Behavioral Health Legislator Voting Behavior: A Systematic Review

Background/Purpose:

Behavioral health interventions are effective in improving outcomes for clients, yet most do not benefit, as access to care remains limited across the country. For example, 56% of adults with a mental illness do not receive any form of professional treatment, and the majority of the 20 million Americans per year who need substance abuse services do not receive them.

Existing gaps could be partially addressed through legislative policy making, as legislators have the power to shape the behavioral health system through budgetary and regulatory decisions. However, valuable proposals often do not receive legislative approval, denying vulnerable populations future benefits. It is therefore timely to consider how advocacy efforts may be strengthened by examining factors that influence legislator voting behavior.

Past research has examined ways to influence legislator behavior and improve voting outcomes, but few have focused on outcomes related to behavioral health initiatives. Understanding the potentially unique influences on behavioral health legislative voting behavior could aid future voting outcomes and ultimately increase access to care. Thus, the primary aim of this systematic review is to provide an examination and synthesis of the existing literature regarding the influences of legislator voting behavior related to behavioral health.

Methods:

A comprehensive search of peer-reviewed literature was conducted using a hybrid PRISMA approach with a variation of key search terms to allow for the specification of a term of ‘influence’ to be coupled with terms relating to ‘legislator’ and ‘voting behavior’. Searches were completed using six databases—Political Science Complete, Psychology and Behavioral Sciences Collection, PsycINFO, Public Administration Abstracts, Social Sciences Abstracts, SocINDEX and Social Work Abstracts—and one search engine, Google Scholar. Eligible articles featured American legislators, were published in English between the years 2006 and 2017, and explored influences of legislator voting behavior on health-related legislation. Following the selection of 75 full-text articles based on their abstract, each was reviewed in its entirety to determine analysis eligibility. After evaluation, 22 studies were selected for a thematic analysis.

Results:

The analysis revealed a complex web of factors that may influence legislator voting behavior on behavioral health measures, including some consistent techniques of influence. Legislative voting behavior can be influenced by factors that are both internal and external to the individual legislator. External influences include public and constituency opinion, political party, research, relationships, technology, advocacy/interest groups, and the media. Internal influences include personal and political ideologies, self-interests, and individual and social demographics, such as religion, gender, and race/ethnicity.

Implications:

Social workers are ethically required to be politically active and should advocate for legislative changes to promote social justice, yet the majority do not. Further, most social work students report feeling unprepared for political engagement upon graduation. There is ample evidence of the need for social workers to inform the legislative process, but to do so, both practitioners and students need to understand the process and opportunities to influence it. These results provide new insights that social workers can use to prepare themselves and their students for political advocacy in behavioral health.