Health systems to keep watchful eye on 2020 census

August 1, 2019

Inaccurate decennial count could prove costly


Public health officials, health care foundations and other grant-making organizations, health policy experts and many states are mobilizing in an effort to promote participation in the 2020 decennial U.S. census.

Booth about 2020 Census
A booth offers information about the 2020 Census at a street festival in New York City last month.

The population distribution data and other information that is captured in, or derived by, the census will determine how hundreds of billions of dollars in federal money is allocated among state and local governments for the next decade.

The census officially begins April 1. This year the buildup has been peppered with heated rhetoric related to the inclusion or exclusion of a question on citizenship status. The U.S. Supreme Court blocked the inclusion of the question, and the Donald Trump Administration ultimately relented.

A question of citizenship
Some fear the efforts to include the citizenship question may have frightened and discouraged immigrants from participating in the census.

The California Endowment, a $3.7 billion health care foundation in the nation's most populous state, said it has committed $10 million to support efforts to "educate and mobilize California's hardest to count populations, including immigrant, Latino, African American, Asian Pacific Islander and LGBTQ+, among others."

Douglas Strane, clinical research project manager at the PolicyLab at Children's Hospital of Philadelphia, said that members of Latino immigrant communities and Muslim communities may be less willing to self-identify because of increased hostility being directed toward them. Although the U.S. Census Bureau is prevented by law from divulging personal information, some participants lack trust in the government.

Some of the very attributes most aligned with undercounts — poverty and unstable housing — also make populations more susceptible to poor health, he added.

Census image

In addition to the political and legal battle over the inclusion of a citizenship question, reductions in federal spending to support data collection could impact census participation.

Further, the 2020 census will be the first to be conducted online. This should make it easier for respondents to complete the survey, but it is a concern for communities with limited broadband access. The Census Bureau said the option to respond to census questions by phone or by returning a paper questionnaire is open to everyone. Census takers will conduct outreach if the bureau has not heard from a household.

What's at stake
Failure to accurately count vulnerable population groups could result in states losing their fair share of federal funding for Medicaid, the Children's Health Insurance Program, Temporary Assistance for Needy Families, and the Special Supplemental Nutrition Program for Women, Infants and Children, among other safety net programs.

In 2015, the federal government distributed more than $675 billion in federal funds, grants and support to states on the basis of Census Bureau data. According to an article in Econofact, that amount included $311 billion for Medicaid, $71 billion for the supplemental nutrition program, $38 billion for highway planning and construction and almost $30 billion for the Federal Pell Grant program.

The authors, economists Nora Gordon and Krista O'Connell, wrote that census data is used in calculating the federal medical assistance percentage. That percentage is plugged into the formula that generates the federal government's share of Medicaid spending.


Gordon and O'Connell said if a state's population is undercounted in the census, its per capita income calculations will be inflated. This negatively impacts state Medicaid programs because the federal matching funds range from 50 percent in wealthier states to 83 percent in the poorest states.

Peter Leibold, chief advocacy officer for Ascension, said that in addition to making sure there is sufficient funding to provide Medicaid or CHIP insurance to all who are eligible, there is an ethical reason to encourage a full and accurate census count: Every individual should be counted because every person has worth and dignity.

Endorsements open doors
In Ascension's home state of Missouri, the Missouri Foundation for Health is leading a cross-sector initiative to support an accurate count. In late May the foundation released a call for leaders in the government and private sector to promote census participation. The statement was endorsed by 30 leaders across the St. Louis region, many of them heads of health care organizations that provide direct health care to low-income people or fund grant-based programs that benefit that population. Represented among the signatories were St. Louis-based Ascension, the Daughters of Charity Foundation of St. Louis (now the Marillac Mission Fund), and the Incarnate Word Foundation.


"We understand that there are some unique challenges with the 2020 census that make it even more imperative that private entities help facilitate get-out-the-count efforts with the operations of public entities," said Alexandra Rankin, government affairs manager for Missouri Foundation for Health. As an example of challenges, Rankin said 20 percent of Missouri does not have access to broadband, high-speed Internet.

The statement said that roughly 9 percent of Missouri's population lived in hard-to-count communities during the 2010 census and undercounts that year resulted in the loss of hundreds of millions of dollars in federal funding.

"Households most at risk of being undercounted include those who are low income, renters, people of color, families with children under five, rural, and immigrants," according to the statement. "For every person undercounted in 2010, Missouri forfeited an estimated $1,200 in federal dollars."

Catholic health's trusted voice
Rankin stressed the importance of "trusted voices" in the communities including employers willing to underscore the importance of an accurate census, to persuade people that it's safe to complete the census form, and to encourage people to be counted.

"If households — especially households that are harder to count — are hearing of the significance and the value and the safety of the census from people they trust, they are more likely to participate than if they get a form dropped off or if they have someone knocking on their door that they don't know," she said.

To that end, the Census Bureau began developing its national partnership outreach two years ago — earlier than usual in advance of a decennial count, said Robin Bachman, the Census Bureau's chief of the national partnership program. Partners help educate and encourage people to fill out the census forms. Bachman staffed the bureau's booth at the Catholic Health Assembly in June in Dallas, distributing materials promoting the 2020 census.

"We are trying to (work) through trusted voices in the community to help educate and motivate our respondents to fill out the form," said Bachman, who previously worked as vice president of government and public policy at Cleveland-based Sisters of Charity Health System. "Catholic health ministry is a great member of the community and so for us it was a place where we were excited to go and start some of these conversations."

Kathy Curran, CHA's senior director of public policy said, "Getting an accurate census count is crucial so that states have the resources to provide people with access to health care through Medicaid and CHIP.  Even without a citizenship question, some communities will still avoid the census out of fear.   Catholic hospitals are trusted voices in their communities and CHA will be working with our members to provide outreach and education resources" to support and encourage census participation.   


Copyright © 2019 by the Catholic Health Association of the United States

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