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The Census–Why Counting Everyone Matters So Much :

January 21, 2020

The 2020 Census is featured in the local, national and AAP news right now, and I found a bit of background helpful to my planned advocacy for census participation.

The 2020 Census is featured in the local, national and AAP news right now, and I found a bit of background helpful to my planned advocacy for census participation. Article 1, Section 2 of the US Constitution mandates that the United States (US) Census occur once per decade; the original purpose of counting each person was to calculate how seats in the U.S. House of Representatives should be divided among the states. The very first census took place in 1790.  The 2020 Census will start January 21, 2020 in Toksook Bay, Alaska: since 1870 Census takers have begun their work by knocking on doors in remote and difficult-to-reach regions in order to count people in their homes before the spring thaw makes homes unreachable (thawing of ice prohibits dog sled, snow mobile and bush plane access) and before anyone leaves for seasonal hunting and fishing. By April 1, 2020, each of us will have received an invitation to participate in the census; once your invitation arrives you can choose to respond by mail, by phone, or online. In April 2020, Census takers will begin visiting hard to count populations, such as college students, seniors and others living in group residences, and in May 2020 Census takers will begin to knock on doors of homes that have not yet responded. By December 2020, the US Census Bureau is required to deliver its report to Congress and the President.

Why does the Census count matter? You likely already know that an accurate and complete count of the US population is critical because distribution of nearly $675 billion dollars in public funding is dependent on the results of the Census. While not every federal program uses “head counts” to allocate funding, five programs that incidentally comprise 48.1% of all federal grants to states, and that disproportionately impact children, do: Medicare Part D, Traditional Medicaid (approximately 45% of beneficiaries are children), State Children’s Health Insurance Program (CHIP), Title IV-E Foster Care and Title IV-E Adoption Assistance. The Department of Health and Human Services is required by the Social Security Act to use a formula called the FMAP (Federal Medical Assistance Percentage) to allocate state funds.1 Each state’s FMAP cannot be higher than 83% or lower than 50%; higher is better because the FMAP determines how many cents on the dollar the federal government gives the state when granting funds.  FMAP depends on PCI (per capita income) – the US Bureau of Economic Analysis figures out each state’s PCI by taking the state residents’ total income and dividing by the total (counted) population of the state. Thus if fewer residents are counted (Census undercount), the PCI goes up, and the FMAP goes down, because the FMAP + PCI must equal 100.  There are currently 37 states that have FMAPs above 50, and thus have “room to lose” with a Census undercount. In fiscal year 2015, the estimated cost (to the state) per “uncounted” person is estimated at about $1,091.1 A 1% population undercount has potential to cause millions in lost (and needed) revenue for these states.

Who isn’t counted? It’s not a secret that persons of color and children are disproportionately undercounted.2,3 There are sad historical legacies that precede today’s problems. For more than 75 years, African-American slaves were each counted as three fifths of a person, due to pressure from Southern landowners who sought to increase their own representation in Congress. For nearly 80 years Native Americans were not counted at all. Even in 2010, it is estimated that the Census missed 1.5 million people of color, including African-Americans, Hispanics and Native Americans.2 The US Census Bureau itself acknowledges the ongoing undercounting of children, especially those ages 0-4 years, and has dedicated research and resources to the problem.3 Their research shows that households with young children, compared to those without, are more likely to have internet access but less likely to be familiar with the uses of the Census; this provides evidence to drive ways to contact and message to engage these households.4 Finally, there is evidence-based concern that a proposed, but rescinded, question about citizenship is likely to “harm the quality of the census count” by undercounting minorities and immigrants who may become fearful of census participation.5 The citizenship question, however, is not included in the final census.6 And for anyone who wonders, the citizenship question is not a question about immigration status (which could have legal implications). More importantly, the information non-citizens provide cannot be used against them. In fact, the Census Bureau must keep all responses confidential, and is prohibited (under Title XIII of the US Code) from releasing any information to US Immigration and Customs Enforcement (ICE) or to the Department of Homeland Security, or to any other government agency or court of law. Counting non-citizens is crucial to adequate representation in Congress for districts with minority and immigrant populations.

What can you do? First, become informed so you understand what the issues are and what is at stake. Then, use any of the many excellent resources available to inform families in your practice and support their active participation in the census. Resources for patients and families abound. There’s a great article in the January 2020 AAP News with websites and links to handouts, including a short advocacy video for colleagues developed by Dr. Lauren Gambill and colleagues in Texas. The US Census Bureau has a family-friendly postcard sized handout called, “A few minutes can shape your future,” with clear text about why the Census is important, safe and easy. These can be handed out at patient registration and reinforced by staff with a few friendly words. If you conduct voter registration at your practice, the cards can be shared at that point of contact also. Now that you know something, you have a chance to do something! Let us know what you think, and how you are moving Census participation forward in your practice.


1. Reamer A. COUNTING FOR DOLLARS 2020 The Role of the Decennial Census in the Geographic Distribution of Federal Funds. Report #2: Estimating Fiscal Costs of a Census Undercount to States. GW Institute for Public Policy. March 19, 2018. Accessed 1/5/2020.
2. Bereitter C. A History of Undercounting People of Color: Why the 2020 Census May Make it Worse. Common Cause. Sept 13, 2018. Accessed 1/5/2020.
3. Decennial Census of Population and Housing,  2020 Census Research, Operational Plans, and Oversight , Research and Testing, The Undercount of Young Children. United States Census Bureau. Updated Nov 3, 2019. Accessed 1/5/2020.
4.  Researching the Attitudes of Households Reporting Young Children – A Summary of Results from the 2020 Census Barriers, Attitudes, and Motivators Study (CBAMS) Survey. United States Census Bureau. Revised June 13, 2019. Accessed 1/5/2020.
5. Abowd JM. Memorandum for Wilbur L. Ross. Jan 19, 2018. Accessed 1/5/2020.
6. Wines M. 2020 Census Won’t Have Citizenship Question as Trump Administration Drops Effort. The New York Times. July 2, 2019. Accessed January 15, 2020.

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