AJPH PERSPECTIVES
Inaccuracies in the 2020 Census Enumeration
Could Create a Misalignment Between States’
Needs
As the most accurate reflection
of the United States popula-
tion, the US decennial census is
vital to health policymakers and
others at all levels of govern-
ment. Competing priorities re-
lated to cost containment and
the introduction of new reforms
raise concerns about the re-
sources available to the US
Census Bureau to conduct an
accurate population enumer-
ation in 2020.
We examined the state of the
Census Bureau’s preparations
for the 2020 Census and how
inaccuracies in the coming cen-
sus enumeration could influence
public health and health equity
in the coming decade. The re-
sults of the 2020 Census will be
used to allocate trillions of dol-
lars in federal funding to states,
including support for programs
vital to public health such as
Medicaid and the Special Sup-
plemental Nutrition Program for
Women, Infants, and Children.
Inaccuracies in the census
enumeration could create a
misalignment between states’
needs and allocation of federal
resources. Also, a census mis-
count of the population could
create challenges for public
health surveillance and research
activities that inform public
health policies and interven-
tions. (Am J Public Health. 2018;
108:1330–1333. doi:10.2105/
AJPH.2018.304569)
1330 Perspectives From the Social Sciences
Douglas Strane, MPH, and Heather M. Griffis, PhD
T
he US decennial census
provides the most compre-
hensive portrait possible of the
United States population. The
accuracy of its results is vital to
policymakers at all levels of
government and affects the
health and well-being of people
in the United States. The func-
tion of the census enumeration
is to count each person in the
United States only once and in
the correct place. The breadth
of this mission supports its
wide-reaching impact on public
policy, including public health
policies and interventions that
persons in the United States
navigate every day.
The 2020 Census’s success is
dependent on the groundwork
laid in the years prior, including
development of technological
and personnel infrastructure. An
estimated funding shortfall of
$3.3 billion and leadership gaps
currently leave the US Census
Bureau without the resources it
needs to prepare for the 2020
Census. These concerns have led
to placement of the 2020 Census
on the Government Account-
ability Office’s high-risk list,
which calls attention to federal
agencies and programs at high
risk as a result of mismanage-
ment.1 Although other elements
of federal health policy have re-
cently attracted far more atten-
tion, much is at stake for the
public health community as the
2020 Census draws closer. Here
we examine two important
topics: the state of preparations
Peer Reviewed Strane and Griffis
for the 2020 Census with respect housing units required follow-up
to the potential for inaccuracies in at a cost of more than $1.5 bil-
the decennial enumeration and lion.3 Magnifying this issue, the
how census enumeration inac- 2020 Census will enumerate the
curacies could affect public and largest US population in history.
population health. To confront these costs, the
Census Bureau is seeking to
implement numerous informa-
tion technology reforms, in-
CHALLENGES FACING cluding allowing respondents to
THE 2020 CENSUS complete census forms online for
The challenges currently fac- the first time and allowing enu-
ing the Census Bureau are sub- merators in the field to complete
stantial. Specific challenges data collection on mobile
confronting the 2020 Census devices.2
include new costs and insufficient
At the same time, the Census
funding appropriations, field Bureau has revised its 2020
testing issues, and leadership Census life-cycle estimate from
changes. $12.3 to $15.6 billion, driven
largely by the costs of new
technologies.4 This comes after
Decennial Census Cost
and Funding Shortfall several years during which White
The per-household cost of House requests and congressional
conducting a US census has appropriations for the Census
Bureau were lower than needed.
risen in recent decades: in 2020-
The Census Bureau has been
adjusted dollars, the 1970 per-
household cost was $16, whereas instructed by Congress over the
in 2010 the cost had risen past decade that the 2020 Census
to $92 per household.2 These should cost less than the 2010
cost increases have been driven Census.5,6 This funding shortfall
by declines in response that re- affects testing of new cost-saving
quire follow-up with households technologies, establishment of
in person or over the telephone. technological and personnel in-
In 2010, nearly 50 million frastructure, and creation of the
ABOUT THE AUTHORS
Douglas Strane is with PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA.
Heather M. Griffis is with PolicyLab and the Healthcare Analytics Unit, Children’s Hospital
of Philadelphia.
Correspondence should be sent to Douglas Strane, MPH, PolicyLab, Children’s Hospital of
Philadelphia, Roberts Center for Pediatric Research, 2716 South St, 10th Floor, Philadelphia, PA
19146 (e-mail: straned@email.chop.edu). Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.
This article was accepted May 22, 2018.
doi: 10.2105/AJPH.2018.304569
AJPH October 2018, Vol 108, No. 10

community partnerships neces-
sary for success. Although Census
Bureau funding increased in early
2018, a much greater increase
will be needed in 2019 as the
Bureau rapidly builds its capacity
to carry out the 2020 Census.
Field Test Cancellations
To ensure that these techno-
logical reforms are carried out
securely and successfully, testing
of new technologies is essential.
Beginning in 2016, lack of
funding spurred the cancellation
of census field test operations at
several sites.1 The Census Bureau
planned to conduct three “end-
to-end” tests of the census in
2018 (effectively a dress rehearsal
for the full 2020 Census carried
out in selected locations). In
July 2017, however, it was an-
nounced that the tests in two
of the three locations had been
cancelled because of budgetary
constraints.7 This is of particular
concern because these tests, in-
cluding new survey methodolo-
gies and outreach strategies, will
no longer be conducted in rural
areas that have historically been
undercounted in past census
enumerations.8 Without ade-
quate testing, the Census Bureau
cannot ensure that new methods
will lead to collection of high-
quality data, that they can be
successfully implemented at
a national scale, or that they will
ensure equitable representation
of all communities in the 2020
Census.
Leadership Changes
In May 2017, Census Bureau
director John Thompson abruptly
announced his resignation. As
of spring 2018, a replacement has
not been nominated for either
Census Bureau director or deputy
director. Although interim lead-
ership is in place, uncertainty
created by Thompson’s departure
October 2018, Vol 108, No. 10 AJPH
came during a crucial period in the
Bureau’s preparations for the 2020
Census. This is a critical time in
which the Bureau requires con-
sistency in vision and priorities
to advocate for additional
funding to put in place the
technological and personnel in-
frastructure needed to conduct
the census.
THE CENSUS AND
PUBLIC HEALTH
An accurate census enumera-
tion is among the most basic
yet essential tools used to guide
and inform public health poli-
cymakers. The Census Bureau’s
funding shortfall and inability
to adequately prepare for the
2020 Census should concern the
public health community be-
cause of the field’s reliance on
accurate data. Census data are
vital to three domains of public
health relevance: health equity,
allocation of funding for health-
related federal programs, and the
ability of public health practi-
tioners and researchers to quan-
tify disease burdens in the
communities they serve.
Undercounting and
Health Equity
Although differential under-
counting of minorities, well
documented since the 1940s, has
improved in recent census enu-
merations, the uncertainties
facing the 2020 Census could
undermine the Bureau’s efforts to
ensure continued representation
of historically undercounted
populations in the census.8,9
Undercounting can occur for
a variety of reasons, including
omission of household addresses
from Census Bureau mailing lists,
residences in informal housing, or
nonresponse to census follow-up
efforts.10,11 A 2010 Census report
Strane and Griffis
showed that White populations
were overcounted by 0.8%,
whereas Black and Hispanic
populations were undercounted
by 2.1% and 1.5%, respectively.12
Minority children in rural
areas fare worse: Hispanic chil-
dren in rural communities were
undercounted by 17.4% in the
1990 Census, as compared with
an undercount of 6.9% among
Hispanic children in urban areas.8
Renters, who are dispropor-
tionately likely to have low in-
comes and to be members of
minority racial/ethnic groups,
were undercounted by 1.1%,
whereas homeowners were
overcounted by 0.6%.12 Al-
though it is possible to statistically
adjust census counts to reflect
undercounting via estimation
techniques, it would likely be
highly controversial and without
historical precedent.
In addition to challenges of
undercounting faced in the past,
there are concerns about the
willingness of Hispanic and La-
tino immigrant communities and
Muslim communities to partici-
pate or self-identify in the 2020
Census because of increases in
hostility directed at these com-
munities, as well as the addition
of a citizenship question in this
census. Although the Census
Bureau is by law prevented from
disclosing personally identifiable
information, public perceptions
of risk and lack of trust in gov-
ernment may decrease participa-
tion in the 2020 Census among
members of these communities.13
The same factors that con-
tribute to undercounting in the
census, such as poverty and un-
stable housing, are also associated
with countless adverse health
outcomes that are of specific
interest in public health equity
efforts.14,15 As discussed sub-
sequently, however, differential
undercounting has the potential
to undermine health equity
Peer Reviewed Perspectives From the Social Sciences
AJPH PERSPECTIVES
because representation in the
census plays an essential role in
identifying public health con-
cerns and how resources will
be used to address them.
Funding Population
Health Programs
Public policy and spending
priorities are among the most
important societal determinants
of health and health outcomes.16
Census-derived estimates are
used widely by the federal gov-
ernment to inform how billions
of dollars are allocated each
year.17 A miscount in the de-
cennial census could misalign the
distribution of funds with the
reality of the population’s need
for federal resources. In particu-
lar, programs that support direct
health care access, such as
Medicaid, and programs that
address social determinants of
health, such as the Special Sup-
plemental Nutrition Program
for Women, Infants, and
Children (WIC), will be
affected.
Medicaid, the third largest
domestic program in the federal
budget, is financed jointly by
states and the federal govern-
ment. The share of program costs
paid for by the federal govern-
ment is determined through the
Federal Medical Assistance Per-
centage (FMAP). The formula
used to determine each state’s
FMAP is inversely proportional
to the state’s per capita income.
States with lower per capita
income levels have a greater
number of Medicaid enrollees
and therefore a higher FMAP,
requiring the federal government
to pay a greater share of their
Medicaid program costs.18 Were
the 2020 Census to undercount
a state’s population, it would
artificially inflate the state’s per
capita income, leading the federal
government to pay a smaller
1331
AJPH PERSPECTIVES
share of the state’s Medicaid
costs.19 An undercount, how-
ever, would not be uniformly
distributed among the US pop-
ulation; states with larger
Medicaid-eligible populations
could experience a greater degree
of undercounting, meaning that
states with the greatest need for
federal Medicaid support would
also be those most likely to be
fiscally affected by a census
undercount.
Census data are also used, in-
directly, in determining the dis-
tribution of federal funds to states
in support of programs such as
WIC. The amount of funding
each state’s WIC program re-
ceives is proportional to the
state’s share of the national
population that is eligible for
WIC according to age and in-
come. The federal government
uses the American Community
Survey to determine the size of
this population in each state.
The survey’s estimates, produced
each year by the Census Bureau,
are weighted to adhere to de-
cennial census enumerations.
An undercount of a state’s
WIC-eligible population in the
2020 Census would be propa-
gated in American Community
Survey estimates for the next
decade and could result in an
insufficient allocation of WIC
funds to that state.17
Similar concerns apply to
Section 8 housing choice
vouchers, Head Start, Early Head
Start, the Low Income Home
Energy Assistance Program, Title
I grants to local education
agencies, and many other pro-
grams that promote health and
the social and economic well-
being of US residents.17 These
federal programs support the
foundations of public health for
the most vulnerable populations
in the United States and counter
the socioeconomic drivers of
health disparities. The long-term
1332 Perspectives From the Social Sciences
consequences of inadequate or
misaligned funding for public
health and social services are
difficult to quantify but have
the potential to undermine im-
provements made in population
health.20–23
Public Health Practice
and Research
Public health agencies’ ability
to address population-level
health is closely tied to the de-
cennial census. Routine and
ongoing public health surveil-
lance efforts, including those
related to disease-specific in-
cidence, prevalence, and mor-
tality, play a central role in
informing the strategy and pri-
orities of public health agencies.
The accuracy of these metrics
depends on the use of population
denominators that reflect the true
population.21,24 Such population
estimates are calculated each year
after the decennial census through
a combination of census results
and vital records.25
Problems with the 2020
Census enumeration, such as
inconsistent undercounting or
overcounting, could therefore
bias the population estimates used
to determine population-level
disease burdens. Without reliable
population estimates, public
health surveillance could mis-
identify community disease
burdens, making it difficult to
target public health interventions
to the right population at the
right time or to evaluate the ef-
fects of interventions already in
place. An undercount would
have a disproportionate impact
on the very populations (e.g.,
low-income, housing-insecure,
or minority groups) most likely to
be the target of public health
activities as a result of their overall
increased disease burden.14,15
Finally, numerous data sets
widely used in public health and
Peer Reviewed Strane and Griffis
health services research rely on
accurate census counts, including
the American Community Sur-
vey, the National Health In-
terview Survey, and the Medical
Expenditure Panel Survey. Sub-
samples of the US population,
derived in part from decennial
census enumeration results, are
contacted to take part in surveys
used to monitor public health and
identify emerging trends. These
data sets provide invaluable in-
formation to researchers and
policymakers about topics such as
community-level demographic
characteristics, access to health
care services, health insurance
coverage, health-related behav-
iors, and immunizations.
In each of these data sets,
population estimates derived
from the decennial census are
used to develop survey weights
that make results generalizable to
the national population. A de-
cennial census undercount of
marginalized populations could
therefore mean that members of
marginalized communities are
inadequately or incorrectly rep-
resented in research findings used
to steer health policy decisions,
identify new public health pri-
orities, and evaluate progress
made toward public health goals.
CONCLUSION
The mission of the US census
to give representation to every
person within the country’s
borders requires a complex combi-
nation of administrative, financial,
logistical, and community-
engaged coordination. Although
the census is historically under-
funded, the 2020 Census has
particularly inadequate financial
resources relative to previous
decades, leading to the cancella-
tion of important tests of new
census methodologies. Of vital
importance to the public health
community, accurate enumera-
tion is essential to the health and
well-being of people in the
United States through support of
social programs such as Medicaid.
Also, basic public health activi-
ties, research, and surveillance
will be disrupted without reliable
census data.
Representation in the census
is a basic right of residents of the
United States and is outlined in
the US Constitution. The ability
of our country and our com-
munities to provide responsive
public health support to those
they serve is dependent on that
right being fulfilled in 2020.
CONTRIBUTORS
D. Strane conceptualized the article,
conducted background research, and
wrote and revised the article. H. M. Griffis
conceptualized, reviewed, and revised the
article.
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October 2018, Vol 108, No. 10 AJPH Strane and Griffis Peer Reviewed Perspectives From the Social Sciences 1333