The relationship between voting restrictions and COVID-19 case and mortality rates between US counties

Background Since the 2010 election, the number of laws in the U.S. that create barriers to voting has increased dramatically. These laws may have spillover effects on population health by creating a disconnect between voter preferences and political representation, thereby limiting protective public health policies and funding. We examine whether voting restrictions are associated with county-level COVID-19 case and mortality rates. Methods To obtain information on restricted access to voting, we used the Cost of Voting Index (COVI), a state-level measure of barriers to voting during a U.S. election from 1996 to 2016. COVID-19 case and mortality rates were obtained from the New York Times' GitHub database (a compilation from multiple academic sources). Multilevel modeling was used to determine whether restrictive voting laws were associated with county-level COVID-19 case and mortality rates after controlling for county-level characteristics from the County Health Rankings. We tested whether associations were heterogeneous across racial and socioeconomic groups. Results A significant association was observed between increasing voting restrictions and COVID-19 case (beta = 580.5, 95% CI = 3.9, 1157.2) and mortality rates (beta = 16.5, 95% CI = 0.33,32.6) when confounders were included. Conclusions Restrictive voting laws were associated with higher COVID-19 case and mortality rates.