• Article
  • May 29, 2019

Census 2020: What Undercounting of Children Means for Pediatric Hospitals

Undercounting children can prevent children’s hospitals from receiving proper Medicaid funding and support for families.


Undercounting children is a problem almost as old as the census itself. Children have been undercounted in the census for decades, meaning states and localities receive less public support. The 2010 Census missed more than 10% of young children—that’s one of every 10 children ages 0 to 4, or about 2.2 million children, according to William O’Hare, Ph.D., a demographer and data consultant with a focus on children.

What it means for children’s hospitals

“So many of the kids we see in our clinical settings rely on public benefits and public support that have their origin in accurate census data,” says Andy Beck, M.D., M.P.H., associate professor in the Department of Pediatrics at Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine. “Without an accurate headcount, I'd be really concerned that the support our patients rely on would be unmet.”

Children and families lose out when young kids are undercounted. Children’s hospitals—which use census data for everything from research and quality improvement to needs assessments and staffing decisions—lose out too as they work to meet the health and development needs of their patients.

“Having good data is really the cornerstone of good decision-making in public health,” says Doug Strane, M.P.H., a research project manager at PolicyLab at Children’s Hospital of Philadelphia (CHOP). “And the census is really the best way we have of understanding the populations we serve.”

Trillions of dollars of aid at stake

A report from the GW Institute of Public Policy shows that annual lost Medicaid funds are anywhere from $533 to $2,309 for each person uncounted by the census. Since Medicaid provides direct health care access for tens of millions of children and their parents, the unmet health needs could be huge, according to Strane. And this is just one example of the importance of getting an accurate count of kids in this country.

“Between 2021 and 2030, which is when we'll be using this 2020 census data, the federal government will allocate about $25 trillion to states and localities,” says O’Hare. “The fact that young kids are missed at a higher rate, means they're going to be the most penalized by an undercount in the census in terms of getting their share of federal dollars.”

What the data can do

Beck, who uses census data for research and quality improvement, will rely heavily on the 2020 census data to inform his work.

“It is unbelievably important—I can't underscore it enough,” says Beck. “We rely on the census to provide us with an estimate of the number of local children. The closer this is to a 100% count, the better we can be at designing changes to our care practices and supporting community-based interventions in ways that meet the needs of those children. The census count provides us with a population denominator, quantifying the number of our children within our region to whom we must hold ourselves accountable.”

Needed for needs assessments

Another critical function of the census data is in needs assessments. As the director of population health analytics at Ann & Robert H. Lurie Children’s Hospital of Chicago, Tracie Smith, M.P.H., performs needs assessments for the hospital’s Healthy Communities program. The program partners with community leaders and organizations to advance health equity and to create healthier futures for the children of Chicago, including the prevention of violence, obesity, underage drinking and unintentional injury.

Smith looks to census data to help perform the hospital’s needs assessments, to understand the needs of the communities the hospital serves and where those needs live and breathe.

“The kids who are being missed are the kids that we feel we need to understand where they are so we can target resources to those areas,” says Smith. “There could be areas that go undetected because if the kids aren't counted, then we're not even looking at that area as a potential problem area.”

Incorrect assumptions more costly during “key foundational time”

And because a community’s youngest members are typically those most impacted by census undercounting, the stakes are higher.

“Early childhood is perhaps the key foundational time to set people up for success physically and mentally in life, so we need to make sure we can offer support and services to the communities that need them most,” says Ayesha Cammaerts, manager of program and population health in the Office of Community Health at Boston Children's Hospital. “There's a need to make sure we understand where families with young children are and to make sure we don't just make incorrect assumptions based on what some of the census data might show us.”

Learn more on how the 2020 census data will affect children's health care.

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