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 percent gain, compared to a 1.5 percent gain the previous year. For the fourth year in a row, the highest growth (over 70 percent) occurred in the five largest metropolitan counties (Clark, King, Pierce, Snohomish, and Spokane). (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 high of 90,489 in 2016, they have been trending down again. In 2019, there were 84,918 births in Washington, a slight decrease from 2018's 86,047 births. (Department of Health [DOH] Birth Certificate Data)

 

In 2019, an estimated 19.5 percent of the population, or 1.47 million, were female 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. (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 or Latino grew from 8 percent in 2000 to 13.5 percent in 2020, while the percentage identifying as Asian grew from 5 to 9 percent. (OFM) Increasingly, mothers identify themselves on their infant’s birth certificate as more than one race, with that category increasing 40 percent since 2010. (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 in central and eastern Washington, which include large agricultural areas. However, the largest number of Hispanic or Latino people are in the populous western Washington counties. Black or African American, Asian, and Native Hawaiian or other Pacific Islander populations are also generally concentrated in a few western counties, though a significant population of Marshallese people 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, is located 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 makes up 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 low population density, 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, 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. It is the most foreign-trade-dependent state in the United States.

 

Washington’s seasonally adjusted unemployment rate in April 2021 was 5.5 percent, compared to 16.3 percent in April 2020. Before the COVID-19 pandemic, the unemployment rate was at a low 3.8 percent in January 2020. Employment spiked in June 2020 after the lifting of some COVID-19 restrictions, and continued to make gains through the summer of 2020. In the fall and winter, employment growth slowed, turning negative in December, but returning to relatively strong growth in February, with 29,600 jobs added, and March, with 28,100 jobs added. It tapered off a bit in April, with 11,200 jobs added. From March to April 2021, employment increased in eight major industries, decreased in four, and remained steady in one. Among the industries gaining the most jobs were leisure and hospitality, 8,100 jobs, and education and health services, 1,300 jobs. Both of these sectors disproportionally employ women and lower-income workers, especially in leisure and hospitality. Professional and business services experienced the greatest decline, losing 3,400 jobs in that period (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 similar to or 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).

 

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.

 

 

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.

 

Washington experienced over 424,000 confirmed cases and over 6,000 COVID-19-related deaths as of July 20, 2021. By July 14, 2021, 70 percent of Washingtonians 16 years or older had initiated vaccination against COVID-19. Disparities in vaccination rates remain, with communities of color, low-income, and rural communities lacking full access to vaccines. 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 other 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.

 

COVID-19 transmission is highest among health care workers; retail trade workers; manufacturing and food production workers, including those who work in produce and meatpacking plants; and seasonal workers in congregate living spaces. With the cost of housing being an issue even prior to the COVID-19 pandemic, there is growing concern that individuals and families who have been out of work and have fallen behind on rent may face skyrocketing rent increases or eviction when current eviction moratoriums end. Lower-income people and communities of color are at a disproportionally higher risk for this form of homelessness. Schools and educational programs, home visiting programs, and many in-person support services for families are still impacted as well.

 

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 to extend program reach into communities.

 

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.

 

Most of the 29 federally recognized Indian tribes in Washington 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 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.

 

A visual portrayal of DOH’s programs and some key facts are 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 strategic plan focuses on making four foundational transformations in the following areas:

 

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

 

DOH is working 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.

 

Healthier Washington

Washington 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 was the blueprint to transform the statewide health care delivery system to achieve better health, better care, and lower costs. The overarching goals were to improve how services are paid for 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 was the state’s effort to lead strategic changes within Medicaid, allowing for testing of new and innovative approaches to providing health coverage and care. The transformation sought 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 state innovation models grant ended in 2019, and the Medicaid transformation work continues through 2021, continuing the vision of Healthier Washington.

 

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 to better integrate physical and behavioral health care, and to link clinical care with other community services, the collective, multisector 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 also sought to transform our health system through workforce innovation, including 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. DOH is continuing work to implement the recommendations included in this report.

 

Also related to the Healthier Washington initiative, the state Legislature passed Engrossed Second Substitute House Bill 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 similarly 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:

 

• Immunizations
• Primary Care and Prevention
• Behavioral Health
• Effective Management of Chronic Illness
• Ensuring Appropriate Care – Avoiding Overuse
• Effective Hospital-Based Care
• Opioid Prescribing
• Washington State Health Care Spending

 

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 and include current work, emerging issues, health equity data and recommended strategies.

 

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 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. Public hospital districts are guided by independently elected board members.

 

Three hospitals are dedicated children’s hospitals, located in Seattle, Tacoma and Spokane; these are 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 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 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.

 

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, and 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.