Every Child Counts: The Importance of the 2020 Census for Pediatric Health Equity

The decennial census, written as a mandate into the US Constitution over 200 years ago, remains critical to the health of children today. The census count determines the distribution of $1.5 trillion (in 2017 dollars) in federal funds,¹  including funding for over 300 programs¹  that are vital to child health. These include programs supporting health care (eg, Medicaid and Children’s Health Insurance Program), education (eg, Head Start and special education grants), food and nutrition (eg, Special Supplemental Nutrition Program for Women, Infants, and Children and Supplemental Nutrition Assistance Program), housing (eg, Section 8 housing choice voucher program), and foster care.^1–3  Epidemiologists, health services researchers, and businesses also rely on census data to inform their research and investments.⁴  Furthermore, census data determine districting in Congress and state legislatures, ensuring fair representation in our democracy.^2,3  Given the far-reaching impacts of census data on child health and health equity, pediatric health care providers have a strong interest in, and should work to ensure, an accurate count in the 2020 census.

A major challenge with the census is the persistence of hard-to-count tracts. Hard-to-count tracts are districts or segments of the population with a census response rate of <73%.³  An undercount results in inaccurate representation in Congress as well as reduced federal funding for vital resources. It is estimated that Massachusetts, for example, lost >$2300 of federal funding for each person uncounted in the 2010 census.³  That funding is equivalent to the cost of a child’s school lunches for >5 years⁵  for each person uncounted.

Children have been historically undercounted in the census.⁶  In 2010, it is estimated that >2.2 million young children went uncounted (ie, 4.6% net undercount rate),²  which is the equivalent of missing all of the schoolchildren in Wisconsin, New Hampshire, Nevada, Iowa, and Maine combined.⁷  This is a higher undercount rate than for any other age group, and it has been worsening with each census since 1980.² 

Among children, there are certain groups who are at especially high risk for being undercounted. One such group is racial and ethnic minority children; in the 2010 census, black and Hispanic children were uncounted at twice the rate as non-Hispanic white children.²  Infants and young children are also missed, possibly because of a lack of awareness that they ought to be counted as part of a household.^2,6  Children who are coparented, are undocumented, or who live in complex households (ie, with grandparents or other relatives) or in neighborhoods with high poverty rates are also at higher risk for being uncounted.^2,6  Families experiencing homelessness or temporary displacement are more likely to be missed.^2,6  Additionally, college students, children in juvenile custody or foster care, and children with prolonged hospitalizations are more likely to be uncounted.^2,6  Health equity cannot be achieved without addressing disparities in these vulnerable groups, and improving census counts for children is an important step toward this goal.

Although the barriers to ensuring an accurate count of children are long-standing, the 2020 census is at a uniquely high risk for an undercount. This is in part because the 2020 census will be the first majority-digital census, aiming for most respondents to fill out their questionnaire online. Although respondents will also have the option to complete the census by phone or mail, the majority-digital approach may pose a disadvantage to children in rural and low-income areas. Another new challenge relates to public discourse around including a question pertaining to a person’s citizenship status. This proposal was blocked via legal challenges, and ultimately, a citizenship question will not be included in the 2020 census.^3,4  However, there is concern that many undocumented or mixed-status families may still refrain from participating in the census because of fear. In addition to informing families that this question is not included in the 2020 census, pediatric providers can reassure families that census data are securely stored and cannot be shared with anyone, including landlords, government agencies, immigration officials, or law enforcement.^3,4  Furthermore, census enumerators (ie, census staff hired to help ensure a complete count) only visit households that do not complete the census by May and are sworn to protect data.⁴  Given these unique challenges in 2020, pediatric providers have a responsibility to promote the message that the census is important, accessible, and safe.

Given the critical importance of the 2020 census for children and families, all pediatric health care providers should be familiar with the following key information.^3,4 

• • Everyone who resides in the United States on April 1, 2020 (Census Day), should be counted regardless of immigration status, race, ethnicity, income, age, or relationship to others in the household.

• • Respondents can complete the census online, by phone, or by mail.

• • Census informational guides are available in 59 languages.

• •Census forms are mailed to homes in March with reminders throughout April. In May, enumerators will begin going to households that have not yet completed the census.

• • There will not be a citizenship question on the 2020 census.

• • Census responses cannot be released to other agencies, and enumerators are sworn to protect the data of respondents.

• • For more information and resources, providers can visit https://2020census.gov/.

There are many different advocacy actions (Table 1), ranging from brief commitments to deeper involvement, that pediatric providers can take to ensure children and families are counted. As an example of how to enact these actions, we share details of our institution’s campaign to support our patients, families, and employees in being counted in the census. This campaign is led by a coalition within the Office of Government Relations that includes government relations specialists, clinicians, and communications staff. It provides outreach and education to 3 key constituencies: clinical and nonclinical hospital staff, patients and families, and the surrounding community (encompassing multiple hard-to-count neighborhoods). We hope these actions can serve as a model for similar campaigns by other institutions and coalitions.

As part of the outreach to staff, our team is leading educational events at department meetings to educate key stakeholders about the census. We have also created a frequently asked questions flyer to be distributed to providers (available for public use at https://governmentrelations.childrenshospital.org/2020-census-resources/). We are especially focused on staff who may be members of or work with hard-to-count populations, such as trainees, social workers, and interpreters. Our patient and family outreach efforts focus on identifying and educating staff advocates who are accessible to families to help answer census questions. Promotional materials, including buttons and posters, are posted in high-traffic areas to increase visibility and awareness. We are also using volunteers to staff tables in clinical areas and waiting rooms, where staff and patients can complete the census questionnaire on-site. In addition, we are hosting a social media campaign and an educational event on Census Day (April 1). For community outreach, we have partnered with a coalition, including the mayor’s office and local community organizations that serve hard-to-count populations, to create and disseminate educational resources more broadly.

Given the impact on political representation and access to resources, along with the greater risk of being undercounted, the stakes for children are high in the 2020 census. Health care institutions and providers serve as trusted messengers for families and the community and have a responsibility to advocate for their patients. Pediatric providers are on the front lines of the fight against undercounting and should take steps to ensure that every child counts.