According to Think Tennessee’s State of Our State dashboard, the state ranks near the bottom in the number of adults with heart disease, obesity and diabetes. It also ranks near the bottom of all states for the health of senior citizens, infant mortality and number of adults who smoke, and at the absolute bottom in childhood obesity. Tennesseans are, on the whole, not healthy. What can and should our next political leaders do about it?

In the months leading up to the primary elections in August, the Ledger is running an “Election 2018: Issues and Answers” feature, produced by the Tennessee Press Association, as part of an effort to educate readers and voters about key issues facing Tennessee and what candidates for governor and U.S. Senate have to say about them. This installment focuses on health care.

Republicans

Diane Black

As a career nurse, health care has been a passion of mine for my entire life. Our current system is broken. I have the right experience to fix it.

The next governor must have a plan for rural health care. I propose making our county health departments the hub of care for rural Tennessee and the access point to telehealth. Our county health departments should function as a primary care provider with a system that provides health care based on ability to pay.

In addition, rural counties need more doctors. I propose Fast-Track MD programs with reduced tuition in exchange for a commitment of becoming a doctor in a rural county.

In the recent past, Tennessee had a much better health care system. But we were the first state in the nation to have Obamacare — it was an older version of TennCare, which was designed by Hillary Clinton and it destroyed our system. Before TennCare, we had a system that was much more efficient at meeting the needs of our communities. We can bring it back and improve upon it.

Randy Boyd

There are several key opportunities we have to improve the health of our citizens. First, on day one I will begin negotiations with the federal government for a block grant to our Medicaid program. We need a program for Tennesseans designed by Tennesseans, and we can do better than a one-size-fits-all mandate from Washington.

I also believe there is too much discussion about what to do when we are sick, and not enough focus on getting healthier. With Tennessee ranking in the bottom of nearly every health metric — while remaining low in income levels — we simply cannot afford the health we have.

However, we can fix this.

At my company, after eight years of comprehensive health programs, health insurance claims were reduced by 19 percent last year — it can be done. In our schools, we can increase exercise opportunities for students and provide education opportunities about good health.

There is also a need for more primary care doctors in our rural communities. We can solve this is by partnering with medical schools to offer greater residency programs in rural, underserved areas.

Additionally, we must also be better consumers of health care. Imagine a marketplace where no consumer ever asks the price, and no provider knows the price they are charging. By bringing more accountability, transparency and consumerism into the market, we can maintain quality and reduce costs.

Finally, we must bring a heightened focus on mental health and addiction. These are often the roots of many problems. We must make smart investments in treatment and recovery centers, appropriate mental health centers, and in-school counselors.

If we do these things, we can see a transformation in the health of Tennesseans.

Beth Harwell

I think the two biggest keys to improving our population’s health from the government’s standpoint are education and personal responsibility. It is not the role of the government to police things that people are eating or drinking on a daily basis, but what we can do is make sure that we are giving people the information they need to make healthy choices.

We must make sure we are starting young, and are working to increase awareness about these issues among our students. There are ample opportunities in our schools to educate our kids about nutrition, healthy habits, regular activity and exercise. Often, what is taught to our children in school comes home to the parents as well.

We need to also raise awareness about preventive care. Chronic conditions like heart disease and diabetes are much more treatable when caught early. It is extremely important that our population understands the importance of regular check-ups and preventive care. We need to embrace new innovative technologies like telemedicine to ensure that more people have access to health care before these problems arise.

Finally, we can look to other states, as well as the private market, to see what types of programs are working to improve these outcomes. Many health insurance companies have been exploring incentives for their customers to make sure they are taking advantage of preventive care options. Our own state employee insurance program has long offered lower premiums for making healthy choices, and hopefully the Trump administration will give us more flexibility with our TennCare program to explore these options as well.

Bill Lee

There’s no doubt that we face a tsunami of lifestyle diseases in Tennessee. This includes issues such as heart disease, obesity and side effects related to smoking. It is a growing epidemic in Tennessee and across the country as well. Thirty years ago, no state had more than 20 percent of its population that was overweight or obese. Today, no state is below 20 percent, and some are over 30 percent and inching up to 40 percent.

We are seeing this growth in part because our entire health care system is broken. We see skyrocketing costs every year for patients, providers and payers because there are no financial incentives to control them. The system does not provide options for patients to take stock of their health care and know how much it costs, and providers are not rewarded for addressing prevention and wellness. We have to fundamentally break through that mindset to focus less on just delivering health care and more on our overall health.

We’re doing this in my company. Health care premiums have gone up 19 percent and 29 percent in the last two years, and we decided we would institute some incentives for wellness, and costs are going down for those who participate because health care is not just for when we are sick. Health care includes daily choices in prevention as well.

As governor, I will lead an effort to promote smarter engagement in the health system that doesn’t focus on a top-down, government-first approach. Throughout this campaign, I have talked about the need to engage more in public-private partnerships with faith-based and nonprofit communities. These organizations have their finger firmly on the pulse of what’s going on locally, and they often provide better solutions than creating another government program.

I chaired the YMCA of Middle Tennessee, and it has been aggressively trailblazing wellness innovations, providing opportunities for smoking cessation, obesity and diet management, and they have developed a major program in diabetes prevention. In Tennessee, we have an amazing natural resource in the form of our non-profit and faith community partners. Working with them more effectively is a great place to start in improving health in our state.

Democrats

Karl Dean

I firmly believe that our overall quality of life is directly linked to health. It plays a role in our state’s economic viability, productivity and educational outcomes for students.

We simply cannot afford the health we have.

As mayor of Nashville, we made the goal of improved health a focus of my administration. We championed healthy living by expanding access to parks, greenways and community centers. We also built a state-of-the-art public health facility.

We created the “Walk 100 Mile” challenge, the Mayor’s 5k, the Mayor’s Field Day, invested sidewalks, bike paths, established a new bicycle program, and added more parks, greenways, and community centers.

As adults we know the results of unhealthy behaviors, but children do not. We need to equip our schools and teachers with the resource they need to teach our kids how to live healthy lifestyles.

Encouraging preventive care is one of the smartest, most cost-effective things we can do as a government to improve the health of our community.

Additionally, one of my top priorities as governor will be to make sure every Tennessean has access to affordable health care. Those who do not have insurance generally will not get check-ups, so it is that much harder for physicians to advise on healthy choices and catch illnesses early.

Craig Fitzhugh

As the numbers show, Tennessee has a long way to go to improve our individual and collective health. This has not been a sudden occurrence, and while personal responsibility plays a large role in health, political leaders and policymakers have a part to play. The first thing — as I have stated constantly in my legislative career and in my campaign for governor — is that we need to expand Medicaid. It is a must. By expanding Medicaid we could keep our hospitals open, allowing people to see a doctor on a consistent basis, instead of health issues becoming an emergency.

Screenings for blood pressure, cancer and diabetes would go a long way towards curbing our mortality numbers. Testing for and educating people on their health (and teaching them how to prevent, control and treat chronic ailments) leads to longer lives and a better quality of life, and is also cost effective for the individual Tennesseans and our communities.

We have to educate our citizens on good food choices, curbing/eliminating tobacco use and making time for exercise. A great number of low-income areas are food deserts, where nutritious meal choices are very difficult or impossible to access, and in rural/suburban areas that are spread out and there are few public transportation options, they may not be able to get to grocery stores and doctors appointments. Multiple studies have shown that food and medicine are areas that families and individuals cut back on when money is tight. They may turn to lower cost fast food and cut medication in half or not fill prescriptions, thus making health issues worse. We as policymakers must make sure we make healthy infrastructure choices — such as sidewalks, playgrounds and ball fields — available to our citizens. By investing in our health, we are investing in Tennessee’s future.

Republican

Marsha Blackburn

People must take ownership of their health. I continually work to make affordable health care accessible to all Tennesseans.

Improving education will assist in this effort. As a young mom and president of the Middle Tennessee Lung Association board, I developed programs to educate children about the dangers of smoking and to help adults who had begun to smoke and wanted to quit. Then as a state senator, I supported nutrition education for welfare recipients because it improves health outcomes for children. These programs yield better health habits.

In Congress, we continue to work on patient-centered reforms. In 2016, we implemented the bipartisan 21st Century Cures Act, which Sen. Lamar Alexander called the most important legislation of the year. It marked the move from a one-size-fits-all system to precision medicine for well care, chronic disease management, elder care, and seeking cures for vexing problems. We can now better define health care, illness and disease issues in order to yield a better outcome.

We passed the SOFTWARE Act to expand opportunities for rural hospitals health care providers, access to telemedicine, tracking genetic information, and remote monitoring to patients who are homebound. This marks the way forward as MHealth apps allow you to measure calories, track exercise, sleep, heart rate and other vitals.

Sadly, infant mortality has been an issue statewide, particularly in Memphis. We continue to improve prenatal education plus access to drug treatment and recovery programs for expectant mothers and babies born with addiction to ensure that mothers and children can stay in treatment and recovery programs. The Comprehensive Addiction and Recovery Act 2.0, which I introduced, along with Sen. Rob Portman, will also provide necessary resources.

Further, we should expand Medicare Advantage for seniors because it provides more choice and options.

Expanding health savings accounts, association health plans and across-state-line purchase will allow Tennesseans more flexibility when it comes to their health insurance.

These are provisions I will continue to support as your senator to give you more choice and options for achieving better health outcomes.

Democrat

Philip Bredesen

If you’re like me, when you hear something repeated enough times, you stop paying attention. It’s like that with statistics about the poor health of Tennesseans; we’ve all heard them enough times to block the message out.

But here’s a fresh way to look at our health. The average lifespan of a Tennessean right now is 76.3 years. Imagine for a moment that Tennessee is a country instead of a state. Where would the country of Tennessee rank among all the countries in the world? The answer is 50th. That’s just a number; what does it mean?

One of the things that it means is that Mexico ranks above Tennessee in average lifespan. If you live in Mexico— with its poverty, its far more primitive health care system, its drug gangs — you can still expect to live longer on average than you will in Tennessee. The same is true in Panama. Or Costa Rica. Or Albania.

The reasons for this are not rocket science. The big three killers in Tennessee are heart disease, respiratory disease and cancer. These are deeply linked to obesity and smoking. Tennessee ranks in the U.S. Top 10 in both our smoking and obesity rates.

Changing our smoking, eating and exercise habits will be hard; personal responsibility will have to take the lead. Beyond personal responsibility though, there are many ways that the federal government can make a difference.

For example, the cholesterol-lowering drugs called statins (think Lipitor) are inexpensive and have proven their ability to reduce heart attacks. And yet, extrapolating from national averages, there are about 850,000 Tennesseans who would meet the standard for taking statins, but who are not doing so.

An effort to increase the use of statins through strategies such as eliminating copays or transitioning statins to over-the-counter (non-prescription) status could save many lives and health care costs as well.

Strategies like these are ones I want to work on in the U.S. Senate, and I’m applying for the job.