Demographics, Geography, and Economy
As of April 1, 2022, Washington had an estimated population of 7,864,400. This is an increase of 97,475 people over the prior year and a 1.3% gain, compared to a 0.8% gain the previous year. The highest growth occurred in the five largest metropolitan counties (Clark, King, Pierce, Snohomish, and Spokane), accounting for 67% of the state’s population growth (Washington State Office of Financial Management [OFM]).
The April 1, 2022, population estimate for Washington’s incorporated cities and towns is 5,156,008, an increase of 78,773 people from the prior year. The top 10 cities for population growth, in descending order, are Seattle, Bellingham, Lake Stevens, Lacey, Vancouver, Pullman, Spokane Valley, Tacoma, Ridgefield and Spokane (OFM).
Births in Washington achieved a record high of 90,489 in 2016. In general, they have been trending down since then. In 2021, there were 83,899 births to Washington residents, a 1% increase from 2020's 83,101 births, and a 7% decrease from 2016’s high (Department of Health [DOH] Birth Certificate Data).
In 2022, an estimated 19.8% of the state’s population, or 1.56 million, were female of reproductive age (15 to 44). There were approximately 1.3 million children under the age of 18 in the state, making up 22.8% of the state’s residents (OFM).
Washington is gradually becoming more racially and ethnically diverse especially in major urban population centers. The percentage of state residents identifying themselves as Hispanic or Latino grew from 11.2% in 2010 to 14.5% in 2022, while the percentage identifying as non-Hispanic Asian grew from 7.3 to 10.3%. Non-Hispanic American Indian/Alaska Native residents decreased from 1.3% to 1.2% while non-Hispanic White residents also decreased from 72.7% to 62.9%. (OFM) Increasingly, people giving birth identify themselves as more than one race on their infant’s birth certificate, with that category increasing 28 percent since 2012 (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 absolute 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, and 7 non-federally recognized tribes. In 2022, the American Indian/Alaska Native population of Washington State was 92,672 (OFM). The state has two urban Indian health organizations and 4 recognized American Indian organizations in the Pacific Northwest.
Geographically, the state is divided by the Cascade Range, resulting 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 west side of Puget Sound, where seven of the state’s 10 most populous cities are located, including Seattle, Tacoma, Bellevue, Kent, Everett, Renton and Federal Way. 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 southern area east of the Cascades, with the Okanogan Highlands occupying the northern area of Eastern Washington, extending from the Cascades to the Idaho border. 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; 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. Non-agricultural industries include aerospace, clean energy technology, information and communication technology, online sales, life/health sciences, maritime, and military/defense sectors. The University of Washington in Seattle and Washington State University in Pullman serve as research institutes for the state. It is the most foreign-trade-dependent state in the United States according to the Washington International Trade Association.
Washington’s seasonally adjusted unemployment rate June 2023 was 3.8%, compared to 3.9% in June 2022. Over the prior year Washington State added an estimated 117,900 jobs. From May 2023 to June 2023 total nonfarm employment increased by 11,900 jobs. Industries gaining the most jobs were leisure and hospitality (8,900), education and health services (4,600), government (3,100), construction (1,700), financial activities (1,000) and professional and business services (500). Retail trade, a sector which disproportionally employs women and lower income workers experienced the greatest loss (-2,800) jobs over the prior month. (Washington Employment Security Department, Monthly Employment Report).
Health Status of Maternal and Child Populations in Washington State
For most maternal and child health outcomes, Washington ranks well compared to national rates. However, we see significant differences as we examine data by race and ethnicity, household income, education, and place of residence. Among adults, in general, individuals from minority racial/ethnic populations, those with lower household income, less than a high school education, and/or living outside of urban areas are less likely to report “good” to “excellent” health (Behavioral Risk Factor Surveillance System).
In February 2023, 2,295,654 people in Washington had access to Medicaid services, including 916,702 children under age 19. HCA contracts with managed care organizations to provide physical and behavioral health care services.
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 general indoor mask mandate was lifted. In April 2023, the last statewide mask mandate was lifted.
As of July 2023, Washington has experienced over 1,968,000 confirmed cases and 15,939 COVID-19-related deaths, while 79.3% of Washingtonians 6 months or older have had at least one dose of vaccine and 71.7% have completed the primary series (WA COVID-19 Data Dashboard). Disparities in vaccination rates remain, especially in rural communities. Vaccine uptake in younger Washingtonians tends to lag 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/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.
DOH Transformational 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 Transformational Plan is available online. The plan focuses five foundational Priorities.
- Health and Wellness: Supporting all Washingtonians’ opportunity to attain their full physical, mental and social health and wellbeing potential.
- Health Systems and Workforce Transformation: Assuring that all Washingtonians are well served in health ecosystem that robust and responsive and at the same time promoting transparency, equity and trust.
- Environmental Health: Ensuring a broad range of health environments; natural, built and social.
- Emergency Response and Resilience: All Washington communities have the information and resources they need to build resilience in the face of myriad public health threats and are well-positioned to prepare for, respond to, and recover from emergencies and natural disasters.
- Global and One Health: All Washingtonians live in ever-connected environments that recognize and leverage the intersection of both global and domestic health as well as the connections of humans, animals, and the environment.
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.
In the last biennium, 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 working towards implementing the Pro-Equity Anti-racism framework, an expectation of all cabinet agencies. This framework involves beginning with a baseline equity assessment and building a strategic action plan from that baseline.
Healthier Washington
Washington has been implementing the Healthier Washington initiative, a Medicaid Transformation project, for almost a decade. The Health Care Authority received a five-year renewal of the Medicaid Transformation Project, which focuses on expanding coverage and access to care, ensuring people receive the right care, advancing whole-person primary, preventive and home and community-based care, and accelerating care delivery and payment innovation focused on health-related social needs.
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.
Title V Workforce
The total number of DOH full-time equivalent (FTE) positions funded by MCHBG federal funding is 18.72 FTE. This represent about 43 individuals, as most positions are funded from multiple sources. This is about the same as last year’s level of 18.79 FTE. We were pleased to have Alex Padilla join the Title V team as the Acting Deputy Director of the office, which includes oversight of the management of MCHBG budget and expenditures.
Health Care Infrastructure
Most of the health care delivery system in the state is 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), eight rural hospitals (49 beds or less), 80 Federally Qualified Health Centers and 127rural health clinics. Currently, DOH provides licensing and regulation of approximately 11,000 health care facilities and 463,000 health care providers, including physicians, nurses, dentists, pharmacists, emergency medical technicians, mental health counselors, and other health care professionals. https://doh.wa.gov/about-us/programs-and-services/executive-office-prevention-safety-and-health/health-systems-quality-assurance
Washington has 56 public hospital districts, which are local government entities that run hospitals, clinics, and home health services. Nearly half of all hospitals are part of Public Health Districts. Forty-four districts have hospitals, the others provide other services such as organizing emergency medical services, providing urgent care services and nursing homes. Often, they provide the only access to such services in isolated areas. Independently elected board members guide public hospital districts. The Association of Washington Public Hospital Districts includes this information on their website.
There are three dedicated children’s hospitals, located in the three major urban centers of Seattle, Tacoma, and Spokane. Many other hospitals see pediatric patients, especially for less specialized care. Over 1,200 pediatric health care providers practice in the state according to the Washington Chapter of the American Academy of Pediatrics. The Washington Academy of Family Physicians reports, on their website, approximately 3,950 family physician members in the state.
In relation to maternity services access in rural areas of the state, only 41 percent (15 of 39 hospitals) of Critical Access Hospitals (CAHs) offer obstetrical labor and delivery services. Of the 15 CAHs that do offer labor and delivery services, five deliver fewer than 100 births per year. Laboring mothers may lack the transportation to drive a longer distance to a hospital with L&D services, or face delivering in an Emergency Department. On average it is 34 miles to the nearest labor and delivery service for those communities that lack OB L&D services in the local CAH.[1] Of the seven larger rural hospitals in WA, one, Astria Toppenish, closed L&D services this past year. In total, Washington has 54 hospitals that provide labor and delivery services.
Eighteen community nonprofit and hospital-based neurodevelopmental centers of excellence provide therapy and related services to young children with neuromuscular or developmental conditions. 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. The department will be pursuing PHAB reaccreditation in the coming year.
Title V in DOH
The Title V program is 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.
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