Demographics, Geography and Economy

The April 1, 2019 population estimate places Washington’s population at 7,546,410. Representing an increase of 118,840 persons over the past year, this 1.6 percent gain is the same rate of increase as the previous year. Sixty-nine percent of the growth occurred in the five largest metropolitan counties (King, Pierce, Snohomish, Spokane, and Clark), close to last year’s rate. (Office of Financial Management [OFM])

 

The April 1, 2019 population estimate for Washington’s incorporated cities and towns is 4,910,909, an increase of 74,424 persons from the prior year. The top 10 cities for population growth, in descending order, are Seattle, Bellevue, Tacoma, Spokane, Kennewick, Redmond, Vancouver, Pasco, Kirkland, and Bellingham. The largest numeric increase in population is associated with Seattle, which grew by 16,900 persons to 747,300. (OFM)

 

Births in Washington declined rapidly during the “Great Recession” of the late 2000s and began to recover a few years later. In 2017 there were 87,508 births, down a bit from 2016’s 90,489. In 2017, an estimated 19 percent of the population, or 1.45 million, were females of reproductive age (15 to 44). There were approximately 1.7 million children under the age of 18 in the state, making up 22.4 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 2018, while the percentage identifying as Asian grew from 5 to 8.5 percent. Increasingly mothers are identifying themselves as more than one race, with that category increasing 73 percent since 2004.

 

Hispanics/Latinos are the majority in Franklin and Adams counties, and are approaching a majority in Yakima County, all of which are predominantly agricultural communities in central and eastern Washington. However, the largest number of Hispanics/Latinos are in the populous western Washington counties. African American or Black, Asian, and Native Hawaiian and other Pacific Islander populations are also generally concentrated in a few western counties.

 

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 works with two Urban Indian Health Organizations and 12 Recognized American Indian Organizations in the Pacific Northwest.

 

Geographically, the state is divided by the rugged Cascade range. 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). 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. The Columbia Plateau dominates the area east of the Cascades. Eastern Washington is an area of low population density, with the exception of 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, life science/global health, maritime, and military/defense sectors.

 

Washington’s unemployment rate has dropped in recent years, from a peak of 10.4 percent in late 2009 to 4.7 percent in May 2019. As of 2017, projected median income in Washington was $70,979. Median income varied greatly across the state with incomes in urban areas being higher than those in more rural areas (a projected low of $42,276 in rural Pend Oreille County to $88,466 in heavily urban King County). In 2017, 11 percent of the population was below the federal poverty level, however for children 0 to 17 the rate was 14.3 percent, indicating that poverty is disproportionally pressing on the young in our state.

 

Health Status of MCH 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.

 

The state’s unintended pregnancy rate was 34 percent in 2016. Since 2008, the birth rate in Washington among teens has continued to decline steadily. In 2017, it was 14.3 per 1,000, the lowest rate since 1980, and a decrease of 56 percent over the last decade.

 

Infant mortality remains low, however disparities among racial groups persist. In 2017, the mortality rate of infants born to non-Hispanic White women was 3.3 per 1,000. The rate among infants born to non-Hispanic Black or African American women was much greater, 9.1 per 1,000. The rate for non-Hispanic American Indian/Alaska Native (AI/AN) women was down significantly from 2016, to 4.4 per 1,000. This rate approaches the Washington State goal of eliminating the disparity between infants born to non-Hispanic White women and those born to non-Hispanic AI/AN women. However, the relative standard error for this rate is 45%, indicating a very unstable estimate reflective of the small numbers involved. Likewise, due to small numbers, the Native Hawaiian and other Pacific Islander infant mortality rate has varied considerably year to year, but there are indications that it may also be higher than that of non-Hispanic Whites.

 

In 2016-17, an estimated 18.7 percent of children, equaling around 300,000, were children and youth with special health care needs (CYSHCN). Of these children, 45.7 percent received comprehensive, ongoing and coordinated care within a medical home. Of adolescents, 12 to 17 years of age, 38.7 percent reported receiving the services they needed to make transitions to adult health care. (2016-17 National Survey of Children’s Health)

 

In 2016, the rate of hospitalization for non‐fatal injury for adolescents ages 10 to 19 was 203.9 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 10th grade students reported having experienced symptoms of depression in the previous 12 months. 18 percent of 10th 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.

 

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)

 

Racial and ethnic disparities are found in low birth weight, infant mortality, teen pregnancy, and maternal mortality. Adverse maternal and infant health outcomes are more prevalent among those of lower socioeconomic status and among some race and ethnic groups. Black or African American and American Indian/Alaska Native infants in Washington are about twice as likely to be born low birth weight and almost twice as likely to die in their first year as white infants. Mothers of lower socioeconomic status who receive Medicaid coverage for prenatal care or delivery are more likely than mothers who do not receive Medicaid to report their birth was from an unintended pregnancy, and their infants are more likely to be born low birth weight or to die in their first year of life.

 

Undocumented mothers who are largely of Hispanic/Latino origin and generally have low incomes, have more favorable maternal and infant health outcomes in some areas such as infant mortality, low birthweight, alcohol and tobacco use as well as post-partum birth control use than legal resident women/citizens in similar economic conditions. This may be due to non‐economic factors such as family and community support and possibly the “healthy worker” bias. In other areas, undocumented women do worse than other women, such as prenatal vitamin use, getting into early prenatal care and delivering preterm. Undocumented women are less likely to have reported having an unintended birth than other low income women, but more likely than middle income or wealthy women.

 

Dental caries among children in second and third grades were far more prevalent in American Indian/Alaska Native, Native Hawaiian and other Pacific Islander, and Hispanic populations than non-Hispanic Whites. 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, which 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.

 

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 in turn 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 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: People in Washington enjoy longer and healthier lives because they live in healthy families and communities.

 

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. While many of its goals affect Title V programs and populations in some manner, the key goal with regard to Title V is Goal 2 – Healthiest Next Generation: Ensure all children in Washington achieve their highest health potential. The objectives and strategies related to this goal are:

 

• Give all babies a planned, healthy start in life.

 

• Develop systems to deliver newborn screening results electronically
• Implement new testing for X-adrenoleukodystrophy (X-ALD)
• Provide technical assistance and funding to support implementation of the American Indian Health Commission’s Tribal Maternal Infant Health Strategic Plan
• Increase participation of African American or Black and AI/AN pregnant women and children under five in the Women, Infants and Children Nutrition Program (WIC) by implementing focused outreach
• Collaborate with partners to improve access to long acting reversible contraception to all women who desire it
• Work with other state agencies to support increased reach of sexual health education and access to teen-friendly services
• Increase the number of hospitals, worksites, childcare, and health care settings that are changing maternity care practices to support breastfeeding

 

• Ensure all children have appropriate developmental screenings and access to services.

 

• Provide training and technical assistance to primary care providers and other community partners who serve children to implement developmental screenings
• Provide statewide, centralized access to information and resources needed by families and children to access services

 

• Increase immunization rates in children.

 

• Provide education and outreach to youth, parents, and health care providers encouraging all three doses of human papillomavirus (HPV) vaccine
• Increase immunization rates at the provider level through increased Assessment, Feedback, Incentives eXchange (AFIX) program site visits
• Improve completion of data reported in the Immunization Information System (IIS)
• Implement the IIS School Module in order to increase school vaccination rates

 

• Create environments and systems that support healthy eating and active living.

 

• Support early learning settings, schools, and communities to provide safe and healthy meals, snacks and beverages
• Support early learning settings, schools, and communities to provide opportunities for physical activity
• Increase WIC program retention by changing from paper checks to Electronic Benefit Transfer (EBT) cards to improve shopping experiences

 

• Promote safe, stable, nurturing relationships and environments, including preventing and mitigating Adverse Childhood Experiences and other complex trauma.

 

• Sustain and strengthen the Essentials for Childhood partnership to promote safe, stable nurturing relationships and environments
• Provide information to local communities in order to increase their capacity to develop and enhance trauma informed organizations, and develop policies and practices across sectors including; primary care, schools, and law enforcement

 

• Reduce the use of tobacco, e-cigarettes/vaping devices, and marijuana in persons under 21 years old: Identify and implement policy, environment and system changes to prevent youth access and use of these controlled substances.

 

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. The Healthier Washington infographic shows initiative components.

 

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 stakeholders 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, with a report to the legislature due in June 2019.

 

Together with a variety of partners, DOH held the 5th annual statewide CHW Conference, with a record attendance of over 400 CHWs. This two-day conference featured more than 40 learning sessions covering topics such as community partnerships, healthy lifestyle, substance misuse prevention and education, and health equity.

 

 

A fundamental aspect of the Healthier Washington initiative is the state’s move toward full integration of physical health services, mental health services, and substance use disorder (SUD) services for people enrolled in Medicaid. Before care was integrated, Medicaid clients with co-occurring disorders had to navigate three separate systems, 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.

 

In April 2016, managed care organizations began delivering the full continuum of physical health, mental health and SUD services in Clark and Skamania counties in southwest Washington. At the same time, in all other counties, behavioral health organizations began providing SUD services for all, and specialty mental health services for individuals who met access to care standards. Washington State is making good progress toward its goal for each region to operate in an integrated managed care model by 2020.

 

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 2019 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 Plan for Improving Population Health, a key product of the Healthier Washington initiative, is a set of strategies, data and resources to help promote population health initiatives. These resources are housed on a website called the Population Health Guide. The effort 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.

 

National Accreditation

One element of DOH’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.

 

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.

 

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.

 

Health Care Infrastructure

The majority of the health care delivery system in the state is located in urban areas along the I‑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.