The U.S.’s high obesity rate and its relationship with other chronic diseases is not new information to most public health scientists and physicians, but a new analysis suggests that prevention strategies exist that could counter this continuing trend if they were pursued as a public health priority.

A research letter published Monday by JAMA Internal Medicine reported updated results from an earlier study highlighting the burden of chronic conditions associated with body mass index. The new findings use the most recent data available on obesity – that of 2007 to 2012 – from the National Health and Nutrition Examination survey, or NHANES.

NHANES includes data for individuals 25 years or older and excludes pregnant women. “Overweight” and “obese” were classified by patients’ body mass indexes (BMIs).

Before the release of this study, the most recent examination of nation’s obesity and chronic disease burden was based on information from nearly 20 years ago, when researchers concluded that the prevalence of obesity-related health problems “emphasizes the need for concerted efforts to prevent and treat obesity” rather than just the other health conditions.

In the new analysis, the researchers found that, nearly 40 percent of men and 30 percent of women were overweight, while nearly 35 percent of men and 37 percent of women were considered obese. Comparing this data with statistics from the earlier study, the researchers concluded that overweight and obesity rates in the U.S. have increased over the past two decades. The greatest increase in the proportion of individuals with BMI’s greater than 40, the highest obesity class, was among black women.;

Rising trends demand attention from decision-makers in the health policy and health care fields, said Dr. Lin Yang, a lead researcher of the study.

“Overweight and obesity is something one can deal with as an individual, but we also need strategies for prevention at the collective level,” she said.

Furthermore, in order to address the obesity trend, population-based strategies such as enhancing primary care efforts to prevent and treat obesity, changing behavior in schools and the workplace, and changing physical environments to make healthy food and exercise options more accessible are needed.

Part of the problem right now, according to Yang, is that “clinicians are not talking enough with their patients,” and when doctors see patients, “they probably aren’t doing counseling on the ways patients can change their lifestyles.” Yang proposed having obesity education literature in waiting rooms as a potential way to encourage this conversation or at least raise patients’ awareness.

But some experts maintain that they are already seeing signs of progress.

“While obesity has increased, in many states we’ve seen a leveling off among some subpopulations, such as kids,” said Dr. Jeffrey Levi, executive director of Trust for America’s Health “I think that’s telling us that we are beginning to know what to do to tap into this problem.” Levi was not associated with this study.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

CHARLOTTE, N.C. — Roughly half a million North Carolinians could soon lose money they depend on for health insurance. The U.S. Supreme Court will rule soon on a key part of the Affordable Care Act. It governs federal subsidies for insurance in states like North Carolina that did not set up their own exchange or marketplace. The result could be disastrous for many low-income Americans and for insurance markets in about three dozen states.

A few years ago, Harlena Harris lost her health insurance after she stopped working to care for her husband, who was battling lung cancer.

“He couldn’t even raise his hands or do anything for himself,” she says. “I had to feed him. I kept him clean. I did everything for him.”

As he got better, her own health deteriorated. The 62-year-old has Type 2 diabetes and high blood pressure. Without insurance, she couldn’t afford her medications.

“When I did get to go to the doctor, I was very, very, very ill,” she said. “My doctor told me that she didn’t know how I was still standing.”

That doctor’s visit was the first thing Harris did after getting insurance on the Obamacare exchange in 2014. Since then, she’s been doing much better with the help of doctor’s visits and medication.

She can afford it because of a federal subsidy that leaves her paying about $20 a month for insurance. Across North Carolina, more than 90 percent of people insured through healthcare.gov receive a subsidy.

But the Supreme Court case King v. Burwell has put those subsidies in jeopardy.

“I think there is a reasonable argument that the statute is ambiguous,” said Neil Siegel, who teaches constitutional law at Duke University in Durham, N.C.

In one section of the Affordable Care Act, it reads that subsides are available through “an exchange established by the state.” But North Carolina and about three dozen other states decided not to establish an exchange. They use the federal healthcare.gov instead.

Siegel says here’s where it get complicated.

“There are other provisions of the law that don’t really make a lot of sense if the subsidy is invalidated,” he says. “There are reporting requirements that require federal exchanges to report on the subsidies that individuals are receiving.”

Also, the whole point of the exchanges is to make it easier to buy health insurance.

Sara Collins is vice president of the research group The Commonwealth Fund. She said if the Supreme Court strikes down subsidies in states like North Carolina, “it would likely completely eliminate the gains that we’ve seen in insurance coverage over the past five years.”

North Carolina ranked seventh in the nation for the percentage of people eligible for ACA insurance who actually signed up. Across the state, about half a million people would lose subsidies. Collins said that would make insurance unaffordable for most of them.

As they drop their coverage, Evan Saltzman of the RAND Corporation said premiums would go up considerably. “We estimated that premiums would go up 47 percent,” he said.

That’s across states that use the federal exchange.

Here’s why: healthier people drop out of insurance pools first, then insurance companies raise premiums to cover the costs of the remaining, sicker customers, “which then leads to more people saying I don’t want to pay those premiums, and you can get sort of this spiraling effect or death spiral that leads to the collapse of the market,” Saltzman said.

To be clear, that’s the individual market, which includes people buying from the exchanges or directly from an insurance company.

Most people get insurance through their jobs, and their premiums shouldn’t be affected, sayd anaylst Collins of Commonwealth.

“The employer market is pretty much walled off,” she said.

Think of it as a separate pool. Insurance companies set premiums for each based on only the costs for that pool. The bottom line is this: for anyone not covered through work, Collins and Saltzman say health insurance could become exorbitant.

The decision could also have a large impact on hospitals.

“If suddenly a lot of people who are currently insured become uninsured again, that really leaves hospitals in the crosshairs,” says Caroline Pearson of Avalere Health, a consulting firm.

The health law included payment cuts to hospitals since, in theory, more people would have insurance and therefore be able to pay for their care. Those cuts don’t go away if the Supreme Court strikes down the subsidies and insurance rates plummet.

Pearson said the result could be some hospitals with thin margins closing.

“These are the providers of last resort, and they are often the only place that low-income uninsured people can go to get care – I mean, that’s why folks show up in those emergency departments,” she said. “And so to put more fiscal strain on those providers is a very dangerous thing in terms of maintaining a safety net.”

In Charlotte, Harlena Harris’s subsidy is nearly $700 a month. Without that, she says she couldn’t afford insurance.

“Don’t just take it away and we’re setting here in limbo,” she said, addressing state and federal officials. “Have something ready to go in place.”

A few states are aiming to protect their subsidies by creating a state-supported exchange – basically, sticking with the healthcare.gov website while taking on more responsibility on the state level such as regulation and consumer assistance.

When asked about a backup plan for North Carolina, Governor Pat McCrory’s administration said that it is closely monitoring the case.

This story is part of a partnership that includes WFAE, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Terri Anderson signed up for Medi-Cal earlier this year, hoping she’d finally get treatment for her high blood pressure. But the insurer operating her Medicaid plan assigned the 57-year-old to a doctor across town from her Riverside, Calif. home and she couldn’t get there.

“It was just too far away,” said Anderson, adding that she cares for her 90-year-old ill father and can’t leave him alone to make an hour round-trip drive to the doctor. Now she’s crossing her fingers that a health clinic near her house will accept her new insurance.

In an effort to control costs in its rapidly expanding Medi-Cal program, California has relied heavily on managed care insurance companies to treat patients like Anderson. The state pays insurers a fixed amount per enrollee and expects the companies to provide access to doctors and comprehensive care. But a scathing state audit released last Tuesday shows that California is failing to make sure those plans deliver. Like Anderson, many enrollees have insurance cards but often have trouble getting in to see doctors.

The California audit found the state didn’t verify that insurers’ directories of doctors were accurate or that the plans had enough doctors to meet patients’ needs. The state Department of Health Care Services also didn’t do its own required annual audits of the plans.

And thousands of phone calls to an ombudsman’s office — created to investigate complaints — went unanswered every month.

The audit focused on three health plans but underscores a broader problem in California: the lack of sufficient oversight of a program that now serves about 12 million beneficiaries, three-quarters of whom are in managed care. Advocates and experts say the state has moved too quickly to shift enrollees into managed care plans and given too much unsupervised responsibility to the companies.

The sheer number of enrollees — along with their complexity — means the state needs to do a better job tracking the plans responsible for caring for them, said Gerald Kominski, director of the UCLA Center for Health Policy Research.

“The audit indicates now that so many Californians are enrolled, how important it is for the state to have adequate oversight,” Kominski said. “The state has a long way to go to reach that goal.”

Aimee Mejia, a single mother in South Gate, just a few miles southeast of downtown Los Angeles, said finding specialists to treat her diabetes and psoriasis was challenging – some didn’t accept her Medi-Cal insurance and others were too busy to see new patients. She finally found doctors but driving to one takes about 40 minutes and the other, more than an hour.

“I thought that was normal to be rejected by doctors or to wait for care,” she said. “But there is something wrong here.”

New proposed federal regulations designed to improve Medicaid managed care could help by requiring states to ensure patients have enough access to doctors and hospitals, limiting profit margins and establishing a quality rating system for plans. In addition, a proposed bill in California would require plans to provide accurate and up-to-date provider directories.

California Department of Health Care Services officials said they already have made some changes and are monitoring doctor networks more thoroughly than the audit found.

But even if oversight improves, many argue the state still needs to increase Medi-Cal payments to doctors and other providers so that more will participate. A coalition of unions, doctors and hospitals are pushing to raise rates in California. If that doesn’t happen, more regulation will only go so far, said Sean Wherley, spokesman for SEIU-United Healthcare Workers West.

“If there still aren’t doctors taking new Medi-Cal patients, how is that any better for patients?” he said.

The issue of managed care oversight isn’t limited to California. Several states have transferred responsibility to managed care insurers but aren’t closely tracking whether Medicaid patients are getting the care they need, said Joan Alker, executive director of the Georgetown University Center for Children and Families.

“This is a national problem,” Alker said. “More beneficiaries with chronic and difficult health conditions and more public dollars are going into managed care. We absolutely need more accountability … in how those dollars are being spent.”

Oversight efforts have been hurt by state budget cutbacks and the loss of seasoned employees, she said. In addition, more companies taking care of Medicaid patients have a responsibility to return profits to their shareholders. “That comes up against the responsibility of dealing with a population of people who have a lot of health care needs,” Alker said.

California didn’t get here overnight. The state has been moving large numbers of poor patients into managed care for decades. Over the past few years, however, the pace has accelerated. Many newer beneficiaries, including seniors and people with disabilities, have multiple chronic illnesses. And people who gained Medi-Cal coverage through the Affordable Care Act also may have gone without treatment for a long time and have serious health needs.

Each transition has been rocky, with patients and advocates raising concerns about patients’ inability to find primary care doctors or specialists.

Linda Lindsey, 60, lives in Weaverville, a rural town outside Eureka in far northern California with limited numbers of doctors. Lindsey said she was moved into a Medi-Cal managed care plan a few years ago and said she has even fewer options for doctors and pharmacies than she did before.

At one point, Lindsey, who has Crohn’s disease, said she drove about 50 miles to see a specialist only to be told that the office didn’t accept her plan. “I was upset, to say the least,” she said.

Some of the issues have arisen because Medi-Cal grew much faster and bigger than anybody predicted, said Stan Rosenstein, a consultant and former chief deputy director at the state health care services department. The numbers jumped from 6.6 million enrollees in 2007 to 12.2 million to this year.

But he said caring for people through managed care is a vast improvement over the old fee-for-service system, where doctors got paid per visit. In managed care, Rosenstein said, “there is a lot more measurement, a lot more accountability and a lot more contractual requirements than there ever had been.”

There are numerous laws on the books requiring state monitoring and sufficient access to doctors. For example, the state is required to determine that plans have enough doctors and that patients don’t have to travel too far to reach them. State officials also must do regular assessments of plans to determine whether they can meet their contractual obligations.

But just having laws isn’t enough to ensure that patients’ needs are met, said Abbi Coursolle, a staff attorney at the National Health Law Program. “Those standards are only as good as the state’s ability to enforce them,” she said.

Blue Shield of California Foundation helps fund KHN coverage in California.

agorman@kff.org

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.