Community Context 

The “Volunteer State” is a largely rural Appalachian state with a few metropolitan centers distributed across its three geographically, demographically, culturally, and politically distinct “Grand Divisions.” 

Overall, Tennessee’s population leans heavily White, with smaller Black and Latino populations. Memphis is unique in that 64% of the population is Black. 

Historically, Tennessee had a strong agricultural economy and agricultural industries are still prominent in some of the state’s rural communities. The state has a strong manufacturing sector as well. In urban centers, healthcare systems, information technology, and financial services are key economic drivers. The music industry is important economically and culturally—particularly bluegrass and roots, country, blues, and jazz. 

Tennessee is a politically conservative state, with Republicans controlling the governor’s office and both legislative branches since 2011. Governor Bill Haslam—who explicitly prioritized education and chronic disease prevention during his tenure—was replaced by Governor Bill Lee in 2018. Governor Lee ran on a “pro-business” platform, and education and infrastructure dominated his budget priorities for 2022. At the local level, politics is largely divided along urban-rural lines, with urban communities leaning more heavily Democratic. 

TennCare, the state’s Medicaid system, has not been expanded beyond recent expansions for the behavioral health safety net, for pregnant and post-partum women, and for dental healthcare. 

Chronic disease prevention has dominated the health agenda in Tennessee as the state struggled with high rates of obesity and tobacco use. The opioid crisis has had a major negative impact on the state’s health and economy, and addressing it has become a priority. 

Tennessee faces an aging population and increasing challenges with access to healthcare due to a lack of transportation, few healthcare facilities, and provider shortages. Over the past five years, hospital closures, mergers, and the pandemic have further constrained access.

Community Actions

Tennessee’s Journey to Promote Health, Well-Being, and Equity

Five years into the Sentinel Communities Surveillance Project, Tennessee’s capacity to address health and well-being comes from an assemblage of state and local departments and agencies, along with healthcare delivery systems and related organizations. Tennessee has largely focused on chronic disease prevention in its statewide health promotion efforts. The state has made improvements in mental health services in the past five years. Connecting health to other goals, such as livability and prosperity, has led to success in engaging cross-sector partners in activities. There have been slight shifts in how people think about and approach health: A focus on chronic disease has waned somewhat among some sectors, and there are signs that the idea that individuals are responsible for their own health has been solidified. Increasing attention has been paid to mental and behavioral health and the social determinants of health—including an ongoing prioritization of education and economic well-being. While on the surface it appears that Tennessee’s approach to health equity remains cautious since 2017, stakeholders have honed their communications strategies, making progress toward procedural changes that may have equity impacts.

Lessons Learned: Where is Tennessee Five Years Later?

Tennessee is illustrative of many communities experiencing challenges with promoting health at the state level in a politically fraught environment. Over the past five years, the state has experienced increasing health and well-being concerns—from the opioid epidemic to the COVID-19 pandemic—and has responded with mixed success. State agencies continue to execute their missions in creative and collaborative ways; and advocacy organizations and nonprofits have tirelessly worked to expand access to services. Market forces and a resistance to accepting government intervention have continued to challenge the state’s rural communities, particularly in the wake of the pandemic. 

Local communities in the state are heavily reliant on community and faith-based organizations to help fill gaps in the safety net. While some progress has been made to increase eligibility for health services at the state level, these organizations will continue to be a key element in the state’s efforts to promote health. Health equity remains a politically charged topic, but creative approaches across stakeholders have elevated topics like post-partum healthcare and mental healthcare access among state leaders. Tennessee’s journey may be informative to other communities who have been challenged by a resistance to government intervention in health and a politicization of health and equity topics.

Tennessee is led by highly capable state agencies that bring diverse partners onboard to engage in health promotion. The state is home to nonprofit organizations that support health promotion efforts. However, political polarization has hamstrung many organizations and years of advocating for policy change have led to burn-out. Rural communities continue to experience vulnerability as they struggle with health challenges, lack of economic opportunity, and poor access to services.

Facilitators:

  • Innovative state agencies engage local partners to ensure buy-in 

  • Advocacy organizations and safety net providers support community members experiencing vulnerability

  • Data commonly used for decision-making

  • Recent expansion of health care and social services access

Barriers:

  • Political polarization has increased

  • Local organizations struggle to describe their health and equity impacts

  • Government transitions have shifted priorities

  • Rural communities have infrastructure challenges and poor participation in government programs