The U.S. is facing dual crises: a crisis of health and a crisis of democracy. Our nation has been getting sicker. We're facing the greatest decreases in life expectancy in over a century -- with causes extending beyond COVID-19 to include rising drug overdoses, injuries, heart and liver diseases, and suicide. Maternal mortality, often considered a test of a society's commitment to health and equality, has risen sharply. On all of these measures of health and equity, we are falling behind most all of our peer nations.
Our democracy, too, is unwell, with few guardrails on campaign financing, allowing wealthy individual and corporate donors to have outsized influence on policy and gerrymandering, making political representation simply unrepresentative of the populace.
The health of our nation is inextricably linked to the health of our democracy. Our laws directly affect whether someone has access to health services (e.g., abortion or transgender care) and safe environments (e.g., workplace safety or gun control). In theory, democracy is all about the public's health, safety, and welfare. Political leaders should have no greater calling. Free and fair elections enable voters to elect leaders who fight to fulfill their health needs; political leaders are incentivized to pay attention to voters' wellbeing, and are held accountable.
Yet, unlimited and dark money has shifted politicians' attention away from constituents' health and toward the interests of big donors. Gerrymandering pushes representation toward the extremes, enabling super-majorities in state legislatures that can pass measures harmful to health (e.g., targeting transgender individuals, forgoing Medicaid expansion, banning abortion, encouraging fossil fuels). And voting rights restrictions often fall on the most vulnerable: the poor and racial minorities. When the voting rights of society's most vulnerable citizens are curtailed, it makes it all too easy for politicians to ignore them.
The Constitution's Preamble expresses public wellbeing as the quintessential aim of American governance: "We the People, in Order to form a more perfect Union" and to promote the "general Welfare" do "ordain and establish this Constitution." The "General Welfare" clause expresses a constitutional value of health, peace, and safety. The Supreme Court was supposed to be the guardian of the common welfare. Yet, it has done the opposite. The justices have given rich donors a virtual free hand to give huge sums of money (often dark money); loosened anti-corruptions restrictions; and allowed extreme gerrymandering and voting rights restrictions.
This term brought surprising, but good, news. The justices refused to allow racial gerrymandering in Alabama, and rejected a legal theory from North Carolina that would have been disastrous for fair elections. Below, we explain the Supreme Court's impacts on democracy and health.
Campaign Financing and Corporate Speech
Perversely, the Supreme Court sees money as speech and corporations as persons. In Citizen's United v. Federal Election Commission (2010), the Court gave corporations outsized influence. It swept away existing, and most future, campaign financing laws designed to keep corporate money out of elections. Corporate free speech opened the door for big businesses -- like food, tobacco, alcohol, and firearms -- to spend unlimited amounts to influence elections. And it is no secret that their investments are designed to benefit shareholders and not the "general welfare." Citizen's United doubled down on the view that corporations are rights-holding persons; a preposterous take considering that shareholders' individual views and interests are far broader than, and often divergent from, corporate interests.
Since Citizens United, spending on federal elections has more than quadrupled, with increased corporate financing resulting in increased political influence. Through "527 organizations" (named after a provision in the IRS code) that pool money from various sources to advance political agendas with little scrutiny, corporations can donate to groups that do their political bidding. Corporations, for example, often publicly support access to healthcare, while funding the campaigns to dismantle the Affordable Care Act; publicly support climate action while donating to attack the EPA's Clean Power Plan; and publicly support LGBTQ+ rights while donating to groups to dismantle anti-discrimination protections.
Corporations -- many of which have taken public stances on racial justice and equality -- have donated substantial funds to organizations that support legislators promoting racial gerrymandering, including in Alabama and North Carolina.
Gerrymandering and Voting Rights
Alabama and North Carolina were at the center of recent Supreme Court cases that threatened to make it even more difficult for voters to elect officials that represent their interests.
A few weeks ago, on June 8 in Allen v. Milligan, the Court ruled 5-4 that Alabama's congressional voting map, redrawn by the state legislature in 2021, violated Section 2 of the Voting Rights Act of 1965, which prohibits racially discriminatory voting practices. Under the new map, Black voters would comprise a majority in only one out of Alabama's seven congressional districts, despite making up 27% of the population. The Court unexpectedly ruled that the Alabama legislature should have fashioned a second district in which Black voters could comprise a majority. The outcome was a welcome surprise, considering a 2021 decision that gutted Section 2 of the Voting Rights Act.
In Moore v. Harper, legislators sued to reinstate a 2021 districting map that North Carolina's Supreme Court struck down as unconstitutional. The map's partisan gerrymander was so extreme that an evenly divided popular vote would yield 10 congressional seats to Republicans and four to Democrats. The Court, in a 6-3 ruling, rejected a radical theory known as the "independent state legislature," which asserts that only the legislature has the power to set rules for federal elections. The Court refused to allow a hyper-partisan state legislature to create grossly unfair districts absent judicial or constitutional oversight.
To show just how political the judiciary has become, in April, after gaining a majority of Republican justices, the North Carolina Supreme Court reversed its prior ruling that the map violates the state constitution. Even though the case appeared moot, the Supreme Court decided to reject the deeply controversial independent state legislature theory.
Democracy and Public Health
Corporate political influence, gerrymandering, and voting rights hold clear repercussions for representative democracy and public health. They disempower voters from choosing candidates that represent their interests and needs, and cause voters to lose faith in the political process.
Medical organizations call voting rights a social determinant of health. The reasons abound: access to voting is consistently associated with better health. Women's suffrage is associated with decreases in child mortality rates as high as 15%; the Voting Rights Act has been tied to reductions in economic inequality and increased health spending. Voting is linked to reduced risks of cancer death and improved mental health, while voting restrictions correlate with higher likelihood of lacking health insurance.
Elections and voting influence multiple health outcomes. It is thus no coincidence that the populations facing the greatest barriers to voting also face the highest health risks and poorest health outcomes, and are most in need of equitable health policies. Public health goes hand-in-hand with historic power imbalances and long-lasting inequities. While the Supreme Court's recent decisions are a breath of fresh air, it's unlikely to last. And we still have a long way to go where political leaders give precedence to people's health and the general welfare.
Lawrence O. Gostin, JD, LLD, is university professor, Georgetown University's highest academic rank, where he directs the O'Neill Institute for National & Global Health Law. He is also director of the World Health Organization Collaborating Center on National & Global Health Law, and the author of Global Health Security: A Blueprint for the Future. You can read more of his writing in "The Health Docket" column. Sarah Wetter, JD, MPH, is an associate with the O'Neill Institute.