Monday’s announcement that the 2020 census will include a question about citizenship was quickly met with uproar. Census data is in a very big way the bedrock of our democracy, as it’s used to decide congressional seats and electors in each state and how voting districts are drawn.
But it’s also incredibly important how federal funds are divvied out to state and localities. And that includes health care.
Asking about citizenship on the census dissuades many families — either undocumented, of mixed immigration status, or just groups who are afraid under this administration — from filling out the census at all. That leads to serious undercounting of certain populations, especially in places like Texas and states across the southern border.
“Particularly with our current political climate, the Latino community will not sign up because they will think that Census will pass their information on and people can come looking for them,” one respondent told Mikelyn Meyers, a researcher at the Census Bureau, last year.
Federal programs, like food stamps and Section 8 housing vouchers, use Census Bureau data — which includes decennial census data, American Community Survey, and geographic program data — in whole or in part to distribute these funds. Sometimes, census data determines a locality’s eligibility for federal dollars. For example, to apply to the Water and Waste Disposal Systems for Rural Communities grant, a locality needs to be a rural area with a population of 10,000 or less.
It’s incredibly important how federal funds are divvied out to state and localities and that includes health care.
A working paper published by the Census Bureau found at least 132 programs used decennial census to distribute more than $675 billion in federal funds during the 2015 fiscal year. A George Washington University’s Institute of Public Policy report found even more programs do: about 300 programs allocate over $800 billion a year based on census-derived statistics.
For most of these programs, total headcount does not determine dollar flow. But there is a small number of programs where “you can draw a line between the number of people undercounted — no matter population characteristics — and the dollar flow to states,” said Andrew Reamer, research professor and author of a series of reports titled Counting for Dollars 2020. “Medicaid is by far the biggest program affected by decennial census.”
It’s not just Medicaid. Accurate decennial census data is also critical for four other programs under the Department of Health and Human Services to determine state reimbursements and payments: the Children’s Health Insurance Program, the Federal Foster Care Program, the Federal Adoption Assistance Program, and the Child Care and Development Fund. These programs use the Federal Medical Assistance Percentage (FMAP), which determines how much federal and state partners pay for the program.
“[I]t will not be until FY 2023 that the decennial data, released probably in December 2020, will be used,” said Vic Miller, a Medicaid finance expert who’s written about the impact decennial census data has on Medicaid reimbursement. He told ThinkProgress states hurt in the interim will be those with “less formal population structures” or rather a less accurate population count. In fact, a research paper by Miller pointed out two instances where the decennial census corrected reimbursement rates for Nevada, because the Current Population Survey (which is also used for Medicaid reimbursement) underestimated the population and thus the state lost federal dollars.
Population data is critical to all of these programs, which is why federal law requires all U.S. residents to participate in the census — regardless of citizenship. And this is likely why — contrary to what White House Press Secretary Sarah Huckabee Sanders thinks — decennial census hasn’t included a citizenship inquiry since 1950. (Other smaller population surveys — like the Current Population Survey and the American Community Survey — do ask about citizenship.)
It’s already challenging to count certain populations. Hurricane displacement and internet accessibility (with the Census Bureau opting for digital responses instead of paper) are existing major issues. The 2010 Census overcounted the white population by 0.8 percent, but undercounted black, brown, and indigenous populations by 2.1, 1.5, and 4.9 percent respectively. That’s 1.5 million people of color unaccounted for. The citizenship will likely exacerbate this.
In 2015, a majority of states forfeited “a measurable amount of funds for each person missed in the 2010 Census,” according to Reamer. It’s because these states are reimbursed by the federal government more than the minimal rate, which is 50-50. Why? The higher the per capita income, the lower the FMAP. And a lower FMAP means a state doesn’t need as much federal assistance.
“Among the 37 states with an FMAP over 50, the median FY2015 loss per person missed in the 2010 Census was $1,091,” according to Reamer’s research.
Reamer found that the 2010 Census counted, for example, roughly 25 million people in Texas. This count meant it received $58.05 by the federal government for every $100 Texas spent on Medicaid beneficiaries. If the 2010 Census undercount in Texas had been one percent higher — and many census experts say there’ll be an undercount in the state in 2020, the question is by how much — it could have resulted in Texas forfeiting millions in federal dollars. Reamer’s study concludes the 1 percent difference amounted to nearly $300 million less in federal reimbursement and $11 million more in state expenditures for 2015.
“It’s very difficult to know how adding a citizenship question will affect states’ FMAPs,” said Karina Wagnerman, with Georgetown University’s Center for Children and Families. “However, if a state’s population decreases and a state’s income stays the same, the per capita income will increase.” And the higher the per capita income, the lower the FMAP. In other words, if the federal government thinks a state is wealthier (due to inaccurate population data), then it won’t reimburse the state as much as it should for programs like Medicaid.
And when a state doesn’t get enough federal help for its health care programs, state officials will be tempted to tax citizens even more, provide a less generous insurance program, or take money from other federal assistance programs.
Amanda Gomez is a health reporter at ThinkProgress (thinkprogress.org).
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