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Read about: “It’s as big a problem as the opioid epidemic.”

Sit down for this: Tennessee didn’t score in the bottom five, or even bottom 10, on the Commonwealth Fund’s latest health system scorecard — but it is still ranked in the fourth quartile. 

Improvements in measures such as access and affordability as well as disparities, specifically, sent Tennessee up five slots in the latest ranking. The 2018 Scorecard ranked the state 40th out of 50 states and Washington, D.C.

The state saw fewer adults in 2016 foregoing care due to cost compared to 2013 and a 6 percent decrease in the number of uninsured. There was also an increase in the number of diabetic adults who received an HbA1C test —which is key to monitoring the disease.

Yet, the scorecard compares 2016 data with that from 2013, so the progress could backslide in future assessments.

There are a number of changes to the Affordable Care Act unfold, including the introduction of additional short-term plans and the repeal of the mandate, that could impact the number of people have insurance or influence costs.

Looking ahead, Tennessee will continue to tackle unwieldy and complicated problems which will take a variety of effort from the public and private sectors — not to mention effort and action by individual people — to improve.

»See the scorecard.

Among the Southern states, Tennessee was one of the ones that made a lot of improvements in both rank and performance, said David Radley, senior study director. Oklahoma, for instance, saw some improvement in performance but not in rank.

Radley brought up a few things about Tennessee that stood out to him:

Affordability

The number of people with high out of pocket costs, which doesn’t include insurance premiums, decreased from 22 percent to 17 percent.

And the number of people without insurance — an almost necessary card to gain entry to most types of preventive or speciality care, decreased to 14 percent from 20 percent.

There are forces working against affordability, such as rising deductibles for people with employer-sponsored coverage as well as higher participation in individually purchased plans.

The new report looks at 2016 data and compares against a baseline from 2013, so recent years aren’t reflected. The percentage of people with high out-of-pocket costs may begin to rise as data factors in the growing number of high deductible plans, Radley said.

Tennesseans have seen deductibles in employer-sponsored plans surge from from 2002 to 2016, according to the Sycamore Institute.

And it remains to be seen how repealing the individual mandate and paving the way for more short-term plans impacts both people’s spending as well as those with insurance.

“It will be interesting the next time we look at this particular measure if we see them go up,” Radley said.

The scorecard, a decade old, is annual but measures change to capture trends or issues that are bubbling up.

This scorecard is generally comparable to the 2013 scorecard, making it a strong indicator of how some measures changed due to the Affordable Care Act, said Radley.

From 2013 to 2016, the number of adults who reported skipping care because of cost fell from 18 percent to 12 percent, which, Radley said, is a big decrease.

»Explore the data.

Mental Health

This scorecard added two mental health measures, filling a “big gap in the scorecard series,” said Radley.

One of the scorecard’s new indicators is a measure of death from despair, including suicide, alcohol and drug use.  

Over the last three years, the rate of increase in deaths from despair in Tennessee increased 17.7 percent. By and large, that’s attributable to opioids, Radley said, and it’s a big problem everywhere. The deaths could be accidental or intentional.

“We know, from just being awake really (in recent years), that this increase is coming from opioids,” he said.

One of the state’s indicators that worsened the most was the number of adults with a mental illness who reported an unmet need for treatment, which increased from 16 percent from 2009-2011 to 20 percent from 2013-2015.

Radley isn’t sure what drove this increase, whether it was a change in access or had more to do with increased awareness of mental health problems due to the coverage of the opioid abuse problem.

That this area is a low point for Tennessee should not be a surprise given the rate of opioid abuse and the record number of suicides in 2015, particularly among men, as analyzed by the Tennessee Suicide Prevention Network using state data.

Vaccines

What stood out to Radley is that Tennessee has a low score for disparity among adults who receive flu vaccinations and people over 65 years old who get a pneumonia vaccine.

That’s seemingly a good thing — low rates of disparity is usually a highlight. But, the low score for disparity means that Tennesseans, no matter the income level, are getting fewer vaccinations than many across the country.

“This measure is bad for people in Tennessee regardless of what income level you’re at,” Radley said.

Obesity

The state ranked last, at 51, for the number of children who were obese, and ranked at 47 for the number of adults who were obese in 2016.

The rise in obesity isn’t limited to the South — although Tennessee’s region has a higher baseline than other parts of the country, said Radley.

The best performing states in the U.S. see an obesity rate among adults of about one in four. While lower performers are near the 40% percent mark. Even Hawaii, historically a state with lower levels of obesity, saw its population get larger.

There was a national effort to curb smoking and Radley would like to see a national effort to change how people think about and access food.

“It’s as big a problem as the opioid epidemic. We need to address both. Both are critical,” said Radley. “The problem really is a national one.”

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