The bottom line: Seattle’s hospital hill has its own map — Harborview, Swedish, and Virginia Mason are covered there. This is the rest of King County: the part run not by famous systems but by four public hospital districts, two voter-approved tax levies passed in 2025, and a ring of suburban campuses from Bellevue to Enumclaw that most metro coverage treats as footnotes. In a single year, King County voters raised the EvergreenHealth levy from 14 cents to 50 cents per $1,000 of assessed value and lifted Valley Medical Center’s levy to 75 cents — the first increase that district had asked for in twenty years. EvergreenHealth is building seven operating rooms into shell space inside a hospital that stays open throughout. A 25-bed critical access hospital in Snoqualmie is building an 85,000-square-foot hub with a climbing gym in the same application as its operating rooms. For the facilities, design, and construction teams who work this county, the action is not on the hill. It is in the districts.
| King County beyond Seattle, at a glance | Figure |
|---|---|
| Public hospital districts | Four — No. 1 (Valley, Renton), No. 2 (EvergreenHealth, Kirkland), No. 4 (Snoqualmie Valley), No. 5 (Vashon). There is no No. 3. |
| The 2025 votes | District No. 2 levy passed Aug 2025 at 60.83% ($0.50 per $1,000 for 2026, up from $0.14). District No. 1 levy passed Nov 2025 at 57.53% (up to $0.75, about $42 million a year). |
| Largest active suburban build | EvergreenHealth’s 2-Silver surgery expansion in Kirkland — about 73,000 square feet of shell build-out; the district’s state application budgets $170 million all-in, its builder publishes $115 million. |
| The exception | Overlake in Bellevue — 349 licensed beds, the Eastside’s anchor — is not a district at all. It has been a MultiCare member since October 2024. |
| The smallest district | Vashon (No. 5): a hospital district with no hospital, funding primary care through a partnership instead. |
Four districts, and the one that never was
Washington’s public hospital districts are municipal corporations under RCW 70.44 — governments, not nonprofits — governed by elected commissioners and funded in part by property-tax levies their voters set. King County’s hospital-district map has four polygons, numbered 1, 2, 4, and 5. The numbering preserves a decision made before 1960: Overlake, in Bellevue, was intended to be Public Hospital District No. 3, but opened as a private nonprofit instead. The Eastside’s largest hospital is the county’s governance exception, and the missing number is still on the map.
District No. 1 is Valley Medical Center in Renton, the oldest and largest public hospital district in Washington. It serves most of Kent, Renton, and Covington and parts of nine other cities across south King County, and its audited financial statements for fiscal 2025 describe a 341-licensed-bed hospital with a Level III trauma program. Valley operates inside the UW Medicine system — but as an independent, community-owned district, and the same audit records a quiet change: Valley is no longer reported as a component unit of the University, and two trustee seats reserved for UW Medicine sat unfilled at the end of fiscal 2025.
District No. 2 is EvergreenHealth in Kirkland, governed by seven elected commissioners, serving a district that covers most of the northern Eastside and, by the system’s count, more than a million residents across north King and south Snohomish counties. District No. 4 is Snoqualmie Valley Health, formed by voters in 1972 along boundaries that roughly match the Snoqualmie Valley School District: a 25-bed critical access hospital, Level V trauma, running an average daily census of about nineteen to twenty patients including swing beds. District No. 5 is Vashon — a hospital district without a hospital. It levies taxes to subsidize primary, urgent, and behavioral-health care delivered through a partnership with Sea Mar, and its 2025 strategic plan builds two reserves: a primary-care reserve funded at $750,000 toward a $1.2 million target, and a capital reserve funded at $500,000 toward a $3 million facility-acquisition target. In February 2026, island reporting described the partnership’s new clinic across from the Vashon IGA Plaza — about 21 exam rooms and six dental operatories — as expected complete by mid-to-late July 2026.
Just as important is what sits outside every district. Overlake in Bellevue, St. Francis in Federal Way, St. Anne in Burien, and St. Elizabeth in Enumclaw are licensed hospitals whose surrounding residents pay no hospital-district levy at all. King County hospital care is a patchwork of tax-backed governments and private nonprofits sharing the same roads — and, increasingly, the same construction market.
The 2025 money: two lid lifts
A public hospital district may levy up to 75 cents per $1,000 of assessed value for operations and maintenance, but raising the rate past the statutory limit factor takes a public vote. In 2025, King County’s two big districts both asked — and both won.
EvergreenHealth went first. On August 5, 2025, District No. 2 voters approved Proposition No. 1 with 60.83 percent of the vote, authorizing a regular levy of 50 cents per $1,000 for collection in 2026 — up from 14 cents levied in 2024. The county assessor’s computed 2026 rate for the district is 0.49639. The district had already sold $39.6 million of bonds in February 2024, structuring debt service to stay under 70 percent of its maintenance-and-operations levy.
Valley Medical Center followed in November. District No. 1’s Proposition No. 1 passed with 57.53 percent, authorizing a maximum regular rate of 75 cents per $1,000 for 2026 — a 46-cent increase the district estimates at about $42 million a year. It was the district’s first levy-lift request in twenty years; the 2005 lift helped fund its South Tower. The stated purposes are operational, not monumental: keep labor and delivery, trauma, emergency, and intensive care running around the clock, and keep the workforce that staffs them. The assessor’s computed 2026 rate is 0.74215. Districts 4 and 5 ran no lid lift in the 2025 results; their computed 2026 rates are 0.25006 and 0.43024. King County voters also renewed the countywide Medic One emergency-medical-services levy that November at 80.70 percent — EMS funding that delivers patients to these hospitals, though not a dollar of it is hospital capital.
Kirkland: surgery built inside a hospital that cannot pause
EvergreenHealth’s active construction program is a study in occupied renovation. The 2-Silver surgery expansion builds out roughly 73,000 square feet of existing shell space for seven operating rooms, six catheterization labs, and one hybrid operating room, with prep and recovery; modernizes about 5,000 square feet of C-section operating rooms under a new rooftop air-handling platform; and renovates about 15,000 square feet on the Blue building’s first level into five endoscopy rooms. The district’s application to the state Project Review Committee budgets the work at $170 million all-in, including $98 million of construction; Mortenson, the GC/CM contractor, publishes a $115 million project cost. Both figures are in print; they are different accountings of the same job, and any team pricing work here should know which one a given conversation is using. Construction runs from October 2026 to substantial completion in September 2027, with NBBJ as designer of record.
The application’s own language is the demand signal: the work sits “within a fully operational hospital,” with patients in the intensive care unit above, the emergency department below, and rooms adjacent at all times. A smaller solicitation tells the same story at $595,000 — an IDF refresh in the Coral Building requiring “uninterrupted patient care, building operations, infection control requirements, and continuous operation of critical hospital systems.” And the district’s next decade arrived as a gift: in September 2026, EvergreenHealth announced a $100 million donation from the Dean Weidner estate — the largest in its history — toward an eight-story patient-care tower. No budget, size, or timeline for the tower has been published; what exists is the gift, the levy behind it, and a district that has now funded its future in public, twice, in thirteen months.
Kirkland’s system also reaches into Redmond, where EvergreenHealth runs a 24-hour emergency department on 161st Avenue Northeast — not a second hospital, but the east side’s always-open front door, with urgent care upstairs on a shorter clock.
Renton: the phased build, funded in advance
Valley Medical Center’s capital program is smaller than Kirkland’s and more patiently sequenced. Its cancer center is being built in phases on the Renton campus: Phase 1A opened February 3, 2025 — about $15 million of a roughly $60 million program — bringing infusion and immunotherapy, an infusion pharmacy, and the Trapper & Samantha Wellbeing Resource Center, connected by a skywalk the district calls the Bridge of Hope. A $6 million Norcliffe Foundation grant followed, directed at Phase 1B, which finishes the floor with oncology and hematology clinics, a multidisciplinary clinic, and a café; the district’s reporting describes Phase 1B as under construction with a September 2026 opening. Phase 2, aimed at late 2027 in the district’s public account, adds radiation oncology and imaging — and is explicitly contingent on fundraising.
The district’s second front is in Covington, where it owns a two-story, 37,550-square-foot medical office building whose first floor is an occupied urgent-care clinic. A September 2026 application proposes to convert that floor into a combined freestanding emergency department and urgent care — new air-handling unit, structural stiffening of the second-floor slab — and to build out about 9,400 square feet of shell above it as a multispecialty clinic. The application’s total budget is $17,961,032, funded from operating capital and property-tax revenue, with construction phased across 2027 and into 2028. It is an application, not an approval. It is also a document worth reading for what it admits: Valley writes that its clinics may remain operational throughout construction, and that before filing its second-ever GC/CM application it studied EvergreenHealth — the district across the county — as the model public-owner. The districts are learning public-works delivery from each other.
The valley: a 25-bed hospital builds a hub
Snoqualmie Valley Health’s expansion is, proportionally, the boldest project in the county. The district broke ground August 22, 2025 on a hub of about 85,000 square feet beside its 25-bed hospital: imaging, immediate care, lab, a retail pharmacy, physical therapy, clinics, and a four-operating-room ambulatory surgery facility — operating rooms that will be licensed as part of the hospital even though they do not physically touch it, which is precisely why the project needed a certificate-of-need application at all. The district’s January 2026 account prices the expansion at $147 million, funded substantially by $130 million in revenue bonds and $17 million in limited-tax general-obligation bonds, with more than 30 new providers and 225 staff expected, and an opening expected in fall 2026.
The certificate-of-need filing makes the case in the language of out-migration: valley residents now travel to Bellevue or Seattle for routine procedures scheduled months out, past a state interchange project — I-90 and SR 18, about 31,000 vehicles a day — that is being rebuilt beside the campus. And the building program refuses the usual separation between clinical and civic: the same application that carries the operating rooms carries a restaurant, meeting space, a retail gym, and a climbing gym, with the massing opening toward the wetlands north of the site. In a valley with no café street outside the hospital door, the hospital is building the street.
The private map: south county and the second Eastside anchor
South of Seattle, the non-district systems hold the map. Virginia Mason Franciscan Health runs three hospitals down the county’s southern tier: St. Francis in Federal Way, certificate-of-need approved for 148 beds and Level IV trauma; St. Anne in Burien, at 159 licensed beds, also Level IV; and St. Elizabeth in Enumclaw, a 38-bed critical access hospital that counts as 25 beds in the state’s need math, Level V. MultiCare holds Auburn Medical Center — 195 licensed beds, 131 medical-surgical and 58 psychiatric, Level III trauma — and the 58-bed Covington Medical Center, and has asked the state to move a six-bed Level II nursery from Auburn to Covington: a $2.85 million application, still pending, argued on drive times and the newer building’s family-centered design.
On the Eastside, Swedish Issaquah — licensed for 175 beds — has applied for the third time in five years to add adult elective PCI, the scheduled heart-catheter procedures it says are leaking out of the King East planning area at roughly a third of all PCI volume and closer to half of outpatient volume. The application carries a capital cost of zero: the rooms and the emergent program exist; what is being requested is permission. And Overlake, the would-be District No. 3, completed its six-year Project FutureCare renewal in January 2023 — a 240,000-square-foot tower, a childbirth center with a Level III nursery, a 14-bed behavioral-health unit — and then changed owners without changing address: since October 1, 2024, MultiCare has been Overlake’s sole corporate member, with Overlake’s own governance, management, and foundation left in place and its 349 beds anchoring MultiCare’s new North Sound region. Two of the county’s three system flags changed at the governance level in the past three years. None of it shows from the street.
The amenity economy: where King County families actually eat
Read the visitor pages of these campuses together and a pattern emerges: a named daytime food hall, a branded espresso operator, a list of hotels the hospital does not run, and a thin all-night layer underneath.
Overlake runs three food counters — Stanzas Café, serving Starbucks by a fireplace in the north lobby; the Atrium Café, with Starbucks, a Boar’s Head deli, and a salad bar, open daily into the evening; and a Beecher’s Handmade Cheese café by the main entrance — inside a campus whose renewal added a 6,500-square-foot interior courtyard and a single front door two blocks from the Wilburton light-rail station. Its lodging page hands families an unendorsed list: the Hilton Garden Inn and Residence Inn downtown, the Hilton Bellevue, and properties stretching toward Redmond. EvergreenHealth’s Café 128 serves seven stations and about thirty entrées a day, while Whidbey Coffee runs three satellite delis, including the espresso bar at the cancer center’s entrance; its lodging list starts with a Comfort Inn six-tenths of a mile away and includes Madison House, across the street — furnished apartments that serve three meals a day, the closest thing in the county to a purpose-built family residence. Valley’s Trendz Café anchors three espresso bars, one of which — the Legacy Espresso Bar, between surgery and the emergency department — never closes: twenty-four hours, seven days, the one all-night coffee counter in this county’s hospital record. Its cancer center bakes the amenity into the capital program, pairing a family resource center with Phase 1A and a café with Phase 1B.
Swedish Issaquah’s Café 1910 runs a menu without fryers or soda machines — Wood Stone oven pizza, a wok, made-to-order salads — beside a Starbucks and a gift shop selling local craft. St. Anne’s cafeteria feeds Burien from a fourth floor with three hot-meal windows a day and free parking below. St. Francis pairs its Rose Garden Café with an actual rose garden and a chapel that stays open all night. And in Snoqualmie, the amenity layer is not a tenant list at all — it is a line item in a construction budget, restaurant and climbing gym included, because the alternative was to build a hospital that assumes families will drive somewhere else. After the counters close, the county’s families rely on the Renton espresso bar, emergency-department vending, and the two 24-hour emergency departments in Redmond. Evening restaurant service inside these hospitals remains the exception, and every campus that has closed that gap has done it deliberately, as a design decision with a budget line.
Two authorities for every project
Every substantial hospital project in King County answers to two reviewers. The Department of Health’s Construction Review Services must approve construction documents — projects of $500,000 or more need a presubmission conference by the halfway point of design — and the submittal must include an infection-control risk assessment and an interim life-safety plan. That state review sits on top of, never instead of, the local building permit. Then certificate of need gates the service itself: detached operating rooms in Snoqualmie, a six-bed nursery crossing between two licenses in southeast King, elective PCI in Issaquah at zero capital cost. The planning-area line between King East and Southeast King is the regulatory geography that decides whose migration numbers count.
The energy clock is also already running. Washington’s Clean Buildings Performance Standard puts hospital campuses on a square-footage calendar — reporting deadlines of June 1, 2026 for the largest buildings, 2027 for the middle tier, 2028 for the rest — against a climate-zone 4C hospital energy target of 215. The standard counts the hospital activity’s gross area including its cafeterias and retail: the amenity square footage is inside the compliance math whether it was designed to be or not. And the code stack under all of it is municipal: unincorporated King County enforces the 2021 state codes, the wildland-urban interface code is not in effect in the county — the foothill fact for Enumclaw and Snoqualmie — and a campus in Bellevue, Kirkland, Renton, or Federal Way answers to that city’s code and that city’s stormwater manual.
What this means for design and construction teams
The corridor’s client is often a government. Districts 1 and 2 buy major construction through Washington’s GC/CM statute, with elected commissioners, prevailing wage, public bid openings, and a debt-service test measured against the maintenance-and-operations levy. A design contract written for a private nonprofit owner will miss the commission meeting where the project is actually decided. The owners here say so themselves: the two big districts are explicitly copying each other’s public-works practice, and both name infection control and continuous operation as the delivery constraint — EvergreenHealth’s solicitation documents put it in writing down to a $595,000 IT refresh.
The work itself is shell space, roofs, and clinics that stay open: operating rooms built into a Kirkland shell floor, a new air handler set on an existing roof, an occupied urgent-care clinic in Covington converting into an emergency department underneath a shell build-out, operating rooms in Snoqualmie licensed across a parking lot. Firms already named in the owners’ own filings — NBBJ designing in Kirkland and drawing in Renton, Mortenson building in Kirkland, Sellen in Renton’s first phase, Flourish advising both districts — are the visible bench. The county to the south has its own map (Pierce County’s facility types); this county’s distinguishing fact is that so much of its hospital plant belongs, literally, to its voters.
Frequently asked questions
How many public hospital districts does King County have?
Four: No. 1 (Valley Medical Center, Renton), No. 2 (EvergreenHealth, Kirkland), No. 4 (Snoqualmie Valley Health), and No. 5 (Vashon Health Care District). There is no No. 3 — Overlake in Bellevue was intended to take that number but opened as a private nonprofit in 1960.
What did King County hospital districts ask voters for in 2025?
Both large districts won levy lid lifts. EvergreenHealth’s District No. 2 passed in August 2025 at 60.83 percent, setting a 50-cent-per-$1,000 levy for 2026, up from 14 cents. Valley Medical Center’s District No. 1 passed in November 2025 at 57.53 percent, authorizing up to 75 cents — its first lift in twenty years, estimated at about $42 million a year for 24/7 operations.
Is Overlake a public hospital?
No. Overlake is a private nonprofit in Bellevue. Since October 1, 2024, MultiCare has been its sole corporate member; Overlake’s local governance, management, medical staff, and foundation remained in place. It is licensed for 349 beds and is the Eastside’s anchor hospital.
What is certificate of need deciding in King County right now?
Three suburban applications were pending in the record reviewed for this piece: Swedish Issaquah’s request to add elective PCI, MultiCare’s request to move a six-bed nursery from Auburn to Covington, and Snoqualmie Valley Health’s detached operating rooms — each a service decision, separable from whether the building exists.
Which King County hospital district has no hospital?
District No. 5, Vashon Health Care District. It funds and backstops primary, urgent, and behavioral-health care on Vashon Island through a partnership with Sea Mar, and is building reserves toward acquiring facilities of its own.
Healthcare Facility Hub tracks the standards, surveys, and construction practice behind projects like these — hospital expansion, behavioral health design, ICRA containment, and the codes these buildings are held to. If you work in King County facilities, design, or construction and see something here that needs correcting or sharpening, we want to hear it: talk to the Hub — facility leaders’ corrections make these briefs better, and we credit contributors by name and organization, or anonymously, as they prefer.