III.B. Overview of State

Demographics, Geography, and Economy

The April 1, 2021, population estimate places Washington’s population at 7,766,925, representing an increase of 110,725 people over the past year, this is a 1.4% gain, compared to a 1.5% gain the previous year. For the fourth year in a row, the highest growth (over 70%) occurred in the five largest metropolitan counties (Clark, King, Pierce, Snohomish, and Spokane). (Washington State Office of Financial Management [OFM])

 

The April 1, 2021, population estimate for Washington’s incorporated cities and towns is 5,064,210, an increase of 73,520 people from the prior year. The top 10 cities for population growth, in descending order, are Seattle, Vancouver, Pasco, Auburn, Everett, Kent, Lacey, Yakima, Bellevue, and Ridgefield. The largest numeric increase in population is associated with Seattle, which grew by 8,400 people to 769,500. (OFM)

 

Births in Washington declined rapidly during the “Great Recession” of the late 2000s and began to recover a few years later. After increasing to a record high of 90,489 in 2016, they have been trending down again. In 2020, there were 83,101 births in Washington, a 2% decrease from 2019's 84,918 births, and an 8% decrease from 2016’s high. (Department of Health [DOH] Birth Certificate Data)

 

In 2020, an estimated 19.5% of the state’s population, or 1.49 million, were female of reproductive age (15 to 44). There were approximately 1.70 million children under the age of 18 in the state, making up 22.2% of the state’s residents. (DOH Community Health Assessment Tool)

 

Washington is gradually becoming more racially and ethnically diverse. Communities of considerable diversity include the population centers of and those surrounding Seattle and Tacoma. The percentage of state residents identifying themselves as Hispanic or Latino grew from 11.5% in 2011 to 13.5% in 2020, while the percentage identifying as non-Hispanic Asian grew from 7 to 9%. Non-Hispanic American Indian/Alaska Native residents decreased from 1.3 to 1.2% while non-Hispanic White residents also decreased from 72% to 67%. (OFM) Increasingly, mothers identifying themselves as more than one race on their infant’s birth certificate, with that category increasing 35 percent since 2011 (DOH Birth Certificate Data).

 

According to 2020 Census estimates, Hispanic or Latino people make up the majority of the population in Franklin, Adams, and Yakima counties located in the Columbia Basin of eastern Washington, which include large agricultural areas. However, the largest number of Hispanic or Latino people are in the more populous western Washington counties. Black/African American, Asian, and Native Hawaiian or Pacific Islander populations are also generally concentrated in a few western counties, though a significant population of people of Marshallese Island descent live in Spokane County in eastern Washington.

 

Washington is home to 29 federally recognized Indian tribes, each with varying populations and land areas. The American Indian/Alaska Native population of Washington State is 140,345 (OFM). There are seven additional tribes, some of which are seeking federal recognition. DOH also works with two urban Indian health organizations and 4 recognized American Indian organizations in the Pacific Northwest.

 

Geographically, the state is divided by the Cascade Range. This results in a notable 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, is in the far southwest of the state, across the Columbia River from Portland, Oregon and part of its recognized metropolitan statistical area. Many residents of Vancouver receive services in Portland. Residents of Clarkston in Asotin County in the southeast corner of the state have a similar dynamic with Lewiston, Idaho, across the Snake River.

 

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 consists of the Olympic National Park, which is designated wilderness, isolating the Pacific Coastal 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 less population density than Western Washington, with two major population centers: Spokane, the state’s second-largest city, and its metropolitan area, which includes Spokane Valley, the tenth-largest city; and the Tri-Cities metropolitan area, comprising Richland, Kennewick, and Pasco in Benton and Franklin counties.

 

Washington has a highly diversified economy. It is a leading national producer of agricultural commodities, including apples, pears, wheat, milk, potatoes, hops, asparagus, berry crops and forest products. High-growth industries also include aerospace, clean energy technology, information and communication technology, online sales, life science/global health, maritime, and military/defense sectors. It has many leading research Universities including the University of Washington in Seattle and Washington State University in Pullman. It is the most foreign-trade-dependent state in the United States.

 

Washington’s seasonally adjusted unemployment rate in March 2022 was 4.2%, compared to 5.8% in March 2021. Among the industries gaining the most jobs in the prior month were professional and business services (2,300), leisure and hospitality (1,400) jobs, information (1,400) and construction (1,300) jobs. The leisure and hospitality sector disproportionately employs women and lower income workers. Retail trade, another sector which disproportionally employs women and lower income workers experienced the greatest loss (-1,000) jobs over the prior month (Washington Employment Security Department, Monthly Employment Report).

 

Health Status of Maternal and Child Populations in Washington State

The Needs Assessment Update and State Action Plan Narrative by Domain sections of this application and report include relevant data and discussion about the state’s maternal and child population and health status.

 

For most maternal and child health outcomes, rates of poor outcomes in Washington are lower than national rates. However, we see significant differences as we examine data by race and 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).

 

In July 2022, 2,219,770 people in Washington had access to Medicaid services, including 903,756 children under age 19. HCA contracts with managed care organizations to provide physical and behavioral health care services.

 

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 higher in rural areas of the state. Some mortality rates are also significantly higher, including the overall mortality rate, rates for young people (ages 1 to 24), and rates for deaths from transportation accidents, suicide, and diabetes. Many factors may contribute to these poorer outcomes, including geographic isolation and decreased access to care, lower socioeconomic status, and older age. Disparities in health outcomes for different populations have been amplified by the effects of the COVID-19 pandemic with the older population, communities of color and individuals with underlying health conditions being disproportionally affected.

 

COVID-19 Pandemic in Washington

Washington state recorded the first officially identified case of SARS-CoV-2 infection in the United States on January 21, 2020. On March 23, 2020, Gov. Jay Inslee issued a stay-at-home order to help to control the spread of the virus. Washington did not see the same degree of infection rates many other states did, in large part due to the “Stay Home, Stay Safe” campaign. Through the remainder of 2020 and early 2021, statewide regulations on public gathering, space capacity limits, and facial coverings changed based on current conditions. The state launched the “Healthy Washington – Roadmap to Recovery” campaign in January 2021, which outlined a phased recovery plan using a regional approach. On June 30, 2021, the state moved beyond this recovery plan to allow for full reopening of services. In April 2022 the indoor mask mandate was lifted. The impact of the April 2022 Federal court decision to strike down Federal mask mandates is still incompletely understood at this time.

 

Washington has experienced over 1,666,000 confirmed cases and 13,238 COVID-19-related deaths as of July 2022. As of April 2022, 81.5% of Washingtonians 5 years or older have had at least one dose of vaccine while 74.0% have been fully vaccinated. Disparities in vaccination rates remain, especially in rural communities. Vaccine uptake in younger Washingtonians lags behind older residents. Strategies in our statewide vaccination efforts to address these disparities are continually evolving.

 

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 Native Hawaiian or Pacific Islander communities’ especially hard hit. DOH surveys infection rate, recovery rate, hospitalization rate, mortality, and vaccination by race/ethnicity, and reports on the disparate impact to communities of color. Updated data and analysis are available on the DOH COVID-19 website; an example report is COVID-19 Morbidity and Mortality by Race, Ethnicity and Spoken Language in Washington State.

 

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. It is comprised of four main sectors: The State Board of Health, local health jurisdictions, the state Department of Health, and the tribal health system. 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 to extend program reach into communities.

 

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. In accordance with this philosophy, 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 to form a joint district. Board of health members are often county commissioners or council members, but the boards may include other elected or nonelected officials, as long as the majority are elected officials.

 

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.

 

Most of the 29 federally recognized Indian tribes in Washington provide public health and health care services. While some members, especially those not living on tribal lands, seek and receive care outside of tribal services, those services remain available 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. The Washington State Board of Health made up of ten members appointed by the Governor, sets the rules governing public health in the State of Washington. The SBOH is also responsible for drafting public health administrative code for the 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 help ensure a safer and healthier Washington by:

 

• Working to improve health through disease and injury prevention, immunization, and newborn screening.
• Providing health and safety information, education, and training so people can make healthy choices.
• Promoting a health and wellness system where we live, learn, work, play, and worship.
• Addressing environmental health hazards associated with drinking water, food, air quality, and pesticide exposure.
• Protecting people by licensing health care professionals, investigating disease outbreaks, and preparing for emergencies.
• Ensuring equity is prioritized in all we do

 

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

 

Strategic Plan

DOH has adopted an approach to promote equity and optimal health for all. This is the agency’s vision for how to best promote health in the state. It’s approach to acting on this vision, its mission, is to collaborate and work with others in innovative ways to achieve the goals of protecting and improving the health of all people in Washington state.

 

The DOH Strategic Plan is available online. The strategic plan focuses on making four foundational transformations. First is incorporating an outward mindset approach to create an organizational culture that values the humanity of people and focuses on achieving agency objectives in ways that are helpful to employees, partners, and the general public in achieving theirs. Second, on how funding of work is aligned with public health priorities set through inclusive processes. Third, by fostering data sharing, integration and analysis to support improved health outcomes. Fourth, creating a diverse and inclusive workplace that engages with underrepresented communities, and respects their agency, to ensure equity in access to services, opportunities, and information.  The agency is currently revising its strategic plan, which will be finalized by 2023.

 

DOH is working to incorporate Culturally and Linguistically Appropriate Services (CLAS) across all programs. This includes adopting internal policies to improve CLAS compliance, staff training, development of resources and tools, and creating 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.

 

The Governor recently established the Office of Equity which is focused on “everyone in Washington having full access to the opportunities, power, and resources they need to flourish and achieve their full potential and there is equity and justice for all, for the next seven generations and beyond.” The Office of Equity is helping cabinet state agencies to shift our systems and processes to be more embedded in principles of equity. DOH is charged in the coming years to create pathways for communities to direct more of our work and to diversify our workforce.

 

Healthier Washington

Washington has been implementing the Healthier Washington initiative, a Medicaid Transformation project, for almost a decade.  At the time of this report, the Health Care Authority is seeking to reauthorize its Healthier Washington initiative, which has been adapted to strengthen a focus on care coordination to meet the social determinants of health.  The Accountable Communities of Health continue to serve as regional hubs for community-clinical linkages and leaders in value-based purchasing.

 

 

 

Dismantling Poverty

In 2017, Governor Inslee established a statewide Poverty Reduction Workgroup, which was tasked with developing a 10-year plan to dismantle poverty in Washington State.  The resulting plan contains several systems level recommendations, including health-focused investments, critical to undermining the legacy of poverty in our communities.  Every cabinet state agency has committed to investing in this plan, including the DOH.  There are important links to the maternal, child, and adolescent health work in our state.

 

CHW Workforce Development

The COVID-19 Pandemic has increased the staff recruitment and retention, and workforce development challenges. The Department of Health has significantly increased its staffing to respond to COVID-19 related needs. This has had multiple trickle-down effects on all programs, including Title V. Many staff members have been activated for temporary incident management and response assignments, taking them temporarily away from their regular work. In addition, as new response and recovery teams have been developed, some staff members have chosen to move into long-term COVID-19 project positions, leaving six Title V position vacancies. However, COVID-19 response has also offered opportunities for many staff members to learn more about the specific needs of the state’s maternal and child populations and practice new skills in response.

 

The total number of DOH full-time equivalent (FTE) positions funded by MCHBG federal funding is 18.79 FTE. This represents 40 to 45 individuals, as most positions are funded from multiple sources. This is an increase from last year’s level of 17.76 FTE (portions of 40 positions).

 

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 Spokane near the Idaho border. There are 93 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 (24 beds or less), seven rural hospitals (49 beds or less) and 120 rural health clinics. In 2020, DOH provided licensing and regulation of 11,288 health care facilities and 423,567 health care providers, including physicians, nurses, dentists, pharmacists, emergency medical technicians, mental health counselors, and other health care 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. Independently elected board members guide public hospital districts.

 

Three are dedicated children’s hospitals, located in Seattle, Tacoma, and Spokane. In addition to the many other hospitals that see pediatric patients. Over 1,100 pediatric health care providers practice in the state. The Washington Academy of Family Physicians reports approximately 3,700 family physician members in the state.

 

Nineteen community nonprofit 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 meeting needs specific to its community.

 

National Accreditation

One element of DOH’s commitment to excellence and continuous improvement is maintaining accreditation by the Public Health Accreditation Board (PHAB). DOH was one of the country’s first PHAB accredited public health departments, 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 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 the state’s Title V Maternal and Child Health Director. Washington’s Title V Children with Special Health Care Needs Director position is also within OFCHI. Organization charts are included in the Appendix. Additional information about how Washington’s Title V program is organized, and how our work is directed and supported by the agency, is included in the State Title V Program Purpose and Design section.