March 29, 2018

What a newly announced change to the US census could mean for Medicaid

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    The U.S. Department of Commerce (DOC) on Monday announced that, beginning in 2020, the census will again ask individuals whether they are U.S. citizens—and some say the change could affect Medicaid funding.

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    How the change came about

    According to CNN, the U.S. census used to ask individuals about their citizenship status, but it has not included such a question in its main questionnaire since 1950. Margo Anderson, a professor of history at the University of Wisconsin, said it is not uncommon for questions to be removed from the census "when they're not very important anymore." She explained, "In 1960, we had essentially had very low levels of immigration for 30-35 years. ... There weren't very many new immigrants coming. When you started collecting the data, there wasn't much to find out."

    In the 1970s, the Census Bureau again began asking individuals about their citizenship status on a long-form questionnaire that was sent to samples of households. Anderson said, "We passed major new immigration legislation in 1965, and so the question became relevant again."

    The question remained on long-form questionnaires until the Census Bureau stopped using them in the early 2000s. The Bureau then included a citizenship question on its ongoing sample survey, called the American Community Survey (ACS), which the agency began using in 2005.

    However, the Department of Justice (DOJ) in December 2017 requested that DOC again begin asking about individuals' citizenship status as part of the census to help DOJ better enforce the Voting Rights Act. An email sent to individuals last week from President Trump's re-election campaign also supported the idea, CNN reports. The email stated, "[Trump] wants the 2020 United States census to ask people whether or not they are citizens."

    DOC Secretary Wilbur Ross in a memo released Monday said it would comply with DOJ's request. Wilbur said, "The citizenship question [that will be included on the census] will be the same as the one that is asked on the yearly [ACS]." According to the Wall Street Journal, the ACS asks whether an individuals is a U.S. citizen by birth, is a naturalized citizen, or is not a citizen. It does not ask whether an individual's presence in the United States is legal.

    What the change could mean for federal funding, including Medicaid

    According to CNN, the census is used to count the entire U.S. population, including undocumented immigrants. The federal government uses Census data to determine where to distribute federal funds, including Medicaid funding, TIME reports.

    Some observers have raised concerns that including a citizenship question on the census might discourage undocumented immigrants from participating, which could result in a large number of individuals living in the United States going uncounted. As a result, states that see response rates drop significantly could end up receiving less federal funding, including federal Medicaid funds.

    According to Axios' "Vitals," the federal Medicaid funding states receive "is based on their per capita income," or their "total income divided by their population, as determined by the census." Therefore, if a state's census response rates do not accurately reflect their populations, it could "skew the calculation of the state's per capita income and decrease the amount of money it receives for Medicaid," "Vitals" reports. William Frey, a demographer and senior fellow at the Brookings Institution, said states with large immigrant populations—such as California, Florida, Illinois, New Jersey, New York, and Texas—could be affected.

    But Wilber in the memo said DOC conducted a review of how reinstating a citizenship question might affect the census and did not find any evidence it would cause the response rate to "decline materially." He wrote, "In discussing the question with the national survey agency Nielsen, it stated that it had added questions from the ACS on sensitive topics such as place of birth and immigration status to certain short survey forms without any appreciable decrease in response rates." Overall, Wilber said DOC "determined that obtaining complete and accurate information to meet [DOJ's] legitimate government purpose outweighed the limited potential adverse impacts."

    Reaction and legal challenges

    Still, some advocates have pushed back on the change.

    Kristen Clarke, president and executive director of the Lawyers' Committee for Civil Rights Under Law, said, "This is an arbitrary and untested decision that all but guarantees that the census will not produce a full and accurate count of the population as the constitution requires."

    California Attorney General Xavier Becerra (D), and California Secretary of State Alex Padilla (D) in an opinion piece published Monday in the San Francisco Chronicle questioned the constitutionality of the change, arguing that the Trump administration is attempting to "hijack the 2020 census for political purposes."

    According to CNN, California on Tuesday filed a lawsuit challenging the change. Civil rights groups also have threatened legal action, and New York Attorney General Eric Schneiderman (D) said he would head a multistate lawsuit seeking to stop the Trump administration from implementing the change. Schneiderman on Tuesday said, "This move directly targets states like New York that have large, thriving immigrant populations, threatening billions of dollars in federal funding for New York."

    According to the Journal, a DOC spokesperson said legal challenges over the matter are meritless and DOC expects it will prevail in such litigation.

    Democrats in the House and Senate also have introduced legislation that would stop the Census Bureau from adding a citizenship question to the census, though the bills likely will not advance in the Republican-controlled Congress, the Journal reports (Baker "Vitals," Axios, 3/28; Brusk/Wallace, CNN, 3/27; Shoichet, CNN, 3/28; Adamy et al., Wall Street Journal, 3/27; Rhodan, TIME, 3/27; DOC memo, 3/26).

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