Blog & News
SHADAC Responds to Proposed American Community Survey (ACS) Sexual Orientation and Gender Identity (SOGI) Test Questions
December 4, 2023:
View the U.S. Census Bureau's full request for comments in the September 19th edition of the Federal Register. |
On September 19, 2023, the U.S. Census Bureau released a request for comments regarding the proposed addition of test questions regarding sexual orientation and gender identity (SOGI) for the American Community Survey (ACS). According to the notice in the Federal Register, the Census Bureau specifically hopes to test question wording, response categories, and placement within the survey itself.
Researchers at SHADAC reviewed the proposed test questions included in the Register proposal, as well as the methodology and reasoning behind the Census Bureau’s choices, and responded with comments regarding the measurement of sex and gender identity. Specifically, researchers discuss the limitations of the two-step gender identity questions, language and inclusivity concerns, and recommendations for a more streamlined and accessible two-step question format.
SHADAC’s Comments on Measuring Sex and Gender Identity
When designing survey questions, the consumer experience is paramount. Maximizing the accessibility and acceptability of question language improves data quality in multiple dimensions, including item non-response, misclassifications, and overall response rates.
In the case of measuring sex and gender identity, context matters. It is important to acknowledge how these questions might differ in various settings - when asked on a survey compared to when asked in an administrative or clinical setting, for example. We are concerned that the ACS is missing a key opportunity to update questions on sex and gender in ways that both enhance user experience and are specific to the survey setting.
The test questions for sex and gender identity as proposed use overly academic language that is better suited for a clinical setting, by asking first ‘what sex was NAME assigned at birth’ followed by ‘current gender identity.’ While such questions have utility, such as for verification of specific health insurance benefits, this approach is not optimal for a population survey such as the ACS.
Unnecessary jargon makes questions less accessible for respondents with lower literacy levels or who are non-English speaking and adds to the cognitive burden for all respondents. Survey language should minimize the respondent burden in order to support data quality and user experience. The limitations of the proposed two-step gender identity question have been described by the National Academies of Sciences, Engineering, and Medicine (NASEM).
Specific concerns worth highlighting are:
1) The proposed response options for ‘current gender’ are not inclusive of transgender experiences because these options imply that transgender is a tertiary or ‘other’ category and mutually exclusive from male or female identities. Allowing for multiple answers (one of the proposed test options) does not address this conceptual limitation.
2) Asking chronologically about ‘sex assigned at birth’ followed by ‘current gender identity’ may be perceived as invasive and/or invalidating for transgender respondents, which could increase item nonresponse for this critical population.
3) Asking a third question for verification of gender status when a respondent’s answers to ‘sex assigned at birth’ and ‘current gender’ don’t match places an undue burden on the transgender and nonbinary population. At minimum, the testing process should assess false positive rates and seek to avoid unnecessarily burdensome questioning of transgender and nonbinary people.
4) ‘Sex assigned at birth’ is not inclusive of intersex or nonbinary designations on infant birth certificates. These situations are increasingly common, and the current wording could lead to false positives for transgender, along with unnecessarily invasive questioning among individuals born with intersex traits.
SHADAC recommends that the Census consider a more streamlined two-step question approach that gathers the same information (sex assigned at birth and current gender) while providing a more inclusive and accessible experience for respondents. Specifically, we recommend asking first ‘what is your gender’ followed by ‘are you transgender.’ This approach was developed in Oregon via extensive stakeholder engagement. Similar language has also been used by administrators to update population survey questions in Minnesota.
The alternative two-step question addresses the limitations described above in the following ways:
1) Response options for ‘gender’ should include male, female, nonbinary, and a write-in response option. Asking about transgender identity in a separate question avoids portraying transgender as mutually exclusive with male or female. For respondents who need an explanation for ‘transgender,’ a hover box or an interviewer can provide a definition as follows: ‘Transgender describes a person whose gender identity differs from their sex assigned at birth.’
2) Asking simply about ‘gender’ first is clear and inclusive. Avoiding the ‘sex assigned at birth’ initial question would be less duplicative and more accessible for many respondents.
3) Asking directly about transgender identity (with ‘yes/no’ response options) prioritizes accessible language to minimize respondent burden and may eliminate the need for additional verification for transgender respondents. Ethically, the ACS should avoid asking all transgender respondents for extra verification without strong data to indicate that doing otherwise would lead to significantly elevated false positive rates.
4) Not asking about ‘sex assigned at birth’ avoids unnecessary collection of personal health data. This supports privacy for all respondents. Additionally, this approach could help reduce item nonresponse and false positives among intersex individuals as well as cisgender respondents who are unfamiliar with and/or dislike the language and concepts in the initially proposed test questions.
Thank you for your consideration. We know that the Census Bureau faces many important decisions and appreciate the chance to share our feedback on this important content test.
Blog & News
2022 ACS Tables: State and County Uninsured Rates, with Comparison Year 2021
November 17, 2023:Each year, SHADAC uses data released from the American Community Survey (ACS) via the U.S. Census Bureau's data.census.gov tool to produce estimates of uninsurance at the state and county level.*
Click on a state below in the interactive map to see a PDF table of uninsured rates by state and sub-state geographies, but also by demographic characteristics (e.g., age, race/ethnicity, and poverty level) for 2022 and comparison year 2021.
Click here to view uninsurance estimates for the United States.
Click here to view uninsurance estimates for Puerto Rico and its municipios.
Note: These tables present uninsured rates, which indicate the share of the population that is uninsured. For example, a 10 percent uninsured rate for adult women indicates that 10 percent of all adult women are uninsured.
Maps & Tables of Private, Public, & Uninsured Changes from 2021 to 2022
- Private Coverage Rates by State, Change from 2021 to 2022, for All People
- Public Coverage Rates by State, Change from 2021 to 2022, for All People
- Uninsurance Rates by State, Change from 2021 to 2022, for All People
About the ACS
The ACS is a household survey that began in 2005 and produces annually updated data on a variety of population characteristics, including health insurance coverage. In total, the ACS surveys approximately three million U.S. households each year. An important feature of the ACS is that it includes a large enough sample for state‐level and sub‐state estimates.
The ACS began asking survey respondents about health insurance coverage during the 2008 calendar year. Specifically, the survey asks respondents about current coverage for each person in the respondent’s household. A person is categorized as “insured” if he or she has coverage at the point in time at which the survey is administered.
*Why Aren’t Estimates Provided for All Counties?
Due to sample size constraints, single-year ACS estimates are available at the county level only for counties with a population greater than 65,000.
How Are These Estimates Different from the Estimates that SHADAC Publishes Using Census Bureau Micro-Data Files?
Two definitions used by the Census Bureau to generate the tabulations above differ from those that SHADAC uses to generate tabulations for State Health Compare. The definitional differences are as follows:
Family
The Census Bureau defines a family as “all related people in a household.”
SHADAC defines a family using a measure called the “Health Insurance Unit” (HIU), which includes all individuals who would likely be considered a family unit in determining eligibility for either private or public coverage.
To learn more about the 2020 update of SHADAC's Health Insurance Unit (HIU) see our HIU resource page, which houses two issue briefs: The first describes the SHADAC HIU, its purpose, the most recent update, and improvements to HIU data inputs; and the second outlines the impacts of using the SHADAC HIU in analysis so that researchers can assess whether the SHADAC HIU is suitable for their research and what the potential impacts of its use might be. The page also provides a link to STATA and SAS codes to aid in the use of the HIU variable.
Family Income
The Census Bureau determines family income as a percentage of the Federal Poverty Level (FPL), which is a definition of poverty used primarily for statistical purposes. For example, FPL is used to estimate the number of Americans living in poverty each year.
SHADAC determines family income as a percentage of the U.S. Department of Health and Human Services’ Federal Poverty Guidelines (FPG), which is a measure used for administrative purposes. For example, FPG is used to determine eligibility for federal programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP).
To learn more about the difference between FPL and FPG, read our updated blog post from April 2023.
Related ACS Materials:
- An Annual Conversation with the U.S. Census Bureau: 2022 Health Insurance Coverage Estimates from the ACS and CPS
- 2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases
- CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic)
Publication
An Annual Conversation with the U.S. Census Bureau: 2022 Health Insurance Coverage Estimates from the ACS and CPS
On Thursday, September 28th at 1:00 PM CST, SHADAC hosted a webinar covering the release of new 2022 health insurance coverage estimates from two key, large-scale federal data sources: The American Community Survey (ACS) and the Current Population Survey (CPS).
Estimates from both surveys were presented at: the national and state levels, as well as by coverage type, and a range of other demographic categories (age, geography, poverty level, and more), during the webinar. Technical and analytic insight was provided from experts at the U.S. Census Bureau, which administers both the ACS and CPS, and SHADAC researchers joined with our special guests from the Census Bureau to answer questions from attendees after the presentation.
Attendees were able to learn about:
- New 2022 health insurance coverage estimates
- When to use which estimates from the ACS vs the CPS
- How to access the estimates via Census reports and the data.census.gov website
- How to access state-level estimates from the ACS using SHADAC tables and State Health Compare web tool
Speakers
Kathleen T. Call, Moderator
Principal Investigator
SHADAC Dr. Call has been an Investigator with SHADAC since its launch in 2001. She is also a Professor in the Division of Health Policy and Management at the University of Minnesota (UMN), School of Public Health (SPH). She demonstrates her commitment to community-engaged scholarship through her leadership in the Clinical and Translational Science Institute, and the Interdisciplinary Research Leaders (IRL) program, and by co-chairing the UMN, SPH Health Equity Work Group.
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Katherine Keisler-Starkey, Speaker Economist in Health and Disability Statistics Branch United States Census Bureau Katherine Keisler-Starkey is an economist in the Health and Disability Statistics Branch in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Ms. Starkey provides subject matter expertise on health topics for the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) and has authored the Census Bureau’s Health Insurance Coverage in the United States report for the last four years. Her research interests focus on Applied Microeconomics, including Health Economics, Public Finance, and Labor Economics, and she is the author of several topically focused Census working papers and blogs in these areas. |
Robert Hest, Speaker
Senior Research Fellow
SHADAC Robert Hest joined SHADAC in 2017 and was recently made Senior Research Fellow. Mr. Hest provides expertise in survey data, data analysis and processing, and project management. Mr. Hest also manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data.
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Sharon Stern, Speaker
Assistant Division Chief
United States Census Bureau Sharon Stern is the Assistant Division Chief for employment characteristics in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Ms. Stern oversees statistics on the labor force, health insurance and disability from several Census Bureau surveys. She has authored a wide variety of Census Bureau reports and papers on topics related to poverty, disability, and health insurance.
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Related Resources
SHADAC
- Webinar slides from SHADAC
- CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic) (Blog)
- 2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases (Blog)
U.S. Census Bureau
- Webinar slides from Census Bureau
- Health Insurance Coverage in the United States: 2022 (Report)
- Health Insurance Coverage of U.S. Workers Increased in 2022: Health Insurance Rates for Working-Age Adults Higher by Race, Hispanic Origin, Region (Blog)
- Uninsured Rates Decreased in Over Half of U.S. States in 2022: Changes in Types of Health Insurance Coverage Contributed to Declines in Uninsured Rates From 2021 to 2022 (Blog)