agency Information Collection Activities, published at 89 Fed. Reg. 57,417 (July 15, 2024).

1. Interest of Commenters

The Leadership Conference on Civil and Human Rights is a coalition charged by its diverse membership of more than 240 national organizations to promote and protect the rights of all persons in the United States. It is the nation’s oldest, largest, and most diverse civil and human rights coalition, and it was founded in 1950 out of the belief that the fight for civil rights could not be won by one group alone — but needed to be waged in coalition. Through advocacy and outreach to targeted constituencies, The Leadership Conference works toward the goal of a more open and just society — an America as good as its ideals. The Leadership Conference was at the vanguard of the movement to secure passage of the Civil Rights Acts of 1957, 1960, and 1964, the Voting Rights Act of 1965 and its subsequent reauthorizations, and every federal voting rights statute enacted in the last decades. More recently, it has advocated for robust implementation of President Biden’s Executive Order on Promoting Access to Voting, No. 14019, which adopts a whole-of-government approach to promoting voter registration and access to the ballot. 

Dēmos is a think tank that powers the movement for a just, inclusive, multiracial democracy. Since 2000, Dēmos has worked through a unique combination of research, advocacy, multi-platform communications, legal expertise, and deep partnerships with grassroots organizations from across the country. Dēmos, which means “the people,” is the root word of democracy. The name is a reminder that America’s power is derived from the diversity of its people. Dēmos has an almost two-decade-long history of working to implement the government agency registration sections of the National Voter Registration Act (NVRA), 52 U.S.C. §§ 20504, 20506 — including submission of comments about the NVRA and HeathCare.gov in response to the comment request by CMS regarding Agency Information Collection Activities: Submission for OMB Review, published at 78 Fed. Reg. 6109, 6110 (Jan. 29, 2013) (commenting on proposed information collection 3, entitled, “Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment Through Affordable Insurance Exchanges, Medicaid, and Children’s Health Insurance Program Agencies”) — and therefore has specific expertise and knowledge related to the integration of voter registration opportunities within agency benefits applications. Indeed, Dēmos’ work, along with partners, has resulted in the facilitation of voter registration applications by at least 3 million new, primarily low-income voters. 

1. Background

On March 7, 2024, CMS published a notice inviting comments from interested persons regarding proposed actions related to the federal applications for health coverage, including those aimed at “provid[ing] consumers interested in voting resources.”^[1] On May 6, 2024, many of the undersigned organizations submitted comments in response to that notice.^[2] 

In our comments, our organizations detailed support of the inclusion in the health care applications of a question aimed at “provid[ing] consumers interested in voting resources,” and we shared the policy considerations supporting that inclusion. Specifically, we described how promoting voting access in the health care context is an extremely valuable way to pursue the objectives of President Biden’s Executive Order 14019, Promoting Access to Voting, explained why the HealthCare.gov application process is particularly well-suited for reaching individuals who are less likely to be registered to vote, and detailed the strong correlation between civic engagement and improved health and well-being. We also made recommendations to improve the proposed design of the incorporation of an offer of voter registration information. We stand by each of those recommendations. 

In the instant federal register notice, CMS has included supplementary materials that show modifications to its initial design for incorporating an offer of voter registration information. Specifically, in the HealthCare.gov electronic application, the information that follows a “yes” response to the voter registration information question appears to have been moved to its own page after the applicant has “signed and submitted” a health care application.^[3] Below, we offer commentary on this modification as well as a recommendation we believe is important to incorporate before rolling out the new design of the voter registration question and information offer.

1. Comment on Design Modification and Further Recommendations 

We continue to applaud the placement of the voter registration question within the process flow of the health coverage application’s determination of eligibility for benefits, which provides a much higher likelihood that applicants see and avail themselves of the opportunity to register to vote than did its former location. Given the proximity of many voter registration deadlines in advance of the 2024 elections and our hope that the redesigned HealthCare.gov application can be launched in September, which is National Voter Registration Month, we urge CMS to launch the new question and design as soon as possible.

1. Movement of the follow-up language to the voter registration question is an improvement over the earlier design.

As we explained in our earlier comments, in determining how and where to present the language directing applicants who respond “yes” to the voter registration question to Vote.gov, two considerations are paramount: (1) the language should be presented in such a way as to minimize the possibility that the applicant fails to finish their health coverage application; and (2) the language should be presented in such a way as to maximize the possibility that an interested applicant will take advantage of the voter registration opportunity offered through Vote.gov. While CMS did not use either of our previously recommended alternatives to meet these objectives, the new design — which separates the voter registration information question from the follow-up language about where to find the information — accomplishes our recommended objectives in a satisfactory manner. We applaud and support the design change for this reason.

1. Modifying the language of the voter registration question and the follow-up information in both the HealthCare.gov online application (Attachment A) and the paper applications (Attachments B, C, and D) will improve clarity about the scope of voter registration information available and improve voter registration uptake. 

1. CMS Should Strengthen and Clarify the Voter Registration Information Question.

CMS proposes asking applicants, “Would you like information on registering to vote?” This proposed language suggests that a “yes” response will result only in information about the process of voter registration rather than the actual result, which includes an available opportunity to access voter registration applications. Instead of using the language identified in the supplementary materials, the voter registration question should make clear that people can access voter registration applications and will be provided an actual opportunity to register to vote, not just generic voter registration information. 

In our first sets of comments, we recommended asking: 

“If you are not registered to vote where you currently live, would you like to apply to register to vote?” 

This alternative phrasing of the question is closely modeled on, but slightly modified from, the language of the NVRA.^[4] Another alternative that simply adds onto the language already planned by CMS is:

“Would you like information on registering to vote, including access to an opportunity to register to vote in your state?”

Use of either alternative conveys to the applicant an ability to take action to apply to register, rather than just passively receive information. We would support any other language that also identifies the ability to access an actual voter registration application because it would accomplish the needed objective.

1. CMS Should Add Explanatory Language Immediately Following a “Yes” to the Voter Registration Information Question in HealthCare.gov.

The supplementary materials accompanying the Federal Register notice do not indicate the presence of any immediate follow-up language after answering “yes” to the voter registration question. This can cause potential confusion since there is no guidance explaining when the applicant will get access to the information. For applicants who answer “yes,” we also strongly recommend adding the following language (or something similar) as an immediate explanation:

“After you sign and submit your information for an eligibility determination, you will be provided directions to access voter registration information and voter registration opportunities in your state.”

1. CMS Should Strengthen and Clarify the Follow-Up Language that Appears After an Applicant “Sign[s] and Submit[s],” for those who answer “yes” to the voter registration information question in HealthCare.gov.

As with the proposed voter registration information question, the follow-up language to the question should be modified to more specifically describe the available access to voter registration application opportunities at Vote.gov rather than suggest that the site contains only information. The follow-up language addressed in this subsection appears for those who respond “yes” after signing and submitting information for an eligibility determination through the HealthCare.gov application in Attachment A and immediately after the voter registration information question for all applicants who use the paper applications in Attachments B, C, and D. As a baseline, we recommend the following alternative language for the HealthCare.gov application:

“You answered that you would like information about registering to vote. You can access an opportunity to register to vote in your state, voter registration information including deadlines, and other voting resources for your state at Vote.gov.” 

We also recommend the following alternative language for paper applications:

“You can access an opportunity to register to vote in your state, voter registration information including deadlines, and other voting resources for your state at Vote.gov.”

These sentences should replace CMS’s proposed language, which reads, “You can get information, registration deadlines, and find resources for your state at Vote.gov.” With these changes, applicants are more likely to understand that an actual voter registration opportunity is available and to avail themselves of that opportunity to apply to register to vote.

1. Our earlier recommendations remain important and should be reconsidered in future iterations of the HealthCare.gov application.

In our prior comments, in addition to the recommended language changes above, we made the following additional recommendations:

• The voter registration question in the HealthCare.gov online application should be programmed as a “hard stop,” i.e., the applicant must select an answer from one of the radio buttons. 
• For the HealthCare.gov online application, CMS should track the responses to the voter registration question.
• At the appropriate point in the process, there should be an automatic redirect to vote.gov, with accompanying explanatory language.

These recommendations would improve the effectiveness of the offer of voter registration application opportunities. That said, quick implementation is a higher priority at this point in time, and therefore we request that CMS consider these upgrades for future iterations of the HealthCare.gov application. 

1. Conclusion 

We appreciate the opportunity to provide these comments regarding CMS’s proposed data collection to support eligibility determinations for insurance affordability programs and enrollment through health benefits exchanges, Medicaid, and CHIP agencies. We urge CMS and HHS to implement our recommended language changes and launch the new application expeditiously to allow for eligible citizens to access voter registration information in time for the 2024 elections.

[1] Agency Information Collection Activities: Proposed Collection; Comment Request, 89 Fed. Reg 16,580, 16,581 (Mar. 7, 2024).

[2] Comments of Leadership Conference on Civil and Human Rights and 33 Additional Organizations Regarding Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid, and CHIP Agencies (Document Identifier: 0938-1191) (May 6, 2024); Comments of Dēmos, ACLU and League of Women Voters of the United States Regarding OMB Control Number 0938-1191, CMS-10440 Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (May 3, 2024).             

[3] In addition, CMS has corrected and modified the language that appeared to instruct some applicants to skip over the voter registration question and that appeared only in Step 3 of the paper Application for Health Coverage in Attachment D. We commend and appreciate the correction to those instructions.

[4] See 52 U.S.C. § 20506(a)(6)(B)(i) (“If you are not registered to vote where you live now, would you like to apply to register to vote here today?”).