Demographics, Geography and Economy

The April 1, 2020 population estimate places Washington’s population at 7,656,200. Representing an increase of 109,790 persons over the past year, this is a 1.5 percent gain, compared to a 1.6 percent gain the previous year. For the third year in a row, nearly 70 percent of the growth occurred in the five largest metropolitan counties (Clark, King, Pierce, Snohomish, and Spokane). (Office of Financial Management [OFM])

 

The April 1, 2020 population estimate for Washington’s incorporated cities and towns is 4,990,690, an increase of 79,781 persons from the prior year. The top 10 cities for population growth, in descending order, are Seattle, Vancouver, Redmond, Bellevue, Tacoma, Pasco, Kirkland, Richland, Bothell, and Lacey. The largest numeric increase in population is associated with Seattle, which grew by 13,800 persons to 761,100. (OFM)

 

Births in Washington declined rapidly during the “Great Recession” of the late 2000s and began to recover a few years later. In 2018 there were 86,407 births in Washington, continuing a downward trend since 2016 (90,489). In 2019, an estimated 19.5 percent of the population, or 1.47 million, were females of reproductive age (15 to 44). There were approximately 1.68 million children under the age of 18 in the state, making up 22.3 percent of the state’s residents. (Department of Health [DOH] Community Health Assessment Tool)

 

Washington is gradually becoming more racially and ethnically diverse. Communities of considerable diversity include the population centers of and surrounding Seattle and Tacoma. The percentage of state residents classifying themselves as Hispanic/Latino grew from 8 percent in 2000 to 13 percent in 2019, while the percentage identifying as Asian grew from 5 to 9 percent. Increasingly mothers are identifying themselves as more than one race, with that category increasing 78 percent since 2004.

 

As of 2019 Hispanic/Latino people comprise the majority in Franklin, Adams, and Yakima counties in central and eastern Washington, which include large agricultural areas. However, the largest number of Hispanic/Latino people are in the populous western Washington counties. Black or African American, Asian, and Native Hawaiian and other Pacific Islander populations are also generally concentrated in a few western counties, though a significant population of Marshallese Islanders live in Spokane County in eastern Washington.

 

Washington is home to 29 federally-recognized Indian tribes, each with varying populations and land areas. There are seven additional tribes, some of which are seeking federal recognition. DOH also works with two Urban Indian Health Organizations and 12 Recognized American Indian Organizations in the Pacific Northwest.

 

Geographically, the state is divided by the Cascade Range. This results in a stark difference in climate and geography between the two regions, with the west being wetter with a moderate climate and the east being drier with a more extreme climate. The northwest quadrant of the state is also split into two distinct land areas by Puget Sound. The most densely populated region of the state is on the east side of Puget Sound, where seven of the state’s 10 most populous cities are located, including Seattle (1), Tacoma (3), Bellevue (5), Kent (6), Everett (7), Renton (8) and Federal Way (9). Vancouver, the fourth largest city in Washington located in the far southwest of the state sits across the Columbia River from Portland, Oregon, comprising part of that recognized metropolitan statistical area. Many residents of Vancouver receive services in Portland.

 

Olympia, the state capital, lies at the southern end of Puget Sound. On the west side of Puget Sound is the less-populated Olympic Peninsula, including the Olympic Mountains wilderness area and coastal shorelines. Much of the north central area of the peninsula makes up Olympic National Park, which is designated wilderness, isolating the Pacific Costal communities from those along the east side of the peninsula. The Columbia Plateau dominates the area east of the Cascades. Eastern Washington is an area of low population density, with two major population centers, the Tri-Cities metropolitan area, composed of Richland, Kennewick and Pasco in Benton and Franklin counties and Spokane, the state’s second largest city, and its metropolitan area.

 

Washington has a highly diversified economy. It is a leading national producer of agricultural commodities, including apples, wheat, milk, potatoes and forest products. High growth industries also include aerospace, clean technology, information and communication technology, online sales, life science/global health, maritime, and military/defense sectors.

 

Washington’s unemployment rate was, prior to the COVID-19 pandemic, low at 3.8 percent in January of 2020. By April 2020, after the Governor’s decree to shut down all non-essential economic activity due to COVID-19 spread, the unemployment rate rose to 16.3 percent, having been at 5.1 percent the month before in March. Total non-farm employment contracted by an estimated 527,000 jobs in one month, March to April. While losses were across the board, with all thirteen major industries contracting their labor forces, the leisure and hospitality sector took the largest hit, losing 177,700 jobs, including 120,500 in food and beverage services and establishments. These positions are disproportionately filled by women, people with lower educational attainment, and racial and ethnic minorities. By May of 2020 the economy had recovered some with total non-farm employment up 52,200 jobs, including a return of 30,000 jobs to the leisure and hospitality sector; the same was not true for government jobs, which were down a further 20,100 from April. This loss of government capacity may hinder public sector efforts to combat the pandemic even further. Preliminary data indicate that the economy continues to improve but the rate of improvement has slowed since May. (WA Employment Security Department, Monthly Employment Report)

 

Health Status of Maternal and Child Populations in Washington State

For most maternal and child health outcomes, rates of poor health outcomes in Washington are similar to or lower than national rates.

 

Since 2008, the overall pregnancy rate in Washington declined by 16 percent. Among teens ages 15 to 18, the drop in the rate was even larger, down 61 percent. Pregnancy rates in young women have also dropped since 2008 but not by as much, down 38 percent in 20- to 24-year-olds, and 18 percent in 25- to 29-year-olds. For women over 34 years old, the trend was opposite, with pregnancy rates increasing by 13 percent since 2008. The state’s unintended pregnancy rate was 35 percent in 2018.

 

Infant mortality in Washington State remains low, ranking eighth lowest among all the states. Compared to other states Washington had the lowest Hispanic infant mortality rate, the second lowest non-Hispanic African American rate, and the fourth lowest non-Hispanic Native American rate. Despite this, however, disparities among racial groups persist (see Health Disparities below).

 

In 2017-2018, an estimated 19.0 percent of children, equaling around 311,000, were children and youth with special health care needs (CYSHCN). Of these children, 45.3 percent received comprehensive, ongoing and coordinated care within a medical home. Of adolescents, 12 to 17 years of age, 38.6 percent reported receiving the services they needed to make transitions to adult health care. (2017-2018 National Survey of Children’s Health)

 

In 2018, the rate of hospitalization for non‐fatal injury for adolescents ages 10 to 19 was 219.7 per 100,000 population. This rate has been in decline since 1990, but unintentional injury is still the leading cause of death among children in Washington.

 

Rates of depression and suicidal ideation among youth have increased in recent years. In 2018, 40 percent of tenth grade students reported having experienced symptoms of depression in the previous 12 months. 18 percent of tenth grade students reported they had made a plan to attempt suicide in the previous 12 months, and 10 percent reported having attempted it. Suicide is the second leading cause of death for Washington adolescents 15 to 19 years of age, with 33 percent of total deaths in this age group. Washington State has developed a comprehensive Suicide Prevention Plan to address the suicide rate. (Healthy Youth Survey)

 

Health Disparities

Washington residents report significant health status differences related to race/ethnicity, household income, education, and place of residence. In general, minority racial/ethnic populations, people with lower household income, people with less than a high school education, and people living outside of urban areas are less likely to report “good” to “excellent” health. (Behavioral Risk Factor Surveillance System)

 

Even though Washington State ranks favorably in infant mortality when compared to other states, there are large disparities among racial and ethnic groups within the state. In 2018, the mortality rate of infants born to non-Hispanic White women was 3.8 per 1,000. The rate among infants born to non-Hispanic African American women was much greater, 9.7 per 1,000. The rate for non-Hispanic American Indian/Alaska Native women was 6.7 per 1,000, and the rate for non-Hispanic Native Hawaiian and other Pacific Islander women was 7.6 per 1,000. Rates among these racial/ethnic groups tend to vary from year to year due to small numbers, but the overall trend of elevated rates has persisted across years. (WA Vital Statistics)

 

Racial and ethnic disparities are found in low birth weight, preterm birth, and first trimester prenatal care. Black or African American (8.0 percent) and Pacific Islander (7.3 percent) singleton birth infants were about twice as likely to be born low birth weight than non-Hispanic White (4.3 percent). Non-Hispanic American Indian/Alaska Native singleton birth infants were almost twice as likely to be born preterm (11.9 percent) as non-Hispanic White infants (6.1 percent). Other racial/ethnic groups had elevated rates as well, Black or African-American (8.7 percent), Pacific Islander (8.4 percent), Hispanic (7.5 percent), and non-Hispanic Asian (6.7 percent). Non-Hispanic Pacific Islander mothers were much less likely than non-Hispanic White mothers to begin care in the first trimester (44.7 percent versus 77.1 percent). Non-Hispanic Black or African American, non-Hispanic American Indian/Alaska Native, and Hispanic women were all also less likely to have begun care in the first trimester (63.7 percent, 61.5 percent and 69.9 percent respectively). (WA Vital Statistics)

 

There are significant disparities between women who had their deliveries paid for by Medicaid and those who did not. Women who use Medicaid were more likely to smoke during pregnancy (9 percent) than non-Medicaid (1 percent) and less likely to report postpartum breastfeeding at two months (73 percent) than non-Medicaid (91 percent). Women who use Medicaid were less likely to have taken a pre-natal vitamins (64 percent) than non-Medicaid women (34 percent) and were also slightly less likely to place their infants on their backs to sleep (78 percent for Medicaid recipients and 86 percent for non-Medicaid). Women who use Medicaid were more likely to report that their most recent infant was unplanned (29 percent) than non-Medicaid women (17 percent). In five of the last seven years Medicaid recipients reported having more symptoms of post-partum depression than non-Medicaid recipients. (PRAMS)

 

Disparities are found in the oral health status of Washington’s children. Dental caries among children in second and third grades were far more prevalent in American Indian/Alaska Native (67 percent), Pacific Islander (75 percent), and Hispanic (71 percent) populations than non-Hispanic White (45 percent). Also, lower income children of all races/ethnicities were twice as likely to have rampant decay involving seven or more teeth than their higher-income peers.

 

Contrary to national data, Washington State data do not show disparities based on socioeconomic factors among CYSHCN. Washington State data do show fewer children of Hispanic/Latino origin to have special health care needs than White children, however this may be due to under‐diagnosis because of insufficient access to health services.

 

Many health disparities in Washington are geographical and are linked to rural versus urban differences. A recent state review of hospital utilization rates and mortality rates showed poorer outcomes in rural areas. The hospitalization rates overall and the hospitalization rates specifically related to cancers and diabetes are significantly higher in rural areas of the state. Some mortality rates are also significantly higher, including the overall mortality rate, rates for younger people (ages 1 to 24), and rates for deaths from transportation accidents, suicides, and diabetes. Many factors may contribute to these poorer outcomes, including geographic isolation and decreased access to care, the lower socio‐economic status of residents, and their older age.

 

One way DOH is addressing health disparities is by implementing a plan to incorporate Culturally and Linguistically Appropriate Services (CLAS) across all programs. This includes the adoption of internal policies to improve CLAS compliance, staff training, development of resources and tools, and the creation of a sustainability system for compliance. This work is supportive of the Governor’s Interagency Council on Health Disparities’ 2018 State Policy Action Plan to Eliminate Health Disparities, which recommends a wide variety of statewide activities in support of equitable health opportunities for all.

 

COVID-19 Pandemic in Washington State

Washington State recorded the first officially identified case of SARS-CoV-2 infection in the United States on January 21, 2020. The case was identified in Snohomish County in an individual who had traveled to Washington State from China. The individual was isolated, treated and made a full recovery. Shortly after, COVID-19 was diagnosed in patients in a nursing home in King County, resulting in multiple deaths. On March 23 Governor Jay Inslee issued a stay-at-home order to help to control the spread of the virus, which at that time had resulted in 110 deaths and infected 2,221 individuals. COVID-19 continued to spread, but Washington State did not see the same sorts of infection rates other states did in large part to the “Stay Home, Stay Safe” campaign. In the beginning of summer, however, Washington State started to experience increases in infections and unlike in the spring, the infections were more state-wide, severely impacting many communities east of the Cascades. The increase continued throughout the summer and in early September 2020, appears to be slowly leveling off.

 

In Washington State, as in other parts of the country, COVID-19 has disproportionately impacted poor and minority communities with Hispanic, Black or African American, American Indian/Alaska Native, and Pacific Islander communities especially hard hit. The DOH surveys infection rate, recovery rate, hospitalization rate, mortality by race/ethnicity and reports on the disparate impact to communities of color. Updated data and analysis are available on the COVID-19 website, an example of which can be accessed here in the COVID-19 Morbidity and Mortality by Race, Ethnicity and Language in Washington State report. Food production facilities, such as produce and meat packing plants, and congregate living spaces, where seasonal workers are often housed, and front-line service industry workers have experienced the greatest burden of COVID-19 transmission.

 

Housing instability remains a pressing issue, with particular concern that if individuals and families who have been out of work become evicted in large numbers, the problems will grow worse. So far, eviction moratoriums has been in place to prevent this.

 

There are still concerns that people may not be seeking or receiving health care due to fears about infection and safety, which is especially concerning about those who are in medically fragile condition. Home visiting programs and Women, Infants and Children Nutrition Program (WIC) appointments have been impacted, and these programs are being modified to best serve populations during the pandemic.

 

There are concerns about increased domestic abuse, with the Seattle Police Department reporting in April a 21 percent increase in reports of domestic violence. Strains on mental health are becoming more prevalent, prompting DOH to provide resources for mental and emotional well-being on its webpage. School-aged children are missing out on important social interactions, with many schools closed and opting for distance learning. Many families are experiencing problems with their ability to participate in educational activities and learn from home due to the digital divide (lack or unaffordability of appropriate infrastructure, services and equipment).

 

As the pandemic continues, DOH will continue to provide services, including case investigation and contact tracing, disease surveillance, support to local public health and the health care system, reliable information for the public, and when it becomes available, an equitable system for the distribution of a vaccine to the residents of Washington. 

 

Results Washington Initiative State Priorities

A key driver for all of state government is Governor Jay Inslee’s Results Washington initiative, launched in late 2013. Results Washington is a data-driven initiative to make government more effective, efficient and customer-focused. Its five goal areas are:

 

• World Class Education
• Prosperous Economy
• Sustainable Energy and a Clean Environment
• Healthy and Safe Communities
• Efficient, Effective and Accountable Government

 

Statutory Environment for Public Health

In Washington State, the governmental public health system is a decentralized model characterized by local control and state-local partnerships. Local and state government agencies work with a network of public and private hospitals, nonprofit and for-profit health care systems, rural health care clinics, and tribal, community, and migrant health centers. They often contract with nonprofit agencies, institutes of higher education, or other community organizations.

 

State law gives primary responsibility for the health and safety of Washington State residents to county governments. It charges the counties’ legislative authorities with establishing either a county health department or a health district within the same boundaries as the county (Chapter 70.05, 70.08, and 70.46 Revised Code of Washington [RCW]), as well as a local board of health (RCW 70.05.060). There are 35 health departments or districts – collectively “local health jurisdictions” (LHJs) – serving 39 counties; several counties have chosen to combine districts. Board of health members are most often county commissioners or council members, but the boards may include other elected or non-elected officials, as long as the majority are elected officials.

 

Most of the 29 federally-recognized Indian tribes in Washington State provide public health and health care services to their members.

 

Washington State Department of Health

The Department of Health works with others to protect and improve the health of all people in Washington State.

 

Our programs and services help prevent illness and injury, promote healthy places to live and work, provide information to help people make good health decisions, and ensure our state is prepared for emergencies. To accomplish this, we collaborate with many partners every day to:

 

• Improve health through disease and injury prevention, immunization, and newborn screening.
• Provide health and safety information, education, and training so people can make healthy choices.
• Promote a health and wellness system where we live, learn, work, play, and worship.
• Address environmental health hazards associated with drinking water, food, air quality, and pesticide exposure.
• Protect people by licensing health care professionals, investigating and responding to disease outbreaks, and preparing for and responding to emergencies.

 

A visual portrayal of DOH’s programs and some key facts is available in a DOH at a Glance infographic.

 

Strategic Plan

Vision: Equity and optimal health for all.

 

Mission: The Department of Health works with others to protect and improve the health of all people in Washington State.

 

The DOH Strategic Plan is available online. The current strategic plan focuses on making four foundational transformations in the following areas:

• Outward mindset
• Funding
• Data information, technology innovations
• Equity, diversity, inclusion

 

Healthier Washington

Washington State completed a State Health Care Innovation Plan in 2013 with participation from both the private and public sector. It focused on integrating mental health services with other health services, developing Accountable Communities of Health (ACHs), and looking at models of payment that would reduce costs. The Health Care Authority (HCA), which administers Medicaid and public employee benefits in the state, was awarded $65 million from the Centers for Medicare and Medicaid Innovation (CMMI) to be used from 2015 to early 2019 to help implement the health care innovation plan, known as the Healthier Washington initiative.

 

Healthier Washington is transforming the statewide health care delivery system to achieve better health, better care, and lower costs. The overarching goals are to improve how we pay for services by rewarding quality over quantity, ensure health care meets physical and behavioral health needs by focusing on the whole person, and build healthier communities through a collaborative regional approach.

 

An element of this initiative is the state’s effort to lead strategic changes within Medicaid, allowing us to move toward a healthier Washington. The Healthier Washington Medicaid Transformation Project Demonstration is testing new and innovative approaches to providing health coverage and care. The transformation seeks to achieve bidirectional integration of behavioral health and primary care, convert 90 percent of Medicaid payments to reward quality of care, improve equity, and improve supports for the aging population.

 

The nine Accountable Communities of Health began formally organizing across the state in 2015, with their boundaries aligned with the state’s Medicaid regional service areas (see map below). The ACHs serve as implementation leads for the Medicaid demonstration project.

 

 

ACHs bring together leaders from multiple health sectors in their communities with a common interest in improving health and health equity. They evaluate health needs, take local action on those needs, and where appropriate, advise state agencies. ACHs will join others in providing feedback on the design and operation of the Medicaid program and how it might be improved, particularly from a local perspective. As Medicaid moves under Healthier Washington to better integrate physical and behavioral health care, and to link clinical care with other community services, the collective, multi-sector insights of ACHs will be critical to designing a supportive payment structure. However, ultimate legal and financial responsibility for Medicaid contracting, including monitoring and oversight, will remain with the state.

 

 

The Healthier Washington initiative seeks to transform our health system through workforce innovation, which includes the use of community health workers (CHWs). Research demonstrates CHWs can improve health outcomes and the quality of care while achieving significant cost savings, particularly when working with underserved populations. In early 2016, the CHW Task Force released recommendations, providing a platform for partners to support a CHW workforce and integration of CHWs within Healthier Washington and other health reform efforts. In a 2018-19 budget proviso, the state legislature set aside funds for a collaborative task force effort to recommend guidelines for CHW education and training, resulting in a report to the legislature in June 2019.

 

A fundamental aspect of the Healthier Washington initiative is the state’s move toward full integration of physical and behavioral health services for people enrolled in Medicaid. Before care was integrated, Medicaid clients with co-occurring disorders had to navigate three separate systems (physical health, mental health, and substance use services), which often did not communicate with each other, leading to duplication of services, poorly coordinated care and poor health outcomes. Through this whole-person approach to care, physical and behavioral health needs will be addressed in one system through an integrated network of providers, offering better coordinated access and care for patients.

 

Also related to the Healthier Washington initiative, the state legislature passed Engrossed Second Substitute House Bill (ES2HB) 2572 in 2014, directing a governor-appointed performance measures coordinating committee to recommend standard statewide measures of health and health care performance. In a well-functioning health care system, everyone should receive a similar high level of evidence-based care for the same condition. An important step in reducing variation is to measure and share results to develop an understanding of what needs to improve.

 

The Statewide Common Measure Set for Health Care Quality and Cost provides a foundation for health care accountability and allows for measurement of progress toward achieving healthier outcomes for all residents. The common measure set includes 63 measures relating to:

 

• Access to Primary Care
• Prevention
• Hospital Care
• Chronic Care
• Avoiding Overuse
• Behavioral Health

 

These measures are tracked, reported and revised as appropriate over time.

 

Finally, the Population Health Guide, a key product of the Healthier Washington initiative, is a set of strategies, data and resources to help promote population health initiatives. It provides a structured process for improving population health as a state, while allowing flexibility for the unique needs and resources of local communities. Resource pages are available for specific health focus areas (including well-child visits, adverse childhood experiences, opioid misuse, and others), and include current work, emerging issues, health equity data and recommended strategies. Diverse communities will be able to take health priorities and assess, engage, measure impact, quantify return on investment, and apply the latest evidence. As a result, they will ideally achieve improvements in the health of their communities, leading to lower costs and greater quality of life.

 

Health Care Infrastructure

The majority of the health care delivery system in the state is located in urban areas along the Interstate 5 corridor in western Washington, and in Spokane near the Idaho border. There are 103 acute care hospitals and 1,419 primary care clinics across Washington. Among these, the large rural areas of the state are served by 39 critical access hospitals and more than 110 rural health clinics. DOH licensed approximately 430,000 health practitioners in 2017, from a variety of disciplines, including physicians, nurses, dentists, pharmacists, emergency medical technicians, mental health counselors, massage therapists and other health professionals.

 

Washington has 58 public hospital districts, which are local government entities that run hospitals, clinics, and home health services. A few of these districts also organize emergency medical services; often, they provide the only access to such services in isolated areas. Public hospital districts are guided by independently-elected board members.

 

Three hospitals are dedicated children’s hospitals, located in Seattle, Tacoma and Spokane; in addition to the many other hospitals that see pediatric patients. Over 1,000 pediatricians practice in the state, and the number of family practices is around 3,500.

 

Nineteen community non-profit and hospital-based neurodevelopmental centers provide therapy and related services to young children with neuromuscular or developmental disorders. The centers are located across the state, each one meeting needs specific to its community.

 

Legal Authority

The state legislature established the Department of Health in 1989, combining programs from several state agencies. State law directs DOH to “provide leadership and coordination in identifying and resolving threats to the public health,” primarily by “working with local health departments and local governments to strengthen the state and local governmental partnership in providing public protection” (RCW 43.70.20). This language supports the concept that DOH should have a limited role in providing direct services.

 

A State Board of Health is authorized to make recommendations to the Secretary of the Department of Health. The Board of Health is directed to “provide a forum for the development of public health policy in Washington State” (RCW 43.20.050), and to adopt rules on disease control, environmental health, public water systems, and other health issues.

 

National Accreditation

One element of the Department of Health’s commitment to excellence and continuous improvement is to maintain accreditation by the Public Health Accreditation Board (PHAB). DOH was one of the first PHAB accredited public health departments in the country, achieving national accreditation in February 2013. In March 2019, DOH became one of the initial health departments, and the first state, to be reaccredited.

 

Title V in DOH

The DOH Title V program is located in the Prevention and Community Health (PCH) division of the Department of Health. Most of the Title V activities are within PCH’s Office of Family and Community Health Improvement (OFCHI), and the OFCHI Director is also the state’s Title V MCH Director. Organization charts are attached in the Appendix, and additional information about how DOH’s Title V program is organized and how its work is directed and supported by the agency is included in the State Title V Program Purpose and Design section.