Overview of the State

 

Covid-19 Special Note: At the time of submission of this report, the U.S. is experiencing the Covid-19 pandemic which has affected individuals and families, and disproportionately impacted the most vulnerable. A statement on the Covid-19 public health emergency and the District of Columbia is included in the Five-Year Needs Assessment Summary.

 

The District of Columbia is located in the urban center of the Washington Metropolitan Statistical Area. This geographic area is bordered by the county of Arlington and the city of Alexandria in Virginia; Prince George’s and Montgomery counties in Maryland, and the Potomac River. At only 61 square miles, it ranks as the 20th most populated city in the United States. The District is divided into approximately 100 ZIP codes, four quadrants (northeast, northwest, southeast and southwest) and eight principal Wards which are subdivisions founded for the purposes of voting and political representation.

 

Age and Gender  

DC’s population skews to a younger age group, with a median age of 33.9 years.[1] Children under the age of 18 comprise about 18% of the total population, with seniors (65 years and over) only composing 11.9%.1 Females comprise 52% of the population. There are over 280,000 households in DC, averaging at about 2.3 persons per household.1

 

Race and Ethnicity  

In 2018, the racial makeup of DC was majority non-White; 44% of the population was non-Hispanic Black and 11% was Hispanic, with Whites accounting for over one-third (37%) of District residents.[2] The Northwest quadrant of the District includes Wards 1, 2, and 3, have disproportionately higher White population, at approximately 44%, 66% and 72%, respectively, and Wards 1 and 4 have a substantial number of Hispanic residents, 20% and 21%, respectively, compared to 11% of the District population.1 Approximately 92% and 89% of the residents in Wards 7 and 8 (the Southeast quadrant) are African American, they experience higher poverty rates, earn lower incomes, and experience higher rates of unemployment than their counterparts in the District's other five Wards.[3]

 

2018 DC Demographics by Ward1 

Ward	Total Population	% Child Population (less than 18)	% Child Population (0-9)	% Population by Race and Ethnicity
				Non-Hispanic Black	Non-Hispanic White	Hispanic/ Latinx	Non-Hispanic Asian/PI
1	85,134	13	9	27	44	20	5
2	77,791	6	5	9	66	12	10
3	85,067	16	10	7	72	11	7
4	87,775	21	13	50	24	21	2
5	87,850	17	11	64	22	9	3
6	94,558	14	10	31	55	6	4
7	81,299	24	15	92	2	3	1
8	85,024	30	18	89	5	3	0

  

 

Socioeconomic Indicators

Education: Nearly 90% of residents are high school graduates or higher, with more than half (57.6%) holding at least a bachelor’s degree. While the District’s median household income is $82,604, about 17% of the population live below the poverty line. About 18% of residents speak more than one language at home, with Spanish being spoken in about 9% of all households.

 

School enrollment data for public schools in the District of Columbia indicate 93,708 students attending all K-12 schools.[4] With regard to educational attainment, 92.1% of residents are high school grads or higher; 17.0% of residents were categorized as high school graduates, 15% had completed some college, 26% had earned a Bachelor’s degree, and 34% had earned a graduate or professional degree.2

 

Income and Unemployment: A review of economic well-being indicators show that in 2007, the unemployment rate was 5.5%. By 2017, the unemployment rate had increased to 7.5%, lower than in 2011 (10.2%), but higher than the national average (4.9%). Annual household incomes also increased during this period. The median annual income for 2000 was $44,200, up to $70,848 for the years 2011 to 2015. In 2011-2015, 18% of District residents were living below the federal poverty level.

 

Housing: Over the last decade, DC has seen rapidly rising housing costs, leading to a significant loss of affordable housing. The median value of owner occupied housing units price of a single family home was $157,200 in 2000. That more than tripled by 2018, with a median price of $607,200. The median rent price in DC is almost $500 higher than that of the United States. About 40% of all DC residents spend more than a third of their monthly income on costs related to rent, mortgages, taxes and other related expenses.

 

DC Socioeconomic Indicators by Ward 

Ward	% in Poverty	% Children in Poverty	Median Income ($)	Employment (Count)	Unemployment Rate	% HS Grad or higher	% Bachelor’s degree or higher	% Single Female Headed Household
1	13.6	33	99,358	62,953	3.7	88.1	68.9	31
2	13.3	3	108,670	65,142	3.5	96.2	85	9
3	8.1	3	126,184	57,598	3.5	98	87.1	11
4	11.2	12	87,487	48,061	4.6	86.9	50.4	23
5	15.9	16	68,375	42,094	6.1	88.8	46.7	42
6	12.1	16	108,967	57,020	4.5	94.2	73.9	25
7	26.6	39	41,438	33,706	8.5	86	19.3	72
8	34.2	46	34,034	26,582	11.2	85.3	16.7	69

 

Data on socio-economic factors and health indicators emphasize the correlation between factors like poverty concentration and health outcomes within the DC population, with emphasis on the maternal and child health population. The differences in outcomes affecting the MCH population between the wealthiest ward (Ward 3) and the least wealthy (Ward 8) areas of DC is shown in the table below.[5]

MEASURE	WARD 3	WARD 8
Child Poverty	2.9%	48.5%
Families Below Poverty with Children	1.3%	25.4%
Grandparents Responsible for Grandchildren	16.0%	47.3%
Infant Mortality Rate	2.2% per live birth	14.6% per live birth

 

Health Insurance

The 2018 American Community Survey reported that the District has one of the lowest uninsured rates in the nation at only 3.2%. Of those insured, approximately 37% of residents receive public coverage (includes Medicare, Medicaid, and other public coverage), while 60% are privately insured. In 2018, about 44% of all District children under age 19 had only public insurance. Of the entire child population, 98% are insured. The District has had historically higher rates of insured residents, in much part due to publicly financed insurance.

 

Health Care System

The District is home to seven hospitals and hospital systems, of which five are birthing facilities. In 2017, two hospitals ceased obstetrical services. Providence Hospital, in Ward 5, announced the closure as part of a revised strategic plan. United Medical Center (Ward 8) permanently closed the labor and delivery unit after a temporary closure by the Department of Health due to concerns with quality of care. Hospitals, are concentrated in the Northwest and Northeast quadrants of the District, leaving many residents to reside in areas with few hospital options. Providers, particularly specialty providers, are also concentrated in neighborhoods that are difficult to reach for many residents. In 2006, the District Government enacted legislation to invest proceeds from the sale of bonds backed by the District’s share of the Master Settlement Agreement in the city’s primary care infrastructure. From 2006 through 2015, the District invested more than $70 million dollars to construct or renovate 14 community health centers in areas of the city with disparate health care access and health outcomes. In a 2018 report by the Association of American Medical Colleges, DC had approximately 122.8 primary care physicians per 100,000 residents – the highest in the nation.[6] Although DC has one of the strongest and most comprehensive primary care safety net systems in the nation, not all DC residents are fully engaged in appropriate primary care. Large portions of DC’s population struggle to access care when and where they want it, and face startling disparities in health-related outcomes despite the availability of health resources. For example, from June 2015–May 2016, only 56% of Medicaid and DC Alliance enrollees had a primary care visit within the last 12-month period.[7] Additionally, between 2011 and 2014 the rate of non-emergent ED visits climbed steadily from 325.8 to 342.8 – a 5% increase over four years. All seven of DC’s acute care hospitals provide inpatient services, emergency services, comprehensive outpatient medical specialty and surgical services, with inpatient care being the core service provided. Based on current licensure data, DC has a total of approximately 2,151 staffed beds. Four hospitals (Children’s National Medical Center, Medstar George Washington University Hospital, Medstar Washington Hospital Center, and Howard University Hospital) are all verified Level I trauma centers. The District also has several neonatal intensive care units (NICUs). Children’s National Medical Center and MedStar Georgetown University Hospital are Level IV NICUs, offering the highest level of care for premature and ill children. Level III NICUs are available at George Washington University Hospital, and MedStar Washington Hospital Center; Sibley Hospital has a Level II NICU.

 

Disease Burden

The District of Columbia’s 2017 Behavioral Risk Factor Surveillance System (BRFSS) survey found that residents living in Ward 7 and 8 were more likely to report having fair or poor health, high blood pressure and pre-diabetes. About one-third of District adults were reportedly overweight, and an additional 22.9% reported being obese. Of those categorized as obese, 36.3% were African American compared to 12% who were White. In 2017, 14.3% of adults were smokers, with the majority of those residents living in Wards 7 and 8. About 20.1% of female residents did not receive a routine doctor checkup within the past year compared to 26.3% of male residents. Lastly, 8.7% of District residents reported 14 or more days that their mental health was not good, with the majority of residents residing in Wards 7 and 8. In 2017, the 10 leading causes of death in the District of Columbia, in ranked order, were heart disease, malignant neoplasms, accidents (unintentional injuries), cerebrovascular diseases, diabetes mellitus, chronic lower respiratory diseases, Alzheimer’s disease, assault (homicide), influenza and pneumonia, and essential hypertension and hypertensive renal disease. These conditions accounted for 73.7% of deaths among DC residents. However, the majority of deaths (55.2%) were attributable to just the top three leading causes. The District of Columbia has seen a positive trend in life expectancy at birth. Over the past several years, the District has improved at a faster rate than the U.S with the average life expectancy increasing from 77.4 years in 2009 to 78.5 years currently.[8] Disparities in life expectancy are evident in DC, with those living in impoverished communities having a lower life expectancy than more affluent residents. Life expectancy estimates for District of Columbia neighborhoods vary by 22.1 years.

 

Governance 

The Home Rule Act of 1973 established the Council of the District of Columbia, the legislative branch of local government. This Act allowed for an elected mayor and Council and limited federal control of DC. The Act was the result of the ongoing push by District residents for control of their own local affairs, however maintains Congressional oversight with provisions that allow Congress to review all legislation passed by the Council before it can become law and to retain authority over the District's budget. The existing local government is the most expanded form of self-government since the establishment of the District as the seat of the federal government. In 1790, when the District was established on land ceded by Maryland and Virginia to the federal government only about 3,000 citizens lived in the area--far less than the 50,000 required to be a state.  

 

The Mayor of the District of Columbia is the head of the executive branch of DC’s government. The Mayor has the duty to enforce city laws, and the power to either approve or veto bills passed by the Council. In addition, the Mayor oversees all city services, public property, police and fire protection, and most public agencies. There are more than 20 District agencies (or departments) divided into five clusters (Planning and Economic Development, Health and Human Services, Education, Economic Opportunity and Public Safety and Justice). Each cluster is led by a Deputy Mayor who reports to the City Administrator. Sworn in on January 2, 2015, Muriel Bowser serves as Washington, DC’s seventh elected Mayor. 

 

The Council of the District of Columbia is the legislative branch of local government. The Council is composed of a Chairman elected at large and twelve Members--four of whom are elected at large, and one from each of the District's eight Wards. A Member is elected to serve a four-year term. The Council’s central role as a legislative body is to make laws. However, its responsibilities also include oversight of multiple agencies, commissions, boards and other instruments of District government. Working with the Mayor and the executive branch, the Council also plays a critical role in maintaining a balanced budget and the fiscal health of the District of Columbia government. 

 

The District of Columbia has historically enacted fairly progressive legislation to support the health and wellbeing of women, children and families residing in the District. Several recent examples are listed below:  

 

Pre-K Enhancement and Expansion Act (2008) expanded access to high-quality pre-K programs for all three- and four-year-olds in DC. The law formally places pre-k as the foundation for school reform — thus ensuring children a great start in school and in life. 

 

Healthy Schools Act (2010), designed to improve the health and wellness of students attending D.C. public schools by enhancing standards for breakfast/lunch access, school nutrition, farm to school food policies, physical activity and education, and health education.  

 

The Food, Environment and Economic Development in the District of Columbia (FEED DC) Act (2010) offers incentives to attract full-service grocery stores into low-income “food deserts”, and also provides funding for a Healthy Food Retail Program, which helps small grocers and markets sell fresh produce and other healthy foods. 

 

Youth Bullying Prevention Act (2012) requires the establishment of a bullying prevention task force, and the implementation of bullying prevention policies at District agencies and educational institutions.  

 

The Healthy Tots Act (2014) is designed to incentivize early care and education facilities to adopt higher nutritional standards and fund sub-grants for physical activity and nutrition programs. 

 

Prohibition Against Selling Tobacco Products to Individuals Under 21 Amendment Act (2015) amends District law to prohibit the sale of cigarettes to those under 21 years of age. 

 

DC Universal Paid Leave Amendment Act (2016) establishes a paid family leave program administered through the District of Columbia. The Act provides eight weeks of leave for caring for a newborn or newly adopted child, six weeks for tending to a sick relative and two weeks for taking care of personal medical needs for any worker employed by a private business in the District. 

 

District of Columbia Minimum Wage Act (2017) gradually increases the minimum wage to $15.00 per hour by July 2020. The Act also provides for a gradual increase in the minimum cash wage to tipped employees to $5.00 by July 1, 2020. 

 

D.C. Maternal Mortality Review Committee Establishment Act (2018) establishes a Maternal Mortality Review Committee to examine the causes associated with maternal mortalities of District residents and to help create a strategic framework for improving maternal health outcomes for racial and ethnic minorities in the District. 

 

Defending Access to Women’s Health Care Services Amendment Act (2018) allows pharmacists to prescribe and dispense self-administered contraceptives and also requires insurers to cover certain health care services without cost-sharing, including breast cancer screening and counseling, screening for HIV and counseling for sexually transmitted infections. 

 

The District’s current Mayor, Mayor Bowser, has emphasized creating pathways to the middle class for residents, and plans to foster a culture of inclusion, transparency and action. One of her top priorities is addressing homelessness and affordable housing. In her first budget, she directed $100 million to the Housing Production Trust Fund, putting a number of affordable housing units into the pipeline, and has released plans to replace the city’s largest aging family shelter with smaller family housing in all eight Wards. Other priorities include: investments in education to accelerate the pace of education reform; strengthening job training programs; attracting and retaining jobs in the District; creating a more transparent and open government through an open data policy; and launching an inclusive technology program to support startups and entrepreneurs offering products and services to underserved communities. 

The Preterm Birth Reduction Pilot Program (2019) established a two-year pilot program to reduce preterm births by increasing access to Progesterone (17P) for women with a history of preterm births. The pilot program is in its second year of implementation. 

 

The Better Access for Babies to Integrated Equitable Services Act of 2018 (BABIES eliminated stand-alone screening programs and consolidated all newborn screenings (metabolic, hearing, and CCHD) to provide a comprehensive program that establishes quality measures, and ensures accountability, regardless of whether the baby is born in a hospital, maternity center, or at home. This bill was not enacted by the DC Council. However the Community Health Omnibus Amendment Act of 2018, which includes the comprehensive newborn screening provisions of the BABIES Act of 2018 was signed by the Mayor on January 30, 2019 and became DC Law 22-290, effective April 11, 2019. 

 

Better Access for Babies to Integrated Equitable Services Act of 2020 (DC Law 23-118)

This legislation, which became effective June 24, 2020, amends the Community Health Omnibus Amendment Act of 2018 to:

 

1. Require individual and group health benefit plans to cover required newborn screenings.

 

2. Authorize civil fines and penalties for the failure of hospitals and birthing facilities to comply with newborn screening, privacy, reporting, and discharge requirements.

 

3. Establish a report card that assesses the performance of hospitals and birthing facilities in meeting newborn screening, inpatient services, and discharge requirements.

 

4. Establish a Perinatal and Infant Health Advisory Committee to provide recommendations to the Mayor and the DC Health Director regarding improving perinatal health and assuring access to quality perinatal health services.

 

Certified Professional Midwife Act of 2020 (DC Law 23-97)

 

Amends the Health Occupations Revisions Act of 1985 to provide for the certification and regulation of certified professional midwives and certified nurse mid-wives. It also specifies requirements for maternity centers, provides reimbursement for services provided by certified professional midwives, establishes an Advisory Committee on Certified Professional Midwives to develop guidelines for licensing professional nurse midwives, and regulating the profession of certified professional midwifery. Finally, the legislation includes certified professional midwives in the District of Columbia Health Professional Recruitment Program. This bill became law effective June 17, 2020.

 

Postpartum Coverage Expansion Amendment Act of 2020 (Bill 23-326)

 

Amends the Telehealth Reimbursement Act of 2013 to extend inpatient and outpatient benefits to at least a year after childbirth. The Mayor is required to seek a Medicaid waiver to enable all health policies covered through the District’s Medicaid program to cover inpatient and outpatient maternity and newborn care for at least a year after childbirth. This legislation is under Congressional Review and is expected to become law on November 16, 2020.

 

The following legislation was brought before DC Council for review: 

Maternal Health Care Improvement and Expansion Act of 2019 (Bill 23-326)

Requires individual and group health insurance plans, Medicaid, and the DC Healthcare Alliance to cover a minimum of 2 postpartum healthcare visits, and cover home visits, fertility preservation services, and stipends for travel to and from prenatal and postpartum visits.  In addition, pregnant residents who meet income eligibility requirements would receive Medicaid coverage for one year postpartum. The legislation also establishes a Center on Maternal Health and Wellness. A public hearing was held on this bill on December 18, 2019.

Perinatal Health Worker Training Access Act of 2019 (Bill 23-341)

Requires DC Health to provide grants to implement a perinatal health worker-training program to train residents in Wards 5, 7, and 8, to provide culturally congruent nonclinical care to women during their perinatal period.  A hearing was held on this legislation on December 18, 2019. 

Baby Friendly Hospital Initiative Act of 2018 (Bill 22-808) 

Requires all general acute care hospitals and special hospitals that have a perinatal unit to adopt the “Ten Steps to Successful Breastfeeding” as adopted by Baby Friendly USA, or an alternate process adopted by a health care service plan that includes evidenced-based policies, practices, and targeted outcomes, or the Model Hospital Policy. This legislation expired at the end of Council Session 22.

[1] U.S. Census Bureau (n.d.). 2018 American Community Survey 5-Year Estimate: District of Columbia.

[2] U.S. Census Bureau (n.d.). 2018 American Community Survey 1-year estimate: District of Columbia. Retrieved on September 2020.

[3] District of Columbia Department of Health. (2019). Health equity report: District of Columbia 2018. Retrieved from https://app.box.com/s/yspij8v81cxqyebl7gj3uifjumb7ufsw

[4] District of Columbia, Office of the State Superintendent of Education (OSSE). (2018) Audit and Verification of Student Enrollment for the 2017-18 School Year.

[5] Merrill, C., & Rieke, A. (2019, June 28). Community health needs assessment: District of Columbia, 2019. Retrieved August 12, 2020, from https://www.dchealthmatters.org/content/sites/washingtondc/2019_DC_CHNA_FINAL.pdf

[6] Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The State of Primary Care in the United States: A Chartbook of Facts and Statistics. January 2018.

[7] DC Department of Health (DC Health). (2018). District of Columbia: Primary Care Needs Assessment. https://dchealth.dc.gov/sites/default/files/dc/sites/doh/page_content/attachments/DC%20Primary%20Care%20Needs%20Assessment%202018.pdf

[8] Arias E, Escobedo LA, Kennedy J, Fu C, Cisewski J. U.S. small-area life expectancy estimates project: Methodology and results summary, National Center for Health Statistics, Vital Health Stat 2(181), 2018.