Public Health & Policy > Medicaid
2020 Census Will Make for Winners, Losers in Health Funding
— Shortened timeline could hurt some groups
by Joyce Frieden, Washington Editor, MedPage Today November 20, 2020
The shortened time allocated for this year's census could have a big effect on funding for healthcare programs in future years, several speakers said Friday at an online briefing sponsored by the Alliance for Health Policy.
The census was originally scheduled to end in July, but due to the COVID-19 pandemic, the federal government pushed that date back to Oct. 31. However, after a series of political maneuvers and negotiations with Congress, the bureau ended in-person data collection efforts on Sept. 30 -- a month early -- and other collection efforts, such as online census-taking, on Oct. 15.
Why does the altered schedule matter? If, for example, New York City misses 20,000 people in the 2020 census, "those people are gone for the decade" when it comes to allocating funding for healthcare programs like Medicaid and the Children's Health Insurance Program, said Andrew Reamer, PhD, professor of research at the George Washington Institute of Public Policy, in Washington. "Whatever issues there are with the accuracy of the census, there are winners and losers."
"After the 2010 census, Arizona lost 4% of its population and Hawaii gained 4% population," Reamer said. "Medicaid is based on the prior 3 years' average per-capita income. So Arizona lost money in Medicaid because it had a lower population, so its per-capita income went up, and it looked richer than in fact it was."
Since the federal government allocates Medicaid funding every year based on population data, what happens during the 10 years in between censuses? "States take the [last census number] and for each year that follows, they add the number of births, subtract the number of deaths, and make an estimate of migration" between states, Reamer explained.
Then, when the next official census number comes through -- as it will for 2020, "the Census Bureau is going to toss out all its population estimates going back to 2011" and will also recalculate the 3-year averages based on the new data. "The numbers for 2018 and 2019 get re-done for every state ... so if a state gets undercounted relative to the nation, it's going to lose money immediately under Medicaid." ("Undercount" refers to the number of people estimated to be missed in a particular region during a census.)
There are times, however, that the undercount can work to a state's advantage, he said. "A community can be undercounted and actually make money because the level of the undercount is below the national average. Whatever screwups happened, whoever had above an above-average amount of screwups loses and whoever has below average makes money."
"Folks who tend to be undercounted tend to be in a marginalized group -- people of color, people experiencing homelessness," said Cara Brumfield, a senior policy analyst at the Georgetown Center on Poverty in Washington, D.C. For example, in the 2010 census, Black people were undercounted at an estimated rate of 2.1%, while whites were overcounted by 0.8%.
New Orleans is an example of the consequences of undercounting, according to Beth Lynk, senior director of the Census Counts campaign, an effort of the Leadership Conference on Civil and Human Rights. "In the 2010 census in New Orleans, it was a number of years after [Hurricane] Katrina, but a lot of the displacement hadn't corrected itself, so New Orleans had a significantly lower number" than before, she said. "But in the following years, people were starting to move back to the city, and as a result there was a huge deficit, particularly in education funding but in healthcare funding as well ... It was up to the city and state to try to make up that difference."
The 2020 census was the first one in which a majority of people participated online, "and there's a lot of concern over what impact that will have," she added. "We know that for communities of color and urban centers, there are a lot of disparities related to connectedness to the Internet." COVID-19's effect on the census also is a concern, said Brumfield. "The Census Bureau does have some strategies for counting the homeless, but places like shelters and food pantries ... were impacted by COVID-19, so we don't know where the folks that would have been using these places have been and where they've gone."
There is one benefit to having people complete the census online, Reamer said. "The quality is much better than the mail [census], because in the mail you can check off two boxes when you're only supposed to check off one, and on the Internet you can't do that."
Joyce Frieden oversees MedPage Today's Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow