National Academy of Medicine

Case Study: Improving Population and Individual Health Through Health System Transformation in Washington State

By Jana Eisenstein and Debbie I. Chang
April 24, 2017 | Discussion Paper

Empowered by federal, state, and community funding, Washington State has been working for years to enact delivery system transformation to improve the health and well-being of its 7 million residents. In fact, in the 1990s Washington State passed legislation offering universal coverage for its residents. But when the individual mandate was repealed just a year after implementation, insurance premiums spiked, and many plans left the state. Then-governor Chris Gregoire shared her state’s lessons with President Barack Obama during his presidential campaign, advising that universal coverage without an individual mandate is a recipe for failure. When the Affordable Care Act (ACA) was signed into law in 2010 with an individual mandate, Washington was already well poised for implementation, having attempted, and learned from, its previous universal coverage experiment.

The health system transformation effort in Washington has evolved since the 1990s and now takes a multipronged approach, especially in the Medicaid program, using a variety of health system improvement strategies. Some initiatives are broad, creating cross-sector collaborations among Medicaid, providers, public health, and community-based organizations in order to advance population health goals. Others are more targeted, providing preventive services to individual Medicaid enrollees in nontraditional ways.

This case study will highlight the innovative range of options available through Apple Health, Washington’s Medicaid program, to provide upstream and population-level health improvement to its residents statewide. To do so, this paper provides a brief history of Washington State’s health system transformation and the context in which its upstream and population health strategies were developed, as well as an analysis of the accelerators of, and barriers to, success, concluding with a review of lessons learned. It is important to note that while obesity prevention is a major priority for current Governor Jay Inslee, and the Healthier Washington framework includes obesity prevention as a focus area, the initial programs and services described below apply to health improvement more generally, with the expectation that they will be expanded and applied to childhood obesity in the future. Read more >>

The Robert Wood Johnson Foundation awarded the Nemours Foundation a 1-year grant to explore and promote the use of existing Medicaid authority to support prevention. The initiatives described in the companion documents are intended to sustain approaches that link the clinic to community prevention efforts addressing chronic disease, including childhood obesity. This case study is part of a practical resource that will include two additional case studies, a roadmap and other tools for states, and a white paper. Together, these resources bring to light how states have successfully created sustainable financing through Medicaid and the Children’s Health Insurance Program for preventing chronic diseases at both the individual and population levels. The toolkit can help states get started or continue their prevention efforts. These additional documents can be found at  

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Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.