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In the coming months, Tennessee's state Medicaid program faces hundreds of millions of dollars in budget cuts. The program, known as TennCare, won't pay for overweight patients to get counseling from dieticians, but it will pay for the morbidly obese to lose weight through surgery, like a gastric bypass. That has led some critics to complain that TennCare won't provide an ounce of prevention, but it will pay for a pound of cure.

From member station WPLN in Nashville, Daniel Potter reports.

DANIEL POTTER: Two years ago, Jane Leck weighed more than 250 pounds. She's in her mid-40s and TennCare was paying for her heart and blood pressure medicine and she was pre-diabetic.

Ms. JANE LECK: I've always battled obesity, genetically. I have family members that are all obese.

POTTER: Leck says she's only ever been close to a normal size when taking diet pills. But she quit because of side effects, gaining back her old weight and then some. Eventually, TennCare paid for her to have a gastric bypass. Surgeons gave her less of a stomach so she feels full faster and eats less. She has since gotten rid of almost all of her old clothes.

Ms. LECK: We're over at the 3 or 4Xs.

POTTER: To show how much weight she's lost, she leafs through a swap rack for obese people at her former clinic where patients drop off old clothes as they slim down.

Ms. LECK: My jacket, my size 3X, before surgery I could barely zip it. And now me and another person can get in it and zip it, so I've lost a whole person.

POTTER: Leck figures the gastric bypass saved TennCare money because otherwise she would have needed heart surgery and other operations. And she's off all her old medicines. The average price of such operations to TennCare, including facility costs, about $20,000. Almost all state Medicaid programs cover bariatric surgery, but only about half pay for diet counseling.

And dietitian Sarah-Jane Bedwell says Tennessee isn't one of them.

Ms. SARAH-JANE BEDWELL (Dietitian): It's like saying we're going to fill your cavities, but we're not going to ever pay for you to get your teeth cleaned or teach you how to brush your teeth.

POTTER: Bedwell helps people fine-tune eating habits and even goes grocery shopping with clients. But TennCare won't cover her services, for which she charges $75 an hour. Bedwell contends she's much cheaper than a surgeon. That's an argument TennCare hears a lot of.

Here's chief medical officer Wendy Long.

Dr. WENDY LONG (Chief Medical Officer, TennCare Bureau): For any benefit that we don't offer through the TennCare program, there is someone that would argue that it would be cost-effective for us to offer a new benefit.

POTTER: While Tennessee ranks among the nation's fattest states, TennCare's budget is stretched thin because of sagging tax revenues. Long says if paying for dietitians saved the state money, they'd do it. But...

Dr. LONG: There's really no evidence to support the fact that providing those services would result in a decrease in medical costs, certainly not immediately, and to even in the longer term.

POTTER: Long says patients on TennCare do get dietary counseling, just from physicians, not dietitians. And anyway, she argues, TennCare's hands are tied by a legal requirement to cover bariatric operations.

Dr. Ronald Clements, head of bariatric surgery at Vanderbilt, sees no problem with the state paying for a gastric bypass.

Dr. RONALD CLEMENTS (Director of Bariatric Surgery, Vanderbilt University Medical Center): The biggest bang for the buck in treatment of obesity is bariatric surgery, hands down. Nothing else comes close. However, only a small percentage of obese patients qualify for it.

POTTER: Patients have to be particularly obese and possibly sick before they're even considered for bariatric operations. Clements says such obese people almost never keep weight off by any means other than surgery. As to whether diet counseling could keep other people from reaching that point, Clements says that's hard to know.

For NPR News, I'm Daniel Potter in Nashville.

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