Elderly Voters: Information on Promising Practices Could Strengthen the Integrity of the Voting Process in Long-term Care Facilities
Published: 2009-11-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Voting is fundamental to the U.S. democratic system and federal law provides broad protections for people with disabilities, including older voters. Many long-term care facility residents, who often have physical or cognitive impairments, vote by absentee or early ballot. Concerns have been raised about the extent to which states and localities are helping the increasing number of facility residents exercise their right to vote, especially those requiring voting assistance, who may be subject to undue influence or unauthorized completion of their ballot by facility staff or relatives. Given these concerns, GAO was asked to identify the actions taken to facilitate and protect voting for long-term care facility residents at (1) the state level and (2) the local level. To address these objectives, GAO interviewed federal officials, national organizations, and researchers; reviewed Election Assistance Commission (EAC) guidance on voting in long-term care facilities; surveyed state and local election officials; and visited seven localities in the weeks prior to the November 2008 federal election to observe the voting process in long-term care facilities.
section_title: What GAO Found
paragraphs: Most states have requirements or guidance to facilitate voting for long-term care facility residents, and some states also provide training and conduct oversight of localities' adherence to state requirements or guidance. States reported that they most commonly provided requirements or guidance for accommodations for absentee voting for residents of long-term care facilities, followed by accommodations for voter registration and voter identification procedures. Almost one-half of the states reported providing training to local election officials specifically on state requirements or guidance to facilitate voting for long-term care facility residents. Additionally, 17 states reported that they conducted one or more oversight activities to ensure that localities were adhering to state long-term care voting requirements or guidance. According to researchers, some of these state requirements or guidance for voting in long-term care facilities may help to protect against voter fraud and undue influence. Localities also used a variety of actions to facilitate voting for long-term care facility residents, including some that may decrease the likelihood of fraud and undue influence. In our survey, 78 of the 92 localities reported taking actions to facilitate voting for long-term care facility residents. The most common actions included supporting facility staff in assisting residents with the absentee or early voting process, including providing staff with early and absentee voting information or guidance. Localities also reported providing services directly to residents. For example, close to one-half of localities we surveyed brought election officials to facilities to assist with the voting process. The seven localities we visited prior to the November 2008 federal election used a range of strategies to facilitate voting for long-term care facility residents, including coordination with facility staff and other stakeholders; the deployment of election teams to facilities; and implementation of procedures to protect and ensure voting integrity, such as requiring bipartisan voting assistance and signed affidavits to document voting assistance. Some local officials reported challenges to implementing these strategies, such as difficulty providing voting assistance to residents with cognitive impairments.

section_title: Letter
paragraphs: Voting is fundamental to the U.S. democratic system and, accordingly,  federal law provides broad voting protections for people with disabilities,  including older voters. However, questions have been raised about the  extent to which states and local election jurisdictions are helping older  voters and others residing in long-term care facilities exercise their right to  vote. In 2008, approximately 9 million Americans over 65 years old  needed long-term care services. Moreover, the number of adults aged 65  and over is expected to increase by more than 23 million between 2010  and 2025, and about 70 percent of adults over age 65 are projected to  require long-term care services at some point during their lifetime due tation.  chronic illness or disability, including memory loss or disorienAs the proportion of older Americans in the country increases, the number  of voters residing in long-term care facilities who may be unable to vote at  polling places on Election Day due to their physical and mental condition  could also increase. While the Help America Vote Act of 2002 (HAVA)  requires each polling place to have at least one voting system for use in  federal elections that is accessible for people with disabilities, other  federal laws provide broader protections for people with disabilities that  may apply to alternative voting methods, such as absentee ballots. Many  long-term care facility residents cast absentee ballots and at least one  study has recognized that absentee balloting can be vulnerable to fraud.  Specifically, concerns have been raised that some residents may be  subject to the undue influence of facility staff, family members, or others  over residents’ ballot selections, or the completion of their ballot by  someone other than the resident. These concerns arise in large part due to  the dependency of this population on others, such as relatives and long- term care facility staff, for assistance in completing ballots. Concerns of  alleged voter fraud in long-term care facilities have sparked debate about  the appropriate balance between access to voting and providing  protections to ensure voting integrity to this population. As states and  localities take action to enhance voting access for the increasing number  of long-term care facility residents, the integrity of the voting process  could be at risk if proper controls are not utilized. Given these concerns,  you asked us to identify the actions taken to facilitate and protect voting  for long-term care facility residents at (1) the state level and (2) the local  level.
To answer both of these objectives, we conducted interviews with officials  at the Department of Justice (Justice), the Department of Health and  Human Services (HHS), and two national organizations that represent  state election officials. We also reviewed relevant federal laws,  regulations, guidance, and other documentation. We did not analyze state  requirements or guidance, but instead relied on states’ responses to our  survey. In addition, we interviewed officials at the U.S. Election Assistance  Commission (EAC) and reviewed the EAC Quick Start Management  Guide on Elderly and Disabled Voters in Long Term Care Facilities. We  also reviewed relevant literature and interviewed multidisciplinary  researchers with expertise in issues of long-term care voting to identify  practices that may facilitate voting in long-term care facilities while  ensuring voting integrity. To gather information on state actions to  facilitate and protect voting for long-term care facility residents, we  administered a Web-based survey of election officials in all 50 states, the  District of Columbia, the Commonwealth of Puerto Rico, and three  territories between December 2008 and February 2009. We received a 100  percent response rate. We did not verify survey responses or other  information provided by state officials.
To gather information on local actions to facilitate and protect voting for  long-term care facility residents, we conducted an e-mail survey of 104  local election jurisdictions between September 2008 and February 2009.  We received an 88 percent response rate. The sample of election  jurisdictions was selected as part of our related study examining polling  place accessibility for voters with disabilities. The survey estimates  calculated for this report did not have a low enough margin of error to  allow us to generalize results to localities nationally. We did not verify  survey responses or other information provided by local officials. In  addition, to gather more detailed information on local actions to facilitate  and protect voting, we conducted site visits to seven localities— Burlington, Vermont; Chicago, Illinois; the District of Columbia; Kitsap  County, Washington; Multnomah County, Oregon; Shelburne, Vermont;  and Washington County, Oregon—in the weeks prior to the November  2008 federal election. At each locality, we interviewed local election  officials and visited one or two long-term care facilities. In total we visited  10 long-term care facilities and at each we interviewed facility staff and  observed voting procedures. We selected localities generally well-regarded  in their approach to facilitate voting for long-term care facility residents  based on interviews with agency officials, representatives of professional  organizations, and multidisciplinary researchers. We selected long-term  care facilities to visit based on input from local election officials.
We conducted our work from April 2008 through November 2009, in  accordance with all sections of GAO’s Quality Assurance Framework that  were relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.
See appendix I for more detailed information on our scope and  methodology.
subsections: section_title: Background
subsections: section_title: Role of State and Federal Government
paragraphs: The administration of federal elections is a massive enterprise, conducted  primarily at the state and local level, under applicable state and federal  voting laws. Responsibility for holding elections and ensuring that each  voter has the ability to fully participate in the electoral process—including  registering to vote, accessing polling places or alternative voting methods,  and casting a vote—primarily rests with state and local governments, with  regulation and oversight from states and the federal government. Each  state establishes the requirements for conducting local, state, and federal  elections within the state. For example, states regulate such aspects of  elections as ballot access, absentee voting requirements, the establishment  of voting places, provision of Election Day workers, and the counting and  certification of the votes. The states, in turn, have typically delegated  responsibility for administering and funding state election systems to the  more than 10,000 local election jurisdictions nationwide. Federal laws  have been enacted to cover several aspects of the voting process,  including some that are designed to help ensure voting accessibility for the  elderly and people with disabilities. The relevant provisions of these  federal laws are primarily related to the accessibility of polling places,  prohibitions on discrimination, and the allowance of voting assistance  from a person of the voter’s choice. See appendix II for more detail on  federal laws.
Multiple federal agencies are involved with issues related to state and local  governments’ administration of the election process for long-term care  facilities residents, including enforcing election laws, conducting election  research, and ensuring that residents’ rights are protected. Justice’s Civil  Rights Division and its various sections enforce federal statutes  prohibiting discrimination. Specifically, the Disability Rights Section  protects the rights of persons with disabilities under the Americans with  Disabilities Act of 1990 (ADA) and the Voting Section is responsible for  enforcing certain federal statutes protecting voting rights, including  certain protections of the voting rights of persons with disabilities, which  may also include long-term care facility residents. In addition to Justice’s  role, HHS administers certain provisions of statutes related to disabilities  and voting. HHS’ Administration on Aging administers a long-term care  ombudsman program that assists with complaints and provides advocacy  for long-term care residents, while the Administration on Developmental  Disabilities administers a federal grant program that distributes HAVA  funds to support state and local efforts to ensure that people with  disabilities have access to the election process, including grants for  making polling places accessible to individuals with disabilities and  providing individuals with disabilities with information about the  accessibility of polling places. Also, the HHS Centers for Medicare and  Medicaid Services (CMS) sets requirements for states to conduct periodic  studies on nursing homes that participate in Medicare, and then collects,  analyzes, and reports on this data on nursing homes, such as complaints  related to residents’ choices and rights, which could include the right to  vote.
In addition, the EAC, which was established under HAVA, has wide- ranging duties to help improve state and local administration of federal  elections. Among other things, the EAC is responsible for serving as a  national clearinghouse of election-related information and a resource for  information with respect to the administration of federal elections; making  HAVA grants for research and development of new voting equipment and  technologies, and the improvement of voting systems; and periodically  conducting and making publicly available studies regarding methods of  ensuring accessibility of voting, polling places, and voting equipment to all  voters. In addition, EAC reported that of the payments it has provided to  states, states have spent over $800 million on voting systems that comply  with HAVA’s requirements for voting system standards. In 2008, the EAC  published the Election Management Guidelines (EMG), which provides  information on a wide range of election related topics intended to assist  state and local election officials in effectively managing and administering  elections, and a series of Quick Start guides, designed to highlight and  summarize information contained in the chapters of the EMG.
section_title: Characteristics of Long- term Care Facility Residents
paragraphs: In 2007, there were almost 38 million individuals aged 65 or older and the  majority had at least one chronic health condition. By 2030, those aged 65  and over are projected to grow to over 72 million individuals (see fig.1),  and this group is projected to represent a quarter of the voting age  population at that time. Older voters, who consistently vote in higher  proportions than other voters, may face challenges exercising their right to  vote because disability increases with age. Studies have shown, for  example, that the risk of losing mobility doubles with every 10 years after  reaching the age of 65. Moreover, it is estimated that 70 percent of people  over age 65 will require some long-term care services at some point in  their lives, such as residing in a nursing home or assisted living facility.
Long-term care facilities provide an array of health care services for  individuals who may have difficulty caring for themselves because of a  range of physical or mental impairments. The support long-term care  facilities provide can range from independent living with little or no  personal medical care to nursing homes with 24-hour a day skilled care.  While the individuals residing in long-term care facilities are most often  elderly, the resident population may also include younger individuals with  a disabling chronic illness, severe injury, or disease. According to the most  recent National Nursing Homes Survey, in 2004, approximately 88 percent  of nearly 1.5 million nursing home residents were age 65 and older.  Furthermore, nearly all of these older residents were dependent upon  others for assistance with at least one activity of daily living, such as  bathing or dressing. Long-term care facility residents may face challenges  not only with physical impairments, but also with cognitive impairments.  According to CMS, in 2006, 69 percent of nursing home residents  demonstrated some form of cognitive impairment, including various stages  of dementia. These physical and cognitive impairments can make long- term care facility residents dependent on others—family, friends, facility  staff, or election workers—for assistance in exercising the right to vote.
The physical and cognitive impairments of long-term care facility residents  directly affect the balance between voting participation and the integrity  of the voting process. Specifically, the physical and cognitive impairments  of many long-term care facility residents may make it more difficult for  them to independently drive, walk, or use public transportation to get to  their designated polling place. Once at the polling place, they may face  challenges finding accessible parking, reaching the ballot area, and casting  a ballot privately and independently. Furthermore, they often may not  have a valid driver’s license or other form of government-issued photo  identification that some states may require to vote. Consequently, the  number of elderly people who exercise their right to vote through  alternative voting methods, such as absentee, early, and Election Day  mail-in ballots may grow as more elderly individuals reside in long-term  care facilities. These residents may also have limited dexterity, impaired  eyesight, or cognitive impairments, such as dementia, that can make them  dependent on others to read or mark a ballot, regardless of where the  ballot is cast. This makes them vulnerable to fraud and undue influence  from relatives, long-term care facility staff, campaign workers, or  candidate supporters, who sometimes provide assistance when casting  their vote. Some long-term care facility staff may choose to screen  residents to determine their ability to vote using a variety of methods that  may include administering a formal cognitive screening test, asking  election-related questions, or using prior assessments of the resident’s  general mental capacity. In addition, depending on state law, some  residents with cognitive impairments may also face legal limitations to  their right to vote due to court determinations of mental incompetence or  appointment of a legal guardian.
section_title: Most States Have Requirements or Guidance to Facilitate Voting for Long-term Care Facility Residents
paragraphs: Most states have requirements or guidance to facilitate voting for long- term care facility residents. Almost half of the states reported providing  training to local election officials specifically on state requirements or  guidance to facilitate voting for long-term care facility residents.  Additionally, some states conducted one or more oversight activities to  ensure that localities were adhering to state requirements or guidance.  Some state requirements or guidance for voting in long-term care facilities  may help to protect against voter fraud and undue influence, according to  researchers.
subsections: section_title: A Large Majority of States Reported Having Requirements or Guidance to Facilitate Voting for Long-term Care Facility Residents
paragraphs: According to our survey, 44 states reported having at least one  requirement or guidance to facilitate voting for long-term care facility  residents. The most commonly reported state requirements or guidance  were to require or provide guidance to election officials to provide long- term care facility residents with accommodations to assist them in  absentee voting processes, provide accommodations for voter registration,  and provide special accommodations to assist elderly voters in meeting  voter identification requirements (see fig. 2). Eleven states reported having  requirements or guidance for all three of these activities. According to  researchers, without state requirements or guidelines for voting in long- term care facilities, access to voting for residents is largely determined by  the practices and attitudes of the long-term care facility staff, which they  noted can vary.
Accommodations for absentee voting for residents of long-term care  facilities was the most commonly reported type of state requirements or  guidance. Specifically, 42 states reported having a requirement or guidance  for accommodations for absentee voting in long-term care facilities. Some  of these states required election workers to deliver absentee ballots to  long-term care facilities. For example, in Iowa, election officials reported  that they provided guidance to long-term care facility staff on the process  of soliciting absentee ballot requests from their residents and required  bipartisan election teams to deliver absentee ballots to all long-term care  facilities. Other states reported mandating that election officials conduct  in-person absentee voting at long-term care facilities. According to state  election officials, Illinois law requires that election workers conduct in- person absentee voting at long-term care facilities one to four days before  Election Day. Some states reported requiring election workers to facilitate  absentee voting at long-term care facilities if a minimum number of  absentee ballots are requested or if the number of registered voters  residing at a facility exceeds a state-set minimum.
Among the states, 24 reported having requirements or guidance to  facilitate voter registration for long-term care facility residents. For  example, state election officials in Maryland reported that each local  election office is required to contact nursing homes and assisted living  facilities to offer voter registration assistance and visit facilities with more  than 50 residents to facilitate voter registration among facility residents.  Election officials in the District of Columbia reported that they visit long- term care facilities several times—first for voter registration and then later  for assistance with absentee ballots. Officials from two states said that  some long-term care facility residents may benefit from providing  accommodations or assistance in changing their voter registration from  their previous address, which may be in another state, county, election  jurisdiction, or precinct, to the address of the long-term care facility.
Also, 16 states reported requiring or allowing special accommodations to  assist elderly voters in meeting voter identification requirements.  According to some researchers and election officials we interviewed, long- term care facility residents may not have a valid driver’s license or utility  bill that can typically be used for identification. Some states accept  alternative forms of identification from long-term care facility residents.  For example, Massachusetts offers suggestions to municipalities and long- term care facility staff on the acceptable forms of identification—such as a  letter from the facility staff stating the individual resides in their facility. In  addition, Massachusetts election officials reported first-time voter  identification requirements would not apply when they conduct in-person  voter registration drives at long-term care facilities. Similarly, one South  Dakota election official reported that voter identification and affidavit  requirements can be waived entirely for long-term care facility residents  receiving in-person absentee voting assistance from an election official at  the facility. Lastly, only Puerto Rico reported requiring cognitive screening  to assess the ability of a person to vote prior to the casting of his or her  ballot.
section_title: About Half of All States Reported Training Local Officials, While Fewer Reported Conducting Oversight of Local Adherence to State Requirements or Guidance
paragraphs: While most states reported that they provide general training to local  election officials on assisting voters with disabilities, about half of the  states reported providing training to local election officials specifically on  state requirements or guidance to facilitate voting for long-term care  facility residents. For example, state election officials in Puerto Rico  reported that they provided local election officials with general voting  accessibility training to improve the interactions between the election  officials and the voter, which included sensitivity training and simulations  of potential scenarios. Furthermore, 23 states reported providing targeted  training to local election officials specifically on state requirements or  guidance for facilitating voting for long-term care facility residents. The  training that states provided varied, but, in general, included assistance in  adhering to state requirements or guidance on voter registration, absentee  balloting requests, and assisted absentee voting procedures for long-term  care facility residents. For example, in Vermont, state election officials  provided training and distributed a handbook to local election officials on  guidance for facilitating absentee voting in long-term care facilities, which  included information on the role of election officials, public notification  requirements, election supplies and forms, the set up of mobile polling  stations, and the correct procedures for returning completed absentee  ballots. In South Carolina, state officials, upon request, offered a one-on- one training to county election office staff on absentee voting procedures.  Connecticut provided training to local election officials on voter  registration and absentee ballot application procedures, as well as  absentee voting procedures.
Among the states, 17 conducted one or more oversight activities to ensure  localities were adhering to state long-term care facility voting  requirements or following state long-term care facility voting guidance. Of  this group, 11 states reported conducting visits to local election  jurisdictions or long-term care facilities to monitor local actions to meet  state long-term care facility requirements. In Oregon, officials reported  that they visited selected localities during an election cycle to observe  their practices, suggest improvements, and share best practices. In  addition, 8 states reported requiring or requesting localities to report on  actions taken to address state requirements or guidance to facilitate voting  for long-term care facility residents. For example, in Oklahoma, each  county election board reported to the State Election Board after each  election the number of voters who requested a ballot in nursing homes, the  number of nursing homes visited, and the number of voters who voted in  nursing homes. Then, the State Election Board aggregated the information  at the state level and provided statistics to the state legislature, the EAC,  and the public. In addition, county election boards in Oklahoma also  reported to the State Election Board any problems they encountered and  what actions they took to address them. The State Election Board may use  this information to revise the procedures for absentee voting. Finally, 7  states, reported requiring county officials to report the number of long- term care facility residents who voted for tracking and planning purposes  for future elections. See table 1 for a list of the training and oversight  activities reported by each state.
section_title: Some State Requirements and Guidance May Help to Ensure Voting Integrity
paragraphs: Most states reported having requirements or guidance to provide absentee  voting accommodations for long-term care facility residents, which  according to researchers, may help local election officials protect voting  integrity in long-term care settings. Because of the relatively high levels of  cognitive impairments found in nursing home residents, this population  requires assistance with the voting process. This assistance, however, can  make the resident susceptible to fraud or undue influence. While the EAC  has never completed a national study on the frequency and prevalence of  voter fraud in long-term care facilities, there have been several high-profile  cases and other anecdotal evidence suggesting this is an issue. Some  researchers believe that absentee voting, especially by long-term care  facility residents who require assistance casting their absentee ballots, is  susceptible to voter fraud and undue influence. Researchers also believe  that establishing requirements or providing guidance that local election  officials conduct absentee voting in long-term care facilities would help to  standardize efforts across facilities and protect against voter fraud. For  example, according to researchers, requiring local election officials to  deliver absentee ballots in person to facilities or conduct on-site absentee  balloting at facilities—which some states require or allow—can decrease  the likelihood of fraud and inappropriate influence by eliminating the need  for assistance from influential third parties, such as long-term care facility  staff, relatives, or candidate supporters. Specifically, research suggests  that requiring bipartisan local election teams to deliver, collect, and assist  with absentee balloting lowers the risk that election officials from a single  party could unduly influence voters.
In preparation for the November 2008 federal election, the EAC developed  guidance—the Quick Start Management Guide on Elderly and Disabled  Voters in Long Term Care Facilities—for state and local election officials  on facilitating voting in long-term care facilities. In May 2008, the EAC  convened a working group of academics, election officials, and other  experts in the field, which we observed, to share information on  facilitating voting for long-term care facility residents. The EAC developed  the Quick Start guide based on the information discussed at the working  group. The EAC then distributed 13,000 copies of its guidance, which  focused on facilitating voting for elderly and disabled voters residing in  long-term care facilities, to election officials nationally, issued a press  release, and posted the guidance on its Web site. The guidance focused on  the development of a plan for community outreach, coordination with  long-term care facility staff, and implementation of voting assistance to  long-term care facility residents; it did not address actions states or  localities can take to ensure the integrity of the voting process. EAC  officials told us they plan to convene a working group to develop a new  chapter in the EMG on voting in long-term care facilities that would  expand upon the information provided in the Quick Start guide. To date,  the EAC has not collected information nationally nor conducted studies on  state or local methods for identifying, deterring, and investigating fraud  and undue influence in long-term care facilities; however, they told us that  doing so would add value to long-term care voting nationally. According to  the EAC, they have not conducted any studies because quantifying the  level of voter fraud in long-term care facilities is difficult, as fraud often  goes unreported and unprosecuted. However, EAC officials believe that  state and local election officials could provide more education and  outreach on voting rights and voter fraud to long-term care facilities,  including residents’ friends and family, to help reduce the likelihood of  voter fraud or undue influence. Moreover, the EAC, which has limited  resources—a $16.4 million budget and fewer than 50 staff members for  fiscal year 2008—stated it has devoted much of its resources to updating  the Voluntary Voting System Guidelines, instituting a voting system testing  and certification program, and administering and auditing HAVA funds.
section_title: Localities Have Taken a Variety of Actions to Facilitate and Protect Voting for Long-term Care Facility Residents
paragraphs: Localities we surveyed have taken a variety of actions to facilitate voting  access and protect voting integrity for long-term care facility residents.  Specifically, they reported facilitating voting for long-term facility  residents by supporting facility staff in assisting residents with the voting  process and through direct voting services to facility residents, some of  which may help to ensure voting integrity. Most commonly, localities we  surveyed reported providing early or absentee voting information or  guidance to long-term care facility staff. Similarly, the seven localities we  visited employed a range of strategies to facilitate and protect the voting  process. Moreover, each locality we visited used a somewhat different  approach for applying these strategies and some reported challenges in  doing so, such as providing assistance at a reasonable cost and assisting  residents with cognitive disabilities.
subsections: section_title: Most Localities We Surveyed Reported Providing Long-term Care Facilities with Voting Guidance or Other Information and Other Voting Assistance, Some of Which May Help to Ensure Voting Integrity
paragraphs: Localities we surveyed reported taking a number of actions to facilitate  the voting process in long-term care facilities. Specifically, 78 of the 92  localities responding to our survey reported taking at least one action to  facilitate the voting process for long-term care facility residents. Of the  responding localities, close to half (45 of 92) of responding localities  reported taking three or more actions (see fig. 3).
Local officials facilitated voting for long-term facility residents through  actions that supported facility staff in assisting residents with the voting  process and through direct voting services to facility residents (see table  2). Specifically, when supporting facility staff with the voting process,  localities we surveyed reported providing support to long-term care  facility staff in assisting residents with the absentee or early voting  process. Over two-thirds (65 of 92) of responding localities reported  providing early and absentee voting information or guidance to long-term  care facility staff. For example, in Lincoln County, Kentucky, local election  officials reported that they provide information on absentee voting  procedures to the long-term care facility staff, including instructions on  collecting the names of residents interested in absentee voting and  requesting absentee voting applications to be completed and mailed back  to the local election office. Researchers suggest that providing guidance to  long-term care facility staff can help to ensure that residents are receiving  voting assistance that is free of fraud and undue influence. In addition, a  slight majority of the localities we surveyed reported delivering absentee  ballots to facilities, which may help ensure that residents receive their  ballots and reduce the likelihood of fraud. However, one locality reported  that election officials were unable to deliver ballots to facilities because  state law requires that all absentee ballots be sent by mail. Finally, close to  one-third (29 of 92) of responding localities reported that they provide  training to long-term care facility staff which, according to researchers,  can help to ensure that facility staff are providing voting assistance that is  less susceptible to fraud and undue influence.
Some localities we surveyed also reported providing voting services  directly to long-term care facility residents. Specifically, close to half   (45 of 92) of responding localities reported bringing election officials to  long-term care facilities to provide voting assistance. For example, in  Montgomery County, Maryland, local election officials reported that they  sent trained, bipartisan teams of election workers to long-term care  facilities to help residents complete their absentee ballots. As noted  earlier, for state actions to facilitate voting, some researchers suggest that  bringing trained election officials to long-term care facilities can decrease  the likelihood that those providing the assistance to residents will unduly  influence their votes and ensure that ballots are properly cast. In addition,  close to one-third (29 of 92) of the localities we surveyed also reported  designating long-term care facilities as Election Day polling places, which  allows residents to vote in an official polling place without having to leave  their residence. However, local officials from one of these localities  reported that they only designate a portion of the long-term care facilities  in their election jurisdiction as polling places. Designating long-term care  facilities as polling places may provide residents with increased  opportunities to vote privately and independently, because HAVA requires  each polling place for federal elections to have at least one voting system  equipped for people with disabilities. While accessible voting systems  provide opportunities for more private and independent voting, only two  localities we surveyed—Miami-Dade County, Florida, and Travis County,  Texas—reported bringing accessible voting systems to long-term care  facilities for absentee or early voting. Furthermore, 15 localities we  surveyed—including Miami-Dade County, Florida, and Travis County,  Texas—reported providing long-term care facilities with demonstrations  of voting systems equipped for people with disabilities, which could  facilitate a greater use of these systems at Election Day polling places or  for early or absentee voting at long-term care facilities by residents  unfamiliar with electronic machinery. Finally, one locality we surveyed— Falmouth, Maine—reported providing long-term care facility residents  with transportation to polling places on Election Day.
section_title: Localities We Visited Used a Range of Strategies to Facilitate and Protect Voting for Long-term Care Facility Residents and Faced Some Implementation Challenges
paragraphs: The seven localities we visited commonly implemented targeted efforts to  facilitate voting for long-term care facility residents for the November 2008  federal election. However, the characteristics of each locality’s effort  varied in a number of ways, including the number of facilities receiving  voting assistance, the reported cost, and the number of years the effort  had been in practice (see table 3).
Localities we visited employed a range of strategies to facilitate and  protect the voting process—from voter registration to casting ballots—for  long-term care facility residents. Specifically, these strategies included  coordination with stakeholders, such as long-term care facility staff and  others, deployment of election teams, and implementation of procedures  to protect and ensure voting integrity. As figure 4 indicates, these  strategies are generally used in conjunction with one another over a two- month period to facilitate the entire voting process—including casting a  ballot—for long-term care facility residents before Election Day.
While all of the localities we visited employed all three of these  strategies—coordination with stakeholders, deployment of election teams,  and implementation of procedures to protect and ensure voting integrity— each employed a somewhat different mix of approaches to implement its  overall strategy. (See table 4)
Localities we visited coordinated with stakeholders relevant to the long- term care voting process in order to develop long-term care voting efforts.  For example, in one locality—Kitsap County, Washington—local election  officials coordinated with a disability advisory group, that included  representatives from disability advocacy organizations, to jointly identify  long-term care facilities whose residents may have needed voting  assistance. Kitsap County officials also consulted with the advisory group  in the development of its long-term care facility voting effort, which  recommended that local election workers bring accessible voting  machines into facilities. In addition, four localities coordinated with state  agencies to identify long-term care facilities to visit. For example, in  advance of the November 2008 federal election, officials in the District of  Columbia told us they coordinated with District of Columbia Department  of Health to obtain a list of facilities and generated a list of registered  voters at each facility from the District’s voter registration database.
The localities we visited also reported coordinating with long-term care  facility staff on pre-election voting activities, such as voter outreach and  registration. Generally, these localities did not have election workers visit  facilities to conduct voter outreach or voter registration activities, but  instead relied on long-term care facility staff to facilitate the process. For  example, election officials in Chicago, Illinois, told us that they delivered  packets two months before Election Day to all of the long-term care  facilities in the city, which included a letter explaining the city’s Nursing  Home Voting Program, a list of residents who were registered to vote, new  voter registration forms, absentee voting applications, and postage paid  return envelopes that facility staff could use to return completed  applications. Chicago election officials relied on facility staff to identify  interested residents, aid residents in completing the forms, and return the  materials. Providing long-term care facility staff with this type of detailed  information and guidance on facilitating the voting process may help to  ensure that residents are properly registered and receive an absentee  ballot. Furthermore, in one locality—Washington County, Oregon— officials told us that election teams visited long-term care facilities during  the election registration period to conduct a two-hour voter education  presentation on voting access for people with disabilities, including  information on voting rights, accessible voting systems, and resources.
Election officials and long-term care facility staff in a few localities  reported some challenges with coordination. For example, officials from  two localities reported that maintaining program knowledge at the facility  level from election to election can be difficult due to high turnover among  long-term care facility staff. Election officials in Chicago addressed this  potential challenge by assigning one election staff person as the central  contact for all long-term care facility staff. Long-term care facility staff and  election officials in two localities told us that coordinating the voter  registration process with local election officials can also be difficult  because of the transitory nature of residents. Although many long-term  care facility residents reside in facilities for extended periods of time, one  long-term care facility staff member explained that some residents may be  in the hospital during the voter registration process or may reside in the  facility during the registration process, but move before Election Day.
subsections: section_title: Deployment of Election Teams to Long-term Care Facilities
paragraphs: Local election officials in the localities we visited deployed election teams  before Election Day to provide individualized, in-person voting assistance  to long-term care facility residents. To initiate the deployment of these  teams, the localities we visited contacted long-term care facility staff well  before Election Day to schedule a time to provide in-person voting  assistance. For example, in Chicago, election officials told us that they  contact facility staff about one month before the election to schedule a  voting assistance visit during one of the four days prior to Election Day, as  required by state law. In Multnomah County, Oregon, election officials told  us they contacted facility staff to schedule a day to provide voting  assistance once all mail-in ballots were mailed, which is 18 days before  Election Day. To facilitate the voting process, all of the localities trained  election workers or officials to provide voting assistance to people with  disabilities and sent teams of election workers to selected long-term care  facilities to assist individual residents in the reading, marking, and sealing  of absentee, early, or other mail-in ballots. This assistance allowed  residents to overcome visual, hearing, and dexterity impairments in  casting their ballots. For example, in Burlington County, we observed  election workers assisting a resident with hearing and dexterity  impairments in completing a ballot by using a handheld white board to  communicate. In general, these voting assistance activities took place in a  common area in the facility, such as an activity room or library, which  often provided limited privacy due to restricted space. In particular,  residents often communicated ballot selections in loud voices to election  workers, which may have compromised their voting privacy. In most of  the localities, election teams also went to individual rooms to provide  bedside voting assistance. For example, in Multnomah County, teams of  election workers went to the rooms of bedridden residents to provide  voting assistance. Similarly, election teams in Shelburne, Vermont,  provided in-room assistance to residents living in the memory-loss unit to  provide a more familiar and accommodating setting to facilitate the voting  process. In some of the localities we visited, election workers providing  bedside voting assistance were accompanied by facility staff to help meet  resident needs during the voting process. Long-term care facility staff in  some localities we visited noted that, without assistance from election  teams, many of the residents in the facilities would have had to rely on  facility staff, relatives, or volunteers to read, mark, and seal their ballots.
In some localities we visited, local election workers and facility staff faced  challenges in providing voting assistance to residents with cognitive  limitations. During our observations, none of the localities we visited  conducted cognitive screenings—assessing a resident’s ability to vote  prior to casting a ballot by asking election-related questions or based on  an assessment of a resident’s general mental capacity. Generally, election  workers gave any resident registered to vote the opportunity to cast a  ballot if they showed willingness and the intent to vote. Despite this  approach, in some cases, residents who were registered to vote may have  been unable to do so, apparently due to cognitive impairments. For  example, election workers in one locality attempted to provide voting  assistance to a resident who was registered to vote, but after 20 minutes  the resident was unable to articulate any ballot selections. Election  workers observed that she was unable to vote, but encouraged her to vote  in the next election. The fluidity of residents’ health may inhibit their  ability to make a choice at a specific time. While we did not observe  cognitive screenings being performed during our site visits, long-term care  facility staff in some of the localities performed cognitive screenings of  residents before asking them to register to vote or assisting them in  applying for early or absentee ballots. For example, one long-term care  facility staff member explained that she did not ask residents who she  deemed were cognitively unable to vote if they were interested in  registering to vote. In order to determine each resident’s cognition, she  tested the residents’ ability to articulate their name and awareness of their  surroundings. According to researchers, if long-term care facility staff are  not trained to address some of the unique issues of voting by the elderly,  such as determining cognitive ability to vote, they may inadvertently  disenfranchise some residents who are actually able to vote.
Election officials in some localities told us that providing individual voting  assistance to long-term care facility residents is resource intensive. Some  local election officials told us that it was difficult to provide individualized  voting assistance at a reasonable cost. For example, local election  officials in one locality told us that their voting assistance funding and  scope had been cut to reduce the locality’s costs. As a result, the locality  no longer conducts as much voter outreach to long-term care facilities as it  used to. In two other localities, election officials supplemented the cost of  providing long-term care voting assistance with HAVA funds. In addition  to requiring significant monetary costs per individual served, election  officials and long-term care facility staff from a few localities told us that  providing individual voting assistance is a very time-consuming process.  Most localities brought several election teams to each facility to provide  voting assistance, which generally took most of the morning or afternoon.  Part of the time commitment relates to election workers having to read  each ballot aloud multiple times to residents who may have hearing and/or  cognitive impairments. Moreover, this process is more resource intensive  for localities that require bipartisan voting assistance. For example, in one  locality two election officials spent an hour with one resident reading and  marking a lengthy ballot with a number of ballot measures.
section_title: Implementation of Procedures to Protect and Ensure Voting Integrity
paragraphs: Officials in all seven of the localities we visited implemented various  procedures to protect long-term care facility residents against fraud and  undue influence. Figure 5 provides examples of protections that can help  to ensure voting integrity. Most of the localities we visited provided  residents with bipartisan voting assistance when deploying election teams,  which consisted of teams of two election workers with different political  party affiliations providing voting assistance to each resident. According  to some researchers, this practice can lower the risk of one political party  unduly influencing the resident. However, residents may face undue  influence from others, such as facility staff and family members. For  example, at one long-term care facility, a resident told the bipartisan team  of election workers assisting her that she was not sure whether she could  vote for the candidate she preferred because her child told her to vote for  an opposing candidate. Most localities we visited also set up privacy  screens on tables to shield residents’ ballots from the view of others. In  addition, most localities collected completed ballots in a ballot box, and in  a few cases, the boxes were locked with padlocks. Also, four localities we  visited required residents to sign affidavits documenting that voting  assistance was requested and noting who provided the assistance. In  Chicago, the election teams included election observers from law  enforcement agencies such as the U.S. Attorney’s Office or Cook County  State’s Attorney’s Office. These observers generally handle and inspect  affidavits for voting assistance and check poll watcher credentials. While  none of the localities required residents to provide identification, in  Washington County, some residents with physical impairments were able  to sign their ballots using a fingerprint, which was on file at the election  office. In addition, in one locality, election teams sometimes asked  residents for their Social Security numbers to verify that the correct  resident was receiving the ballot.
Some localities implemented additional procedures, which may have  helped ensure voting integrity by promoting independent voting. Election  teams in Kitsap County and Washington County brought electronic  accessible voting systems to long-term facilities, which provided residents  with disabilities the opportunity to complete a ballot independently  without election worker assistance. Chicago election teams provided  residents with sample ballots to demonstrate how to complete the official  ballot. We observed that this practice allowed residents and election  workers to assess whether voting assistance was needed to complete the  ballot. Additionally, the election team in the District of Columbia brought  portable voting booths to each facility, which allowed residents to attempt  to vote independently. We observed election teams in this locality allowing  residents to choose whether to complete a ballot independently in the  portable voting booths or with assistance from an election worker at a  table.
A few localities faced challenges fully implementing procedures to protect  and ensure voting integrity and independence. Specifically, some local  election officials told us that residents were reluctant to use unfamiliar  voting methods, such as an accessible voting system. For example, we  observed only one resident use an accessible voting system in the three  localities we visited that reported using accessible voting systems in  facilities. Election workers in two of these localities told us that the  accessible voting system was seldom used by residents, who preferred  one-on-one voting assistance using a paper ballot. In one instance, local  election workers faced difficulties providing bipartisan assistance. In this  locality, we observed election workers providing assistance to residents  individually rather than in bipartisan teams in order to provide assistance  more quickly to the growing number of residents waiting to vote.
section_title: Conclusions
paragraphs: Many states and local jurisdictions appear to be moving in the direction of  facilitating voting for long-term care facility residents, primarily older  voters, by providing alternative voting methods, such as absentee or early  ballots and, in some cases, Election Day mail-in ballots. However, at the  same time, states and localities vary in the extent to which they ensure  that the ballots of these voters in long-term care facilities are not  fraudulently completed by someone else, or that these voters are not  subjected to undue influence by facility staff or family members. The  EAC’s plans to develop a new chapter in the EMG on voting in long-term  care facilities is a step in the right direction, but remains a work in  progress. For the future, state and local accommodations to address  physical and cognitive disabilities of long-term care facility residents will  directly affect the balance between voting access and the integrity of the  voting process. That is, providing accommodations to facilitate voting for  long-term care facility residents has advantages for these residents by  increasing their access to vote, but can also present challenges for election  officials. Officials must balance providing increased access to voting with  ensuring that ballots are cast by the appropriate voter, and completed  without undue influence from long-term care facility staff, relatives, or  other politically interested parties. A number of localities we visited have  taken some actions that attempt to strike this balance. We acknowledge  that facilitating voting for long-term care facility residents can be a costly  and challenging undertaking, but given the increasing size of the elderly  population, it will become progressively more important to implement  cost-effective approaches to meet the growing demand for voting  accommodations and assistance outside of traditional polling places.  Further guidance on how to cost-effectively provide greater voting access  for long-term care facility residents, while also ensuring voting integrity,  may assist some states and localities in providing voting access and  reducing opportunities for fraud and undue influence of a vulnerable and  dependent population. However, to the extent that states and localities do  not have the opportunity or resources to learn from each other’s success  and challenges, progress across the nation could be hampered.
section_title: Recommendation for Executive Action
paragraphs: We recommend that, as the EAC works with stakeholders to develop  guidance on voting in long-term care facilities, the EAC also collect and  disseminate information on cost-effective promising practices for  providing voting access while also ensuring voting integrity.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to EAC, HHS, and Justice for review and  comment. In its comments, EAC indicated agreement with our findings  and recommendation. Specifically, EAC stated that it shared our concern  that current voting practices in long-term care facilities must be improved  and enhanced, and indicated that it plans to produce a full chapter on this  topic for its EMG on serving voters in long-term care facilities. HHS and  Justice provided no formal comments. HHS provided technical comments,  which we incorporated into the report as appropriate. EAC’s comments  are reproduced in appendix III.
We are sending copies of this report to the EAC, HHS, Justice, relevant  congressional committees, and other interested parties. In addition, the  report will be made available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  Barbara D. Bovbjerg at (202) 512-7215 or bovbjergb@gao.gov, or William  O. Jenkins at (202) 512-8777 or jenkinswo@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix VI.
section_title: Appendix I: Scope and Methodology
paragraphs: Our objectives were to identify the actions taken to facilitate and protect  voting for long-term care facility residents at (1) the state level and (2) the  local level. For both of our objectives, we interviewed officials of the  Department of Justice (Justice), the Department of Health and Human  Services (HHS), national organizations that represent election officials,  and multidisciplinary researchers. We also reviewed relevant federal laws,  regulations, guidance, and other documentation. We did not analyze state  requirements or guidance, but instead relied on states’ responses to our  survey. In addition, we interviewed officials at the Election Assistance  Commission (EAC) and reviewed EAC guidance on facilitating voting in  long-term care facilities. We interviewed multidisciplinary researchers in  the area of long-term care voting and reviewed relevant literature to  identify practices at the state and local level that may facilitate voting in  long-term care facilities while ensuring voting integrity. To obtain  information on state actions, we administered a Web-based survey of  election officials in all 50 states, the District of Columbia, the  Commonwealth of Puerto Rico, and three U.S. territories (American  Samoa, Guam, and the U.S. Virgin Islands). To obtain information on local  actions, we administered a survey of local election officials in 104 local  election jurisdictions and conducted site visits to seven localities. We  conducted our work from April 2008 through November 2009 in  accordance with all sections of GAO’s Quality Assurance Framework that  were relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.
subsections: section_title: Review of Documentation and Interviews with Federal Officials, Researchers, and Organizations
paragraphs: To gather information on the actions states and localities are taking to  facilitate and protect voting in long-term care facilities, we interviewed  federal officials, multidisciplinary experts, representatives of national  organizations, and reviewed relevant documentation. Specifically, we  spoke with officials in the Voting and Disability Rights Sections of the Civil  Rights Division from Justice and in the Administration on Aging and the  Centers for Medicare and Medicaid Services from HHS to better  understand the federal government’s role in facilitating voting for long- term care facility residents. To examine available guidance to state and  local election officials on facilitating and protecting voting in long-term  care facilities, we interviewed EAC officials, observed an EAC working  group meeting on facilitating voting in long-term care facilities, and  reviewed the EAC Quick Start Management Guide on Elderly and  Disabled Voters in Long Term Care Facilities. To gain perspectives of  management, improvement, and challenges to the facilitation of voting to  long-term care residents, we spoke with representatives of the National  Association of Secretaries of State (NASS) and National Association of  State Election Directors (NASED). We also reviewed relevant research  literature and interviewed principal, multidisciplinary researchers in the  area of long-term care voting, including researchers from the American  Association of People with Disabilities, the American Association of  Retired Persons, the American Bar Association Commission on Law and  Aging, the University of Pennsylvania Institute on Aging, and the National  Academy for State Health Policy to identify practices that may facilitate  voting in long-term care facilities and whether they may protect against  fraud and undue influence. We found this research literature to be  sufficiently reliable for the purposes of this report.
section_title: Survey of States, the District of Columbia, the Commonwealth of Puerto Rico, and Territories
paragraphs: To gather information on state actions to facilitate and protect voting for  long-term care facility residents, we administered a Web-based survey of  officials responsible for overseeing elections from the 50 states, the  District of Columbia, the Commonwealth of Puerto Rico, and three U.S.  territories (American Samoa, Guam, and the U.S. Virgin Islands). The  survey included questions about state and local actions to facilitate voting  in long-term care facilities. The survey was conducted using a self- administered electronic questionnaire posted on the Web. We collected  the survey data between December 2008 and February 2009. We received  completed surveys from all 50 states, the District of Columbia, the  Commonwealth of Puerto Rico, and three U.S. territories for a 100 percent  response rate.
Because this was not a sample survey, there are no sampling errors.  However, the practical difficulties of conducting any survey may introduce  nonsampling errors, such as variations in how respondents interpret  questions and their willingness to offer accurate responses. To minimize  nonsampling errors, we pretested draft survey instruments with state  election officials in Kansas, Virginia, and Wisconsin to determine whether  (1) the survey questions were clear, (2) the terms used were precise,   (3) respondents were able to provide the information we were seeking,  and (4) the questions were unbiased. We made changes to the content and  format of the questionnaire based on pretest results. Because respondents  entered their responses directly into our database of responses from the  Web-based surveys, the possibility of data entry errors was greatly  reduced. We also performed computer analyses to identify inconsistencies  in responses and other indications of error. In addition, a second  independent GAO analyst verified that the computer programs we used to  analyze the data were written correctly. We contacted election officials in  some states to gain a deeper understanding of selected survey responses,  and obtained and reviewed relevant documentation for selected states.  The scope of this work did not include contacting election officials from  each state and local jurisdictions to verify all survey responses or other  information provided by state officials. Similarly, we did not analyze  reported state requirements to verify what they require, but instead relied  on the states’ responses to our survey.
section_title: Survey of Local Election Jurisdictions
paragraphs: To gather information on local actions to facilitate and protect voting for  long-term care facility residents, we surveyed 104 local election officials.  The survey asked local election officials to identify whether their election  jurisdiction was taking any action to facilitate voting in long-term care  facilities and to identify any actions taken. We conducted the survey by   e-mail. We collected the survey data between September 2008 and  February 2009 and received an 88 percent response rate.
The sample of local election jurisdictions was taken from a related GAO  study examining polling place accessibility for voters with disabilities that  used a two-stage sampling method to create a nationally representative  random selection of polling places in the contiguous United States, with  the exception of those in Oregon. Specifically, the local election  jurisdictions used for the survey were those which had one or more of  their polling places randomly selected in the sample of polling places. The  survey estimates calculated for this report did not have a low enough  margin of error to allow us to generalize results to localities nationally. In  addition, the scope of this work did not include contacting election  officials from each local jurisdiction to verify all survey responses or other  information provided by local officials.
section_title: Local Site Visits
paragraphs: To obtain a more detailed understanding of local actions to facilitate  voting in long-term care facilities, we conducted site visits to seven  localities —Burlington, Vermont; Shelburne, Vermont; Chicago, Illinois;  the District of Columbia; Kitsap County, Washington; Multnomah County,  Oregon; and Washington County, Oregon. We selected localities generally  regarded as innovative or potentially effective in their approach to  facilitate voting for long-term care facility residents based on interviews  with agency officials, representatives of professional organizations, and  multidisciplinary researchers. We conducted all of the site visits in  October and November 2008, before the federal election on   November 4, 2008.
In each locality, we interviewed local election officials and long-term care  facility staff. During interviews with local election officials and long-term  care facility staff, we used a standard interview protocol that we  developed which enabled us to obtain detailed and comparable  information. In each locality, we discussed with local election officials the  process for facilitating voting for long-term care facilities, including  program history, coordination with stakeholders, and challenges. At each  locality, we selected one or two long-term care facilities to visit based on  input from local election officials. In total, we visited 10 long-term care  facilities and at each we met with facility staff responsible for coordinating  with local election officials regarding the voting process for residents,  which was typically the facility’s Activity Director. During these  interviews, we discussed the voting process for facility residents, including  coordination with local election officials and the unique voting challenges  for residents. While we met with local election officials and long-term care  facility staff in all the localities we visited, in a few instances, we were  unable to complete our interviews during our site visit, but conducted  interviews afterwards over the telephone.
We also observed the administration of the voting process prior to  Election Day at each of the long-term care facilities we visited. During  these observations we used a standard protocol we developed that  enabled us to collect uniform and detailed information that was  comparable across all of the long-term care facilities we visited. We  collected information on the number of election workers, number of  facility residents voting, and the types of voting assistance provided.
section_title: Appendix II: Summary of Federal Laws Related to Voting Accessibility for the Elderly and People with Disabilities
paragraphs: Although state and local governments are responsible for administering  elections, several federal laws set forth requirements that must be met  during the federal election process. Specifically, federal laws have been  enacted in major areas of the voting process, including several that are  designed to help ensure that voting is accessible for the elderly and people  with disabilities.
subsections: section_title: The Voting Rights Act of 1965
paragraphs: The Voting Rights Act of 1965 (VRA), as amended, provides for voting  assistance to voters with disabilities. Specifically, the VRA, among other  things, authorizes voters who require assistance to vote by reason of  blindness, disability, or inability to read or write to be given assistance by  a person of the voter’s choice, other than the voter’s employer or agent of  that employer or officer or agent of the voter’s union.
section_title: Voting Accessibility for the Elderly and Handicapped Act
paragraphs: In 1984 Congress enacted the Voting Accessibility for the Elderly and  Handicapped Act (VAEHA), which requires that political subdivisions  responsible for conducting elections assure that all polling places for  federal elections are accessible to elderly voters and voters with  disabilities, with limited exceptions. One such exception occurs when the  chief election officer of the state determines that no accessible polling  places are available in a political subdivision, and that officer ensures that  any elderly voter or voter with a disability assigned to an inaccessible  polling place will, upon advance request, either be assigned to an  accessible polling place or will be provided with an alternative means to  cast a ballot on the day of the election. Under the VAEHA, the definition of  “accessible” is determined under guidelines established by the state’s chief  election officer, but the law does not specify standards or minimum  requirements for those guidelines. Additionally, the Act requires states to  make available voting aids for elderly and disabled voters, including  instructions printed in large type at each polling place, and information by  telecommunications devices for the hearing impaired. The VAEHA also  contains a provision requiring public notice, designed to reach elderly and  disabled voters, of absentee voting procedures. The VAEHA also contains  provisions that make absentee voting more accessible by prohibiting, with  limited exceptions, the requirement of a notarization or medical  certification of disability when granting an absentee ballot.
section_title: Help America Vote Act of 2002
paragraphs: The Help America Vote Act of 2002 (HAVA) contains a number of  provisions designed to help increase the accessibility of polling place  voting for individuals with disabilities. In particular, Section 301(a)  outlines minimum standards for voting systems for federal elections. The  provision states that the voting system must be accessible for people with  disabilities, including nonvisual accessibility for the blind and visually  impaired, in a manner that provides the same opportunity for access and  participation as for other voters. To satisfy this requirement, each polling  place must have at least one direct recording electronic device or other  voting system equipped for people with disabilities. HAVA may apply to  assisted voting provided to long-term care facility residents, if the long- term care facility is considered a “polling place,” which is generally  designated at the state and local level.
In addition, there are several federal laws that provide broad protections  of the rights of people with disabilities, which indirectly apply to voting.
section_title: Older Americans Act of 1965
paragraphs: The Older Americans Act of 1965 (OAA), as amended, supports a wide  range of social services and programs for older persons. The OAA  authorizes grants to agencies on aging to serve as advocates of, and  coordinate programs for, the older population. Such programs cover areas  such as caregiver support, nutrition services, and disease prevention.  Importantly, the OAA also provides assistance to improve transportation  services for older individuals, which may include transportation to polling  places.
section_title: The Americans with Disabilities Act of 1990
paragraphs: Title II of the Americans with Disabilities Act of 1990 (ADA) and its  implementing regulations require that people with disabilities have access  to basic public services, including the right to vote. However, it does not  strictly require that all polling place sites be accessible. Under the ADA,  public entities must make reasonable modifications in policies, practices,  or procedures to avoid discrimination against people with disabilities.  Moreover, no individual with a disability may, by reason of the disability,  be excluded from participating in or be denied the benefits of any public  program, service, or activity. State and local governments may comply  with ADA accessibility requirements in a variety of ways, such as by  redesigning equipment, reassigning services to accessible buildings or  alternative accessible sites, or altering existing facilities or constructing  new ones. However, state and local governments are not required to take  actions that would threaten or destroy the historic significance of a  historic property, fundamentally alter the nature of a service, or impose  undue financial and administrative burdens. In choosing between available  methods of complying with the ADA, state and local governments must  give priority to the choices that offer services, programs, and activities in  the most integrated setting appropriate.
Title III of the ADA covers commercial facilities and places of public  accommodation. Such facilities may also be used as polling places. Under  Title III, public accommodations must make reasonable modifications in  policies, practices, or procedures to facilitate access for individuals with  disabilities. They must also ensure that no individual with a disability is  excluded or denied services because of the absence of “auxiliary aids and  services,” which include both effective methods of making aurally and  visually delivered materials available to individuals with impairments, and  acquisition or modification of equipment or devices. Public  accommodations are also required to remove physical barriers in existing  buildings when it is “readily achievable” to do so; that is, when it can be  done without much difficulty or expense, given the entity’s resources. In  the event that removal of an architectural barrier cannot be accomplished  easily, the accommodation may take alternative measures to facilitate  accessibility. All buildings newly constructed by public accommodations  and commercial facilities must be readily accessible; alterations to existing  buildings are required to the maximum extent feasible to be readily  accessible to individuals with disabilities.
section_title: Appendix III: Comments from the Election Assistance Commission
section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: Brett Fallavollita, Assistant Director and Amber Yancey-Carroll, Analyst- in-Charge managed this assignment. Ryan Siegel, Katherine Bowman,  Carolyn Blocker, and Laura Heald made significant contributions to this  report in all aspects of the work. Josephine Perez provided assistance with  site visit data collection. Carl Barden, Cathy Hurley, Stuart Kaufman, and  Walter Vance provided analytical assistance; Alex Galuten and Sarah  Cornetto provided legal support; Jessica Orr provided assistance on report  preparation; James Bennett developed the report’s graphics; and Anna  Bonelli verified our findings.
section_title: Related GAO Products
paragraphs: Voters with Disabilities: Additional Monitoring of Polling Places Could  Further Improve Voting Accessibility. GAO-09-941. Washington, D.C.:  September 30, 2009.
Voters with Disabilities: More Polling Places Had No Potential  Impediments Than in 2000, but Challenges Remain. GAO-09-685.  Washington, D.C.: June 10, 2009.
Elections: States, Territories, and the District Are Taking a Range of  Important Steps to Manage Their Varied Voting System Environments.  GAO-08-874. Washington, D.C.: September 25, 2008.
Elections: 2007 Survey of State Voting System Programs.  GAO-08-1147SP. Washington, D.C.: September 25, 2008.
Elections: Federal Program for Certifying Voting Systems Needs to Be  Further Defined, Fully Implemented, and Expanded. GAO-08-814.  Washington, D.C.: September 16, 2008.
Election Assistance Commission—Availability of Funds for Purchase of  Replacement Voting Equipment. B-316107. Washington, D.C.:   March 19, 2008.
Elderly Voters: Some Improvements in Voting Accessibility from 2000 to  2004 Elections, but Gaps in Policy and Implementation Remain.  GAO-08-442T. Washington, D.C.: January 31, 2008.
Elections: All Levels of Government Are Needed to Address Electronic  Voting System Challenges. GAO-07-741T. Washington, D.C.: April 18, 2007.
Older Driver Safety: Knowledge Sharing Should Help States Prepare for  Increase in Older Driver Population. GAO-07-413. Washington, D.C.:   April 11, 2007.
Elections: The Nation’s Evolving Election System as Reflected in the  November 2004 General Election. GAO-06-450. Washington, D.C.: June 6,  2006.
Elections: Federal Efforts to Improve Security and Reliability of  Electronic Voting Systems Are Under Way, but Key Activities Need to Be  Completed. GAO-05-956. Washington, D.C.: September 21, 2005.
Transportation-Disadvantaged Seniors: Efforts to Enhance Senior  Mobility Could Benefit from Additional Guidance and Information.  GAO-04-971. Washington, D.C.: August 30, 2004.
Elections: Electronic Voting Offers Opportunities and Presents  Challenges. GAO-04-975T. Washington, D.C.: July 20, 2004.
Elections: Perspectives on Activities and Challenges Across the Nation.  GAO-02-3. Washington, D.C.: October 15, 2001.
Elections: A Framework for Evaluating Reform Proposals. GAO-02-90.  Washington, D.C.: October 15, 2001.
Voters with Disabilities: Access to Polling Places and Alternative Voting  Methods. GAO-02-107. Washington, D.C.: October 15, 2001.
Elections: The Scope of Congressional Authority in Election  Administration. GAO-01-470. Washington, D.C.: March 13, 2001.