The public comment period closed Aug. 7 on a proposed new question to be added to the 2020 U.S. Census.  If approved, the Census Bureau would ask all U.S. households, "Is this person a citizen of the United States?"

The Census Bureau argues that the new question will provide a more accurate count of voting-eligible residents in each neighborhood, but the proposed question has been sharply criticized.  Cities, states, a group representing mayors, the NAACP, and more have brought lawsuits against the bureau and the Commerce Department, arguing that this question may cause many in communities of color and immigrant communities to opt out of participating in the census, especially in the current climate of uncertainty and fear around immigration enforcement.  Historically, these communities have already been undercounted.

Quoted in one of these lawsuits brought by California, a 2017 Census Bureau memo reported an increase in immigrants' fears about protecting their personal information in surveys and focus groups, given the Trump administration's stance toward immigration.

This isn't the only cause for concern when it comes to the possibility of an undercount, particularly in hard-to-count communities.  The 2020 census will be the first to offer the option of responding online, partially as an effort to reduce the cost of the census.  Participants will be able to call and ask for a paper survey, but advocates worry that this process is cumbersome, and that populations who don't speak English as a first language or who have low levels of literacy are unlikely to participate.

These concerns have been borne out in the only trial to assess the switch to online census collection.  The test run, which took place earlier this year in Rhode Island, was underfunded and underpublicized, and groups have already raised the alarm about the lack of outreach in languages other than English.  It's important that this test did not include the proposed citizenship question, which will not be tested.

An undercount may be a cause for alarm, but why is it a health-care issue?

The census has direct bearing on how hundreds of billions of federal dollars nationwide are allocated to states, affecting the funds states receive for programs such as Medicaid, the Children's Health Insurance Program (CHIP), and other critical programs that help people stay healthy, such as the Supplemental Nutrition Assistance Program (SNAP, or food stamps).

In particular, federal funds for health-care programs are calculated based on the Federal Medical Assistance Percentage (FMAP), which relies on census data and is determined annually.  In 2015, the FMAP guided the allocation of $286.1 billion nationally.  In Pennsylvania, it determined the distribution of $12.4 billion, 90 percent of which went to Medicaid, the health insurance program that serves low-income families, children, seniors, and people with disabilities.

According to a recent study conducted by the GW Institute of Public Policy, if the 2010 census had been undercounted by just an additional 1 percent, Pennsylvania would have lost $221.8 million in federal funds in 2015 as a result of the lower FMAP calculations.  The number would continue to increase the more people are not counted.

This is because FMAP relies on a calculation of a state's per-person income to determine how many federal dollars it gets.  With fewer people counted, the state's calculated per-person income will rise, and the number of dollars it receives will decrease accordingly.  This means fewer dollars to pay for health-care programs in the state's treasury.

Health centers would also likely be affected by an undercount.  Most health centers receive federal grant funding to help underserved and vulnerable populations, but these grants rely on census data to determine the areas of greatest need.  If hard-to-count communities are underrepresented in the count, health centers could be penalized.

In a time when Pennsylvania's budget process is already contentious and lawmakers have repeatedly tried to make cuts to Medicaid, the federal dollars that support these crucial programs are essential to keeping them running smoothly.  We simply can't afford to lose millions of health-care dollars.

There are many reasons to promote an accurate census count in 2020, but keeping our health-care programs financially stable is a critical concern.  Without significant resources put toward outreach to hard-to-count communities and significant effort toward educating immigrant populations about why they should participate, especially if the proposed question is included, we will likely see an undercount in Pennsylvania, and our health-care programs will be put at unnecessary risk.

If Medicaid, CHIP, and health centers lose federal funds, we're likely to see increasing health disparities in our state, and low-income communities, immigrant communities, children and seniors, and people with disabilities would be disproportionately affected.