Iowa Medicaid process likely leaves poor off voter rolls, violates federal law, advocates say

Iowa’s health department is failing to comply with the federal requirement to make voter registration accessible to people applying for Medicaid, multiple advocates say, likely leading significant numbers of low-income Iowans to be left off the rolls.

“I would regard this as major noncompliance with an agency’s obligations under the NVRA,” said Brenda Wright, special litigation and policy counsel at the NAACP Legal Defense Fund. She was referring to the National Voter Registration Act, the 1993 law that requires state agencies to offer their clients the chance to register to vote. 

The concerns come at a time when Iowa already appears to be struggling to get people on public assistance to register, and as the 2024 election approaches.

During the 2021-22 election cycle, only 1,222 Iowa voter registration applications came via public assistance programs, according to figures reported by the state to the U.S. Election Assistance Commission. That represented just 0.1% of Iowa’s total new voter registration applications. (The equivalent figure for the average state has been around 3%, according to a recent report.) 

Voting advocates say there may be multiple reasons for Iowa’s low numbers. But one likely key factor, they allege, is serious problems with how Iowa’s Department of Health and Human Services fulfills its legal requirement to offer Medicaid recipients and applicants the chance to register to vote.

Iowa’s roughly 860,000 Medicaid recipients must renew their coverage each year (the requirement was paused by the federal government during the pandemic, but has been back in effect since last spring). The state health department sends a mailer to all recipients, which must be completed and returned to renew coverage. 

The NVRA requires that clients be offered the chance to register to vote at all transactions with the agency, not just during the initial application, advocates say. They add that because of the annual Medicaid renewal requirement, there are typically more Medicaid renewal transactions than initial applications.

In a renewal mailer sent by HHS to a Medicaid recipient in October and obtained by States Newsroom, the voter registration opportunity appears on the ninth page of the 11-page mailer, and as the twelfth and final bullet point in a section titled “Rights and Responsibilities.” 

It reads, in its entirety:

If you want to register to vote, you can complete a voter registration form at: 

http://sos.iowa.gov/elections/pdf/voteapp.pdf

That URL takes users to a voter registration form that must be printed out and mailed to an election office, though no mailing address is provided.

No additional voter registration information was included in the mailer, the recipient confirmed. 

Asked whether the renewal mailer — which is likely sent to hundreds of thousands of Iowa households each year — typically doesn’t include additional voter registration information, Alex Carfrae, an HHS spokesperson, did not respond.

Four separate experts on the NVRA’s requirements for states confirmed to States Newsroom that the form’s information on voter registration, if it’s not accompanied by additional voter registration materials, violates the law by failing in several ways to provide potential voters with enough help in registering.

It’s not only existing Medicaid recipients who may be unlawfully denied a chance to register to vote. The form for first-time applicants for Medicaid or other health insurance programs contains only the same inadequate sentence and URL.

Carfrae said HHS employees ask voter registration questions during interviews that are required for other types of government assistance, including the Supplemental Nutrition Assistance Program, the Women, Infants and Children program and the Temporary Assistance for Needy Families program. But those interviews are not generally required for Medicaid applicants, Carfrae said. 

Still, Carfrae added, when people apply for Medicaid in person, they’re asked whether they want to register to vote, and, if they say yes, given a registration form. People who apply by phone or online also are asked about voter registration, Carfrae said.

But Danetz said the law requires that in all interactions with clients, the agency provides a written offer of voter registration, using specific language. And she added that the agency must give the applicant a registration form unless the offer is declined in writing.

Asked whether HHS follows these rules, Carfrae did not respond.

In addition, people who don’t apply in person, but instead by printing out the form — which is linked prominently on HHS’s website — and then mailing it in, appear to be given no voter registration opportunity other than the sentence and URL that the experts call non-compliant. 

Asked about people who use that method, Carfrae did not respond.

Carfrae also did not respond to repeated follow-up questions about whether the department believes it is complying with federal law.

The state has been aware of problems with voter registration at its public assistance agencies for nearly a decade. In 2015, the ACLU of Iowa and the advocacy group Disability Rights Iowa sent a letter to Secretary of State Paul Pate, obtained by States Newsroom, warning that the state was “systematically failing to provide the voter registration services” required by the NVRA.

Pate, a Republican, remains in office today. Asked what steps, if any, were taken in response to the 2015 letter, his office did not respond.

Advocates see failure to comply

Wright, Sarah Brannon, a managing attorney with the ACLU’s Voting Rights Project, and Lisa Danetz, a veteran voting rights advocate who serves as an adviser to the Brennan Center for Justice, all said the voter registration language on the paper renewal form and the application form fails to comply in several ways with the NVRA.

All three women have worked for over a decade — in Wright’s case, for two decades — to bring states into compliance with the NVRA, and are recognized as leaders in the field.

Doug Hess, a policy analyst who has closely studied voter registration sign-ups through Medicaid, agreed. 

“People who move need to be offered voter registration services regularly,” said Hess. “By not doing this, Iowa is violating a federal voting rights law and denying tens of thousands of citizens — particularly those with disabilities or low incomes — an easy way to update their voter registration record.” 

The NVRA, often known as the “Motor Voter” law, aimed to boost voter registration by requiring states to offer registration opportunities at motor vehicles departments. 

But because the law’s drafters recognized that many low-income people don’t drive, they also required, in Section 7 of the measure, that states offer voter registration at public assistance agencies. Both then and now, low-income Americans were more likely than higher earners to be unregistered.

“The history is so clear that part of the purpose of Section 7 was to provide voter-registration opportunities for lower-income individuals,” Brannon said.

(Indeed, that very goal angered opponents of the bill. “Motor Voter, with its mandatory registration of welfare and entitlement recipients, will result in the registration of millions of welfare recipients, illegal aliens, and taxpayer funded entitlement recipients,” warned one Republican lawmaker during the congressional debate over the measure. “They’ll win.”)

The advocates said Section 7 requires that public assistance applicants, as well as people renewing benefits, be asked a clear yes/no question about whether they would like to register to vote, if they aren’t already registered — something the Iowa HHS forms don’t do. 

And if the applicant answers yes, or doesn’t answer, they must be provided with a voter registration form. That means those not applying for benefits in person, the advocates said, must be mailed the form, not just given a link.

“Not everyone can download the paper and print it out,” said Brannon. 

“Doing nothing but a link … does not comply with the law. You haven’t distributed a form to the client in a way that everyone can access.”

“They’re much more likely to return it if they get an actual physical form than if they’re told in tiny print that there’s a website somewhere where you can print it out yourself,” Wright said.

The advocates also said the law requires that states provide assistance for someone registering to vote. With the mailed registration form, Brannon said, states should include a cover letter with information about where to send the form, and provide a 1-800 number if someone has additional questions.

“People generally need some guidance in terms of getting registered to vote,” Wright said. “And a passive approach like Iowa is using just won’t accomplish that.”

Danetz said Iowa may have erred by simply mirroring the voter registration language of the federal health-care exchange created by the Affordable Care Act, which in the past has used exactly the same wording. 

For a decade, advocates have been urging the federal government to beef up the voter registration opportunity on the exchange.

“There are lots of reasons why the federal exchange should incorporate voter registration under the model of the NVRA, and this example from Iowa is one of those reasons,” said Danetz. “It is leading states astray, so they are not in compliance with the NVRA.” 

Low numbers of applications

The problems with Iowa’s Medicaid signup are likely a contributing factor to the state’s low numbers of registration applications from public assistance agencies, the advocates said.

“Because they’re not actually distributing forms to clients, it probably has a significant effect on how many people are registering to vote from public assistance agencies,” Brannon said. 

Years ago, Iowa’s numbers for registration applications from public assistance agencies were relatively high for the state’s size. 

For both the 2005-06 and 2007-08 cycles, the figures were over 10,000. By 2011-12, that had dropped to a little over 6,000, and by 2013-14, it was down to 1,560. Despite minor fluctuations — some likely caused by the pandemic — they have stayed low since then.

Danetz said the drop-off a decade ago might have been the result of changes to the Medicaid signup process caused by Iowa’s 2014 Medicaid expansion under the ACA, including the failure of the federal exchange to prominently offer voter registration.

Iowa is far from alone in being accused of violating the NVRA. Over the last two decades, numerous states have entered into agreements with the U.S. Department of Justice or with advocacy groups aimed at beefing up their compliance with the law, some after facing legal action. A 2014 report on voting by a bipartisan presidential commission called the NVRA “the election statute most often ignored.” 

How other states have done it

There’s plenty of evidence that states can boost registration rates from public assistance agencies when they take appropriate steps. 

Alabama saw a massive jump from 5,000 in 2011-12 to 120,000 in 2014-16, after signing an agreement with advocacy groups, according to a recent report written by Hess for the Institute for Responsive Government, a good-government group. 

And in the last cycle, Kentucky, which has made voter access a priority, took in over 88,000 registration applications from public assistance agencies, EAC data show — around 72 times as many as Iowa. (Kentucky’s population is around 4.5 million, compared to Iowa’s 3.2 million.)

Some states, including Massachusetts and Oregon, are even working to integrate automatic voter registration into their Medicaid systems, so that Medicaid applicants who are unregistered but eligible to vote are automatically added to the rolls unless they opt out.

Wright predicted that States Newsroom’s inquiries could spur advocates, or perhaps even the U.S. Department of Justice, to press Iowa to comply with the law. 

“I would imagine that word is going to get around about this as a result of the inquiries you’ve made, and most likely someone will be looking into it,” Wright said. “Whether it’s us or someone else, I don’t know.” 

A spokesperson for the U.S. Department of Justice declined to comment.

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