Census count has implications for public health: Health funding, programs depend on accurate enumeration
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* Kim Krisberg

![Figure1](http://www.thenationshealth.org/https://www.thenationshealth.org/content/nathealth/50/1/1.1/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/50/1/1.1/F1)

Partnership specialists Zee Quintana, left, and Cristina Vaccaro prepare to help residents in Caldwell, Idaho, during the 2010 U.S. census. Public health relies on population data gathered through the U.S. census, which is being carried out this year.

Photo by Charlie Litchfield, courtesy Idaho Press-Tribune/AP Images

With crucial funding and data on the line, work is underway to make sure the 2020 census count is an accurate one. Among the partners working toward that goal: Public health.

“Everyone deserves to be counted, because everyone matters,” said Barbara Ferrer, PhD, MPH, MEd, director of the Los Angeles County Department of Public Health. “For me, that’s the most important reason why our public health department got involved — to make sure all people are getting counted.”

Like many health departments around the country, the Los Angeles agency is an active member of its local census committee — the L.A. County Complete Count Committee — which launched in early 2018 to mobilize area partners around the decennial census and engage with historically undercounted and disenfranchised communities.

For its part, the health department is distributing information to educate residents on why and how to participate in the 2020 census, with a number of staff trained as official census goodwill ambassadors. In March, when the census’ online questionnaire goes live, Los Angeles residents can get counted using special computer kiosks inside the agency’s many public health clinics.

“We’ve established very strong relationships in our communities because we provide a lot of confidential services,” said Ferrer, an APHA member, highlighting the agency’s unique ability to engage with hard-to-count communities. “That confidence helps reassure people that our messages are trustworthy.”

Despite that trust, Ferrer said fears generated by the prospect of adding a citizenship question to the census — a proposal that the U.S. Supreme Court struck down in June — remain a significant barrier to collecting a correct count in a county home to millions of immigrants.

“Our ability to prevent people from getting sick, to prevent the transmission of communicable and infectious disease is very dependent on receiving funding that’s based on an accurate population count,” she told *The Nation’s Health*. “An undercount not only means less money, it also means we don’t have the right denominators when we’re trying to establish rates around disease tracking, outbreaks and inequities in outcomes.”

As the 2020 census kicks into high gear, the results of the national head count will reverberate throughout every community, which means accuracy is critical. The U.S. Census Bureau officially launched the 2020 census count in January, with the first enumeration in the remote town of Toksook Bay, Alaska. The majority of U.S. households will receive letters with instructions on how to participate by mid-March. For the first time in census history, all households will be able to respond online.

Data from the census — which occurs every 10 years and is the single largest civilian governmental undertaking in the U.S. — inform countless decisions across private and public sectors, from how to disseminate federal funds and apportion congressional seats to where to build roads, schools and businesses.

For example, in fiscal year 2017, according to researchers at the George Washington University, more than 300 federal spending programs relied on 2010 census data to distribute about $1.5 trillion to state and local governments, nonprofits, businesses and households, accounting for nearly 8% of the country’s gross domestic product.

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Maria Torres holds her one-day-old daughter, Alejandra, sporting a U.S. Census Bureau onesie in Long Beach, California, in 2010. U.S. Census Bureau workers and partners are working to promote this year’s census count, which kicked off in January.

Photo by Jeff Gritchen, courtesy Digital First Media/Orange County Register/Getty Images

For public health agencies, census data underscore just about every aspect of work, from research and surveillance to funding levels and policymaking. The data also impact many of the programs that target social determinants of health, such as funding for Medicaid, low-income housing vouchers and food assistance. According to a study published in February 2019 in APHA’s *American Journal of Public Health,* an inaccurate 2020 count could hinder public health planning efforts, impede work to eliminate disparities, and make it more difficult to respond to novel and emerging public health threats.

For example, New York City public health workers used census-tract data on the density of childbearing-age women born in countries with active Zika transmission to find local communities at higher risk for travel-related infections during the 2015-2016 Zika outbreak, said study co-author Gregory Cohen, MPhil, MSW, a statistical analyst at Boston University School of Public Health. Workers used the results to more precisely target their prevention messaging.

“The census really allows us to understand how to distribute resources according to need,” he told *The Nation’s Health.*

Cohen said a number of factors heighten the risk of an undercount, including demographic changes, the new online approach, the threat of a citizenship question, and a decline in federal census funding.

In June, researchers at the Urban Institute released estimates showing that nationwide, the 2020 census could miss anywhere from 900,000 to 4 million people, with black and Hispanic residents and children younger than 5 at highest risk of not being counted. Among states, California, Florida, Georgia, Nevada, New Mexico, New York and Texas face the highest undercount risks.

Robert Santos, MA, director of the Statistical Methods Group at the Urban Institute, said even an accurate count can still be unfair. For instance, he said, the 2010 census was very accurate overall, but it came at the expense of overcounting certain populations while undercounting others.

“Historically, white people and more middle- and higher-income people tend to be overcounted, duplicated,” Santos said. “That means when funding gets pushed down to the local level, areas with higher concentrations of minorities tend to get less than what they deserve...If you don’t get counted, your neighborhood might miss that opportunity for a new school or a new road.”

He said local engagement will be “absolutely critical” to making sure everyone gets counted in 2020.

## Communities gear up for census 2020

As of this summer, 21 states had created state-level Complete Count Commissions and 17 had both established a commission and allocated funds to help ensure an accurate 2020 count. Illinois is one of the states that did both.

“You can’t plan for a better tomorrow if you don’t have accurate data,” said Anita Banerji, director of the Democracy Initiative at Forefront, a Chicago nonprofit that oversees Illinois Count Me in 2020, a state coalition focused on reaching undercounted communities.

Last year, the coalition led advocacy efforts calling for state investment in the 2020 census, with Illinois lawmakers eventually appropriating $29 million to support an accurate count. A lot is at stake for the state, Banerji said, including the loss of another seat in the U.S. House of Representatives, something the state has experienced in every decennial census since 1950.

Banerji said state census funds are going to a variety of organizations that typically serve undercounted communities, from libraries to the YWCA, and supporting a range of activities, such as canvassing and public education. Of course, social media will play a major role too — a first for a decennial census.

“Never before in Illinois history have we had this kind of unity and coming together for a decennial census,” she told *The Nation’s Health.*

The picture is a lot different in Texas, where state lawmakers appropriated no funds for census 2020. The decision may make it harder to get an accurate count in the nation’s second-largest state, but local efforts are trying to fill the gap.

“The key is providing a sense of trust that this is OK and that it’s extremely important,” said Rebecca Cedillo, MCP, co-chair of the San Antonio-Bexar County Complete Count Committee. “Every person who’s counted translates into dollars coming back into their community.”

The cross-sector committee, launched in early 2018, is supporting a number of efforts, including an ad campaign featuring local celebrities and athletes, and a mobile computer bank in rural parts of the county without internet access.

The impacts of an accurate count are considerable, Cedillo said, citing research from the Austin-based Center for Public Policy Priorities, which estimated that a Texas undercount of just 1% could mean a loss of $300 million per year in federal funds over the next decade.

“We can’t be remiss in saying we missed someone here and there,” she said. “It all adds up.”

With a quarter of Texas’ more than 6 million residents living in hard-to-count areas, getting accurate census data will be especially challenging, said APHA member Philip Huang, MD, MPH, director of Dallas County Health and Human Services, which is also active in its local census committee — the Dallas Complete Count Committee. Huang said the agency is leaning on its close ties with the community to encourage residents to participate, but is worried that the prospect of a citizenship question may have “done its damage.”

“For epidemiological purposes, the census is where we get our denominator data for all sorts of public health issues,” Huang told *The Nation’s Health.* “It’s pretty key for assessing public health problems.”

Back in California, lawmakers appropriated $187 million in state funds toward getting an accurate census count. The Los Angeles County Complete Count Committee is using its share for a range of activities in the nation’s most-populous county, such as placing questionnaire kiosks in hundreds of locations and training census goodwill ambassadors from historically undercounted communities. In the fall, the ambassador program held 21 trainings and graduated nearly 700 census volunteers, according to Maria de la Luz Garcia, director of the Mayor’s Census 2020 Initiative in the office of Los Angeles Mayor Eric Garcetti.

“It’s going to be a challenge, but we’re not backing away,” she said of the 2020 census. “Even though the citizenship question has created a level of anxiety in our most vulnerable communities, we’re doing everything we can to increase the likelihood that everyone gets counted.”

To learn more about the 2020 census and how to take part, visit [www.2020census.gov](http://www.2020census.gov).

*   Copyright The Nation’s Health, American Public Health Association