For years, Bob Clegg's insurance company paid out some $3,000 a month for doctor visits, drugs and medical devices to treat the health problems caused by his obesity.
In September 2007, when his weight peaked at 380 pounds, he had gastric bypass surgery, and now his health issues — joint pain, sleep apnea and esophageal problems — have vanished, and so have the medical bills.
But even though the surgery — in which the stomach is made smaller and part of the intestine is bypassed — has saved his insurance company money, Clegg, who now weighs 240 pounds, had to pay the $20,000 cost out of his own pocket.
"It wasn't until the doctor said my sleep apnea was at a point where we seriously had to consider a tracheotomy that we talked about gastric bypass," said Clegg, 54. "The irony is that insurance would pay for the tracheotomy, but not the surgery."
Clegg's experience highlights the difficulties facing the United States as it confronts an epidemic of obesity, and the problems for President Barack Obama as he sets about extending health insurance to more Americans at a time of runaway costs.
While his experience is typical, unlike most other people, Clegg was in a position to make some changes.
As a member of New Hampshire's senate, he took what he knew about obesity and the cost of treating related chronic illnesses to the state capitol, where he introduced a bill in January 2008 requiring insurers to offer surgery as a treatment option, just as the state's Medicaid program for the poor does.
While other states — some of which don't cover any obesity treatment — are studying New Hampshire's approach, experts say economics will increasingly drive policy at a time of burgeoning budget deficits.
About two-thirds of American adults are overweight or obese, putting them at an increased risk for diabetes, hypertension, heart disease, osteoarthritis, stroke, gallbladder disease, sleep apnea and respiratory problems and even some cancers.
The direct and indirect costs of obesity is $117 billion each year, according to a 2000 report by the U.S. Surgeon General.
Christine Ferguson, associate professor at George Washington University School of Public Health and the director of STOP Obesity Alliance, said the stigma surrounding obesity and belief that it is not a disease are keeping the government from addressing the crisis.
"At the root of this is that people still have a real problem thinking about obesity as anything other than a willpower issue," said Ferguson. "It is still perfectly acceptable to think about excluding treatment."
Ferguson, who has held high level healthcare posts in Massachusetts and Rhode Island, acknowledged the difficulty in changing the way government thinks about spending on obesity.
"If I have to balance my budget at the end of each year, I have a choice between investing money in children who have mental retardation, or children with developmental disabilities ... or investing in people who have obesity, choosing obesity is a very hard case to make," she said.
This is even though insurers would recover the costs of bariatric surgery within two to four years, according to Pierre-Yves Cremieux, a researcher with the economic consulting firm Analysis Group.
Cremieux led a study that showed the operation helps patients' health and ultimately leads to cost savings. The study was paid for by Johnson & Johnson, which makes bariatric surgery instruments.
Ronald Williams, the chairman and chief executive of health insurer Aetna, said most large employers that it sells policies to have at least one plan that covers bariatric surgery.
But, he said, he's more focused on prevention.
"The bigger end of the story is, How do we help people not become obese to begin with?" he said. "If they are suffering the complications from being overweight or obese, how can we help them manage those conditions?"
Clegg blamed difficultly in pushing his bill through partly on society's bias against the obese. The bill finally passed in June, six months before he left the senate in December.
Other states have had similar difficulties, including Utah, where Jeff Haaga has lobbied the state to require insurers to provide greater coverage there.
"If we could only get our lawmakers to understand, like they did in New Hampshire," said Haaga, who at 360 pounds is classified as morbidly obese.
"Insurers are covering people who are morbidly obese one way or the other, whether it's surgery or just keeping us alive with medication."
In Mississippi, rated the nation's fattest state for the third consecutive year, a bill that would have banned restaurants from serving obese customers died almost immediately after it was introduced in February.
The Trust for America's Health, a nonprofit group that focuses on disease prevention, reported that adult obesity rates rose in 37 states in the past year, while no state saw a decrease.
In its 2008 report: 'F as in Fat: How Obesity Policies are Failing in America', the Trust said Mississippi has per capita medical costs that are among the highest in the nation. It also has a Medicaid policy that specifically excludes coverage for bariatric surgery.
For Clegg, the former New Hampshire lawmaker, Mississippi's obesity problems are clearly linked to its refusal to pay for bariatric surgery under its Medicaid program.
"If Mississippi is that ignorant and would rather pay for diabetic medicine every month and watch people have heart attacks at a cost of $40,000 ... but wont spend $10,000 or $20,000 (for the surgery), well maybe that's why Mississippi has a problem," he said.