Demographics, Geography, Economy, and Urbanization

 

Tennessee spans approximately 500 miles east to west, 110 miles north to south, and is bordered by 8 other states.  The state, comprised of 95 counties, is geographically, politically, and constitutionally divided into three Grand Divisions:  East, Middle, and West.  East Tennessee, comprised of 35 counties, is characterized by mountains and rugged terrain.  This region contains Knoxville and Chattanooga (the 3rd and 4th largest cities in the state) as well as the "Tri-Cities" of Bristol, Johnson City, and Kingsport located in the extreme northeastern most part of the state near the boarders to Virginia and North Carolina.  Middle Tennessee consists of 39 counties, has the largest land area, and is characterized by rolling hills and fertile stream valleys.  Middle Tennessee is the least densely populated of the three Grand Divisions, yet houses the state’s capitol and largest city.  West Tennessee, bordered by the Mississippi River on the west and the Tennessee River on the east, contains 21 counties.  This region has the smallest land area and is the least populous of the three Grand Divisions, yet contains the second most populous city in the state – Memphis.  Outside greater Memphis, the region is mostly agricultural.

 

Tennessee’s population is estimated to be 6.9 million.  Compared to the United States, Tennessee is less racially and ethnically diverse with a smaller foreign born and non-native English-speaking population.  The state has slightly higher rates of homeownership and health insurance coverage.  However, the state sees slightly worse rates of high school graduates, employment, and poverty.  The tables below compare Tennessee to the US as a whole on many different factors.[1]

 

 

 

 

 

Distressed counties rank among the 10 percent most economically distressed counties in the nation. Each year, the Appalachian Regional Commission (ARC) prepares an index of county economic status for every county in the United States. Economic status designations are identified through a composite measure of each county's three-year average unemployment rate, per capita market income, and poverty rate. Based on these indicators, each county is then categorized as distressed, at-risk, transitional, competitive or attainment. As of state FY 2023, there were 10 distressed, and 32 at-risk counties in Tennessee, representing an increase of 1 distressed and 2 at-risk counties from state FY 2022[2]. 

 

Population Characteristics

 

In Tennessee, there are approximately 1.3 million women of reproductive age (15-44), comprising 20% of the state’s total population in 2021. In 2021, there were 81,709 births to Tennessee residents, translating to a general fertility rate (GFR) of 59.7 per 1000 women aged 15-44. There are an estimated 334,628 Tennessee children aged 0-17 with special health care needs, approximately 22% of the population. Through efforts to advance emergency preparedness, Tennessee used AMCHP’s “Public Health Emergency Preparedness and Response Checklist for Maternal and Infant Health” to calculate estimates of the number of pregnant people (S2-A2), as well as infants and children <5 years statewide, by region, and by county. Using the Centers for Disease Control and Prevention’s “Estimating the Number of Pregnant Women in a Geographic Area: A Reproductive Health Tool,” there are an estimated 62,532 pregnant people in Tennessee at a given point in time, with county ranges between 31 – 10,288. There are 81,188 infants in Tennessee, with county ranges between 47 – 12,674. There are 407,366 children under 5 years in Tennessee, with county ranges between 218 –

64,464. A map of population estimates by county for pregnant people, children > 1 year, and children > 5 years can be found in the Supporting Documents section.

 

Health Status of Tennessee’s MCH Population

 

After two reporting cycles without assessing the overall health ranking of states due to the ongoing challenges related to the COVID-19 pandemic, a special edition of the 2022 Annual Report for America’s Health Rankings welcomed their return. Seeing no change from 2019, Tennessee continued to rank 44th in the nation for overall health. Historically Tennessee has ranked in the bottom ten states for this overall measure[3]. Unfortunately, the state ranks poorly on several key MCH, chronic disease, and social determinants of health indicators. From 2021 to 2022, rankings for the following indicators remained unchanged or declined:

 

• Adverse Childhood Experiences (44th)
• Child poverty (41st)
• Drug deaths (45th)
• E-cigarette use (46th)
• Fruit and vegetable consumption (30th)
• Infant child care cost (33rd)
• Mental distress (46th)
• Multiple chronic conditions (46th)
• Physical distress (46th)
• Physical inactivity (43rd)
• Smoking (47h)Teen births (44th)
• Violent crime (48th)
• Well woman visit (32nd)

 

However, the state noted improvements in the rankings of several key MCH, chronic disease, and social determinants of health indicators, including:

 

• Childhood immunizations (33rd)
• Food insecurity (35th)
• High-speed Internet (40th)
• Low birthweight (36th)
• Obesity (31st)
• Premature death (44th) 
• Preventable hospitalizations (33rd)

 

Additionally, the state continued to rank in the top ten for one of the MCH, chronic disease, and social determinants of health indicators:

 

• High school graduation (6th)

 

Similarly, this is the first time since 2019 that the Health of Women and Children Report, a sub-report of America’s Health Rankings Report, included the overall health rankings of states. Tennessee’s overall ranking slightly improved from 2019 (41st) to 2022 (40th). The overall health ranking of women in Tennessee improved in 2022, jumping up 3 slots to 43rd, and the ranking of children moved down two slots to 37th place[4]. Strengths that were noted, included the low prevalence of asthma among children, a high prevalence of developmental screenings, and a high prevalence of cervical cancer screening. A high prevalence of multiple chronic conditions among women, a high prevalence of adverse childhood experiences (ACEs), and a high prevalence of household smoking were identified as challenges.

 

The 2022 report also highlighted a:

• 39% reduction in the rate of neonatal abstinence syndrome diagnoses at hospital birth between 2016 to 2019,
• 35% increase in the rate of drug related deaths among women ages 20-44 between 2015-2017 and 2018-2020
• 34% increase in the percent of women ages 18-44 reporting frequent mental distress between 2015-2016 and 2019-2020

 

 

State Health Agency Roles, Responsibilities, and Priorities

 

Tennessee’s MCH initiatives are administered by the Tennessee Department of Health (TDH), the cabinet-level public health agency.  The mission of TDH is to protect, promote, and improve the health and prosperity of people in Tennessee.  The Department has a strategic plan that focuses on prevention and access to health and healthcare services. TDH’s new strategic plan development process in currently underway. The existing plan for the Department prioritizes these four prevention initiatives:  tobacco use, youth obesity, substance misuse, and adverse childhood experiences (ACEs).

 

Within TDH, the MCH/Title V Program is administered by the Division of Family Health and Wellness (FHW).  This Division manages the Department’s portfolio of programs and initiatives related to Maternal and Child Health, Chronic Disease Prevention and Health Promotion, and Supplemental Nutrition. FHW is responsible for the programmatic implementation of core public health services within local health departments (i.e., family planning, breast and cervical cancer screening, Children's Special Services, WIC) in addition to health promotion activities (tobacco prevention, lead prevention and case follow up, etc.) as well as management of programs external to the department such as Evidence Based Home Visiting and expanding systems capacity for priorities spanning from perinatal care to diabetes prevention programs.

 

Public health efforts in Tennessee have long been focused on the MCH population.  All the current TDH priorities relate to the MCH population, and TDH is committed to improving the health and well-being of the MCH population across the life course.

 

State Systems of Care for Underserved and Vulnerable Populations

 

As of June 2022, Tennessee has 15 Critical Access Hospitals designated to preserve access to local primary and emergency health services.  These hospitals are located in rural counties with less healthy populations that demonstrate higher rates of obesity, diabetes, preventable hospitalizations, cardiovascular deaths and cancer deaths as compared to state and national benchmarks.  Additionally, these hospitals are located in rural counties with fewer physicians and with a higher proportion of patients who live in poverty and a higher Medicaid population.  They have 25 beds or less and are more than 35 miles from the next nearest hospital.

 

As of November 2022, 92 of Tennessee’s 95 counties are federally designated as either whole or partial-county Health Professional Shortage Areas (HPSAs) for Primary Care (based on either the low-income population or geography).  This is down from 94 counties in June 2022.  Ninety-three of the state’s 95 counties are designated as federal Dental HPSAs and all 95 counties are designated as federal Mental Health HPSAs.  Sixty-one of the state’s 95 counties are designated as either whole or partial-county Medically Underserved Areas (MUA).  TDH facilitates state funding for Federally Qualified Health Centers as well as Faith and Charitable Care Centers has strong relationships with both the Tennessee Primary Care Association (FQHCs) and Tennessee Charitable Care Network (faith-based clinics) which has facilitated grants and population health planning among the entities.

 

The distribution of primary care providers varies across the state.  A map with health resource shortage areas for obstetrics and pediatrics can be found in the Supporting Documents section.  As of January 2023, TDH Division of Health Licensure and Regulation[5]:

 

 

The most pressing primary care workforce shortages in Tennessee are in the field of obstetrics. According to FY22 Female Population of Childbearing Age to Obstetric Provider Ratio Table, among the 95 Tennessee counties, twenty-nine (30.5%) have no obstetric providers, three have patient: obstetric provider ratios greater than 128,777:1, nine have patient: obstetric provider ratios greater than 10,526:1, and 25 have ratios greater than 5,117:1. 

With no closures in FY2021, Tennessee maintained a total of 58 birthing facilities and two birth centers in FY2022. This is, however, down from 68 in 2016.[6] In 2018, 60 Tennessee birth facilities participated in the Center for Disease Control and Prevention’s Levels of Care Assessment tool. For maternal care, there were 5 facilities (8%) assessed as < Level I, 27 (45%) as Level I, 19 (32%) as Level II, 2 (3%) as Level III, and 7 (12%) as Level 4. TDH coordinates the Tennessee Regional Perinatal Centers, which contain five regional centers throughout out the state to assure statewide infrastructure to provide high-risk obstetric and infant care through direct clinical care and consultation (available 24/7), education for community hospitals and providers, and technical assistance to state agencies. In FY2022, 106,931 obstetrical consultations (outpatient), 3,750 NICU follow-up clinic visits, 342 neonatal transports were performed by perinatal center staff and 8,535.3 hours of education were provided throughout the state.

 

Since 2012, there have been 11 obstetric closures, including three full hospital closures and seven obstetric facility closures (Figure 1); of these eleven closures, seven have occurred in rural counties. Of Tennessee counties, 57 (60%) do not have a birthing facility.

 

TDH works closely with TennCare, the state's Medicaid agency. TennCare provides health care for approximately 1.3 million Tennesseans and operates with an annual budget of approximately $12 billion. TennCare members are primarily low-income pregnant women, children and individuals who are elderly or have a disability. TennCare covers approximately 20 percent of the state’s population, 50 percent of the state’s births, and 50 percent of the state’s children.  TennCare is a critical and valuable partner in serving Tennessee’s MCH population. 10 More description of this agency and the partnership between the agencies is found in the description of the Health Care Delivery System in the State Action Plan Narrative Overview.

 

Children's Special Services (CSS, Tennessee’s state MCH/Title V CYSHCN program) is a critical gap-filling program supported by federal and state MCH funds. It serves as both a payor of last resort for Children and Youth with Special Health Care Needs as well as a care coordination entity for these families. Founded in 1919, CSS is governed by state code. While CSS is core to CYSHCN services in Tennessee, CYSHCN priorities for this vulnerable population expand beyond the program to include broad family and stakeholder engagement, particularly in the areas of pediatric to adult transition and patient-centered medical home, as determined by the state needs assessment. CYSHCN staff have also coordinated some efforts at behavioral health integration, though this has largely taken place within healthcare delivery facilities, particularly FQHCs and safety net mental health centers.

 

State Statutes and Other Regulations Impacting MCH/Title V

 

Numerous state laws and regulations impact the operation of MCH/Title V program services in Tennessee.  Many of the laws provide TDH authority to operate programs such as Family Planning, CSS, evidence-based home visiting, fetal infant mortality review (FIMR), child fatality review (CFR), maternal mortality review, or teen pregnancy prevention. Child fatality review and, more recently, maternal mortality review legislation provides funding and legal authority to enhance data gathering to inform action.

 

Some state laws mandate specific activities or services related to the MCH population.  For example, laws mandate that infants receive screening for metabolic/genetic conditions, critical congenital heart disease, and congenital hearing loss.  Others mandate coverage for services such as hearing screening or hearing aids.

 

Other laws provide basic protections for the MCH population. These include Tennessee’s child passenger restraint law (which was the first such law passed in the nation), as well as laws that require prophylactic eye antibiotics for infants, prohibit female genital mutilation, require schools to test for lead in water, and prohibit smoking in most public places.

 

Several laws establish committees that advise TDH on specific programs or services.  These include the Children’s Special Services Advisory Committee (services for children and youth with special health care needs), Perinatal Advisory Committee (perinatal regionalization), and the Genetics Advisory Committee (newborn screening and follow-up).

 

In addition to laws passed by the General Assembly, many programs and services related to the MCH population operate under rules and regulations promulgated by the TDH and approved by the Attorney General, Secretary of State, and Government Operations Committee of the General Assembly. Often these rules contain more detailed information on program operations than the law that established a particular program or service. Examples include rules related to newborn screening, operation of the CSS program, and operation of the child safety fund (funding from child safety seat violations used to fund the purchase of additional child safety seats for distribution in local communities).

 

Several new MCH-related laws were passed during the 2023 legislative session:

 

Tennessee State Employee Leave

 

Public Chapter 216 (SB276/HB324) grants eligible state employees absence from work with pay for up to 6 weeks due to the birth of a child or placement of a child with the employee for adoption. Employees must give thirty-days' notice to the appropriate appointing authority, but if the employee learns of the birth or adoption less than thirty (30) days in advance, the employee can give notice as soon as reasonably possible. In addition, this public chapter requires that leave used by an eligible employee pursuant to this section must not be charged to sick, annual, or other leave the employee may have accumulated. Effective as of July 1, 2023.

 

Local Education Agencies Employee Leave

 

Public Chapter 399 (SB1458/HB0983) requires local education agencies (LEAs) to provide licensed employees 6 paid workweeks for the birth, or stillbirth, of the employee’s child or employee’s adoption of a newly placed minor child. This public chapter defines eligible employees as teachers, principals, supervisors, or other individuals required by law to hold a valid license of qualification for employment in a local education agency and who has been employed full-time with a local education agency for at least twelve (12) consecutive months. Effective as of May 11, 2023.

 

Deaf Mentor Programs

 

Public Chapter 327 (SB0004/HB0435) establishes a deaf mentor and parent advisor program to assist families in implementing bilingual and bicultural home-based programming for young children who are deaf, hard of hearing, or deaf-blind at the Tennessee Schools for the Deaf (Knoxville and Nashville campuses) and the West Tennessee School for the Deaf. The program must focus on preventing language deprivation or gaps through insufficient language access; providing a positive impact on a child’s social and emotional development through a deaf role model and on a parent’s emotional journey of having a deaf, hard of hearing, or deaf-blind child through a parent advisor; and ensuring that children who are deaf have equal access to learning opportunities at home and in the community. Effective as of July 1, 2023.

 

Coverage for Breast Examinations

 

Public Chapter 379 (SB0365/HB0355) requires that a health benefit plan that provides coverage for a screening mammogram must provide coverage for diagnostic imaging and supplemental breast screening without imposing a cost-sharing requirement on the patient. Effective 90 days after May 11, 2023.

 

Doula Services Advisory Committee

 

Public Chapter 424 (SB0394/HB0734) creates the doula services advisory committee, administratively attached to the Tennessee Department of Health, to advise the Department by establishing core competencies and standards for the provision of doula services in Tennessee and to recommend reimbursement rates and a fee schedule for TennCare (Medicaid) reimbursement for doula services. The committee consists of five (5) members, one of which is the Commissioner of the Department of Health or his designee with relative experience requirements. Effective as of July 1, 2023.

 

Newborn Screening

 

The Governor’s FY2024 budget includes a state RN4 position in newborn screening for establishing a new long-term follow-up program. The State lab was awarded a new grant from HRSA for $345,000 ($200,000 to the Lab to add Mucopolysaccharidosis Type II (MPS II) to the newborn screening panel and $145,000 to follow-up for its long-term follow-up program).

 

Public Chapter 431 (SB698/HB1358) requests the Tennessee Department of Health to officially request the United States Department of Health and Human Services to add newborn screening for metachromatic leukodystrophy to the recommended uniform screening panel. Metachromatic leukodystrophy (MLD) is a rare genetic brain disease that can be tested for during newborn screenings via a simple pin prick of the newborn’s foot in order to test the blood. Effective as of May 11, 2023.

 

Mature Minor Doctrine Clarification Act

 

Public Chapter 477 (SB1111/HB1380) created the “Mature Minor Doctrine Clarification Act” which prohibits a healthcare provider from providing a vaccination to a minor unless the healthcare provider first receives informed consent from a parent or legal guardian of the minor. The healthcare provider must document receipt of and include in the minor’s medical record proof of prior parental or guardian informed consent. Moreover, this law requires written consent from a parent or legal guardian before providing a minor with a COVID-19 vaccine. Finally, this law prohibits an employee or agent of the state to provide, request, or facilitate the vaccination of a minor child in state custody except upon written request to, and court order from, the appropriate court; if a parent or legal guardian of the minor has provided prior written informed consent to the vaccination; or if the parental rights of each of the minor’s parents or legal guardians have been terminated by a court, and all opportunities for appeal have been exhausted Effective as of May 17, 2023.

 

“Sex” Definition

 

Public Chapter 486 (SB1440/HB239) defines “sex” in code to mean a person’s immutable biological sex as determined by anatomy and genetics existing at the time of birth and evidence of a person’s biological sex. “Evidence of a person’s biological sex” includes, but is not limited to, a government-issued identification document that accurately reflects a person’s sex listed on the person’s original birth certificate. Effective as of July 1, 2023.

 

A list of MCH-related laws is included in the Supporting Documents section.

 

Several new MCH-related policies were proposed or updated in 2023:

 

TennCare

 

In April 2022, Tennessee announced an extension of TennCare, which lengthens postpartum coverage from 60 days to one year. TennCare has also included added dental benefits for pregnant and postpartum women. Through the Governor’s 2024 budget, the TennCare pregnancy category eligibility income threshold will increase to 250% federal poverty level (FPL) from 197% and the parental eligibility income threshold will increase to 100% FPL. Additionally, TennCare introduced outpatient lactation consultant coverage which went live on June 1, 2023. Lastly, TennCare has proposed covering the cost of 100 diapers per month for children under the age of two years. Starting in April 2023, TennCare members began going through state and federally-required redetermination processes to determine continued eligibility for TennCare. The Division of Family Health and Wellness continues to support the TennCare redetermination process through collaboration with Presumptive Eligibility and Community Health Access and Navigation in Tennessee (CHANT) program.

 

Lactation Support Services

 

Lactation support services will now be covered as medically necessary for TennCare (Medicaid) enrollees. Lactation support services include education, counseling, and assistance for common breastfeeding issues, along with skilled, evidence-based care for more complex lactation issues. This new TennCare policy was effective June 1, 2023.

 

Free Baby Diapers

 

TennCare proposed using shared savings dollars to pay for diapers for Medicaid recipients for two (2) years. Implementation of this proposal depends on approval from Centers for Medicare and Medicaid (CMS) and would be a first-of-its-kind Medicaid service. This benefit could become available as early as January 2024.

[1] Data Profiles. Tennessee 2021. https://data.census.gov/cedsci/profile?g=0400000US47

[2] State of Tennessee. Transparent Tennessee. 2023. https://www.tn.gov/transparenttn/state-financial-overview/open-ecd/openecd/tnecd-performance-metrics/openecd-long-term-objectives-quick-stats/distressed-counties.html

[3] America’ Health Rankings. 2022.  https://assets.americashealthrankings.org/app/uploads/allstatesummaries-ahr22.pdf

[4] America’s Health Rankings. 2022 Health of Women and Children Report. https://assets.americashealthrankings.org/app/uploads/allstatesums-hwc2022.pdf

[5] Tennessee Department of Health.  Division of Health Disparities.  Healthcare Provider Census.

[6] Tennessee Department of Health, Division of Vital Records and Statistics, Office of Health Statistics.  Birth Statistical System