A cascade of health problems struck Dan Graber in his early 40s. The Madison attorney — obese for years — developed a frequent thirst, his vision grew blurry and his legs started tingling so much it woke him up at night. Graber was diagnosed with Type 2, or adult-onset, diabetes.

Unlike most of the 19 million Americans with the disease, Graber was soon cured — through a gastric bypass. It's a type of bariatric, or weight-loss, surgery.

The diabetes-eliminating potential of bariatric surgery is gaining more attention, and doctors are emphasizing the benefit to encourage more insurance companies to pay for the surgery. In Wisconsin, few health plans do.

"More people should have this option," said Dr. Michael Garren, a UW Health bariatric surgeon who operated on Graber. "At the very least, they should cover it for diabetics."

Most health maintenance organizations in Dane County don't cover bariatric surgery for any purpose. One — Dean Health Plan — has started a trial run.

Officials with the HMOs say they take their cues from the state's employee benefits. None of the 16 HMOs available to the state's 69,000 workers pay for bariatric surgery. Only the state's premium plan, which costs workers more than twice the others, covers it.

Tom Korpady, insurance administrator for the state Department of Employee Trust Funds, said the department considers bariatric surgery coverage through the HMOs every year. "But we'd have to subtract benefits elsewhere to balance it out," he said.

Mike Pfrang, who works for the state Division of Public Health, was diagnosed with diabetes four years ago. He lost his appeal of the state's refusal to pay for a gastric bypass.

Pfrang, who weighed 265 pounds, has lost 50 pounds through exercise. But his diabetes continues, and at age 65 he doesn't know much longer he can keep up his rigorous workout routine.

"It would be good public policy to cover this," he said.

Altering hormones

Doctors learned more than a decade ago that bariatric surgery can cure Type 2 diabetes.

In the disease, excess weight causes the body to become resistant to the insulin it produces. Insulin, a hormone, regulates blood sugar.

Bariatric surgery has no effect on Type 1, or juvenile-onset, diabetes, in which the body stops producing insulin.

People with Type 2 diabetes take insulin shots or other medications to control their blood sugar and ward off complications such as kidney failure, heart disease, blindness and amputation.

The surgery allows them to stop the treatments because they lose weight and begin to respond again to their insulin, doctors say.

Another reason, in the case of gastric bypass, stems from food being rerouted around most of the stomach and the upper intestine. That appears to alter the release of hormones that regulate hunger and interact with insulin, doctors say.

"By the time many people leave the hospital (after surgery), they're off all of their diabetes medications," Garren said.

Younger patients and those who have developed diabetes recently are the most likely to be cured, he said.

A study in the Journal of the American Medical Association in January compared bariatric surgery to conventional diabetes treatment: diet, exercise and medications. Of 60 patients in Australia, 73 percent who received surgery had a complete remission of diabetes, compared to 13 percent who had conventional treatment.

The study evaluated gastric banding, a type of bariatric surgery in which a band is looped around the top part of the stomach. It is an alternative to gastric bypass.

A few surgeons in other states are performing the surgeries experimentally on diabetics who are only slightly overweight or of normal weight.

But most doctors follow a basic rule: a patient's body mass index must be 40 or more — or at least 35 if they have diabetes. That means someone who is 5 foot 10 must weigh at least 280 pounds — or 245 pounds if they have diabetes.

Doctors generally require patients to make considerable effort to lose weight through diet and exercise before trying surgery.

Gastric bypasses cost about $25,000, and gastric banding is about $18,000. Both types of surgery can lead to remissions from diabetes, though gastric bypass does so more quickly, Garren said.

Garren and his colleague, Dr. Jon Gould, have performed bariatric surgery on about 600 patients since 2001 at UW Hospital or Meriter Hospital.

About 240 of the patients have had diabetes, Garren said. Of them, 60 have been cured within a couple of days, he said. In another 140, their diabetes eventually went away.

Graber, 45, had his surgery in 2005, about six months after learning he had diabetes. His remission came within two weeks.

His blood-sugar level returned to normal, his vision improved and the tingling in his legs stopped.

At 5 foot 11, he has dropped to 205 pounds from a high of 385.

"Now I can reap the benefits of regular exercise," said Graber, who swims or uses exercise machines nearly every day.

An assistant U.S. attorney, Graber has a federal employee health plan that paid for his surgery.

Most Madison-area diabetics who qualify for the surgery don't have insurance coverage, Garren said.

Physicians Plus, Group Health Cooperative and Unity Health Insurance don't cover bariatric surgery.

A major reason: HMO officials fear "adverse selection" of their plans by patients who want the surgery.

"Any individual health plan that would go beyond what the state provides and cover it would have a whole bunch of people joining that health plan," said Dr. Michael Ostrov, Group Health's medical director.

Ostrov also said it would be unfair to cover bariatric surgery for people with diabetes but not for those with other chronic diseases related to obesity, such as heart disease or high blood pressure.

Terry Bolz, chief executive officer of Unity, part of UW Health, said the health plan helps pay for Weight Watchers sessions and fitness classes.

"We provide our members with a wide variety of wellness programs," Bolz said.

He said it likely would require a legislative mandate to get health plans in Wisconsin to pay for the surgery. A few states, including Indiana and Maryland, have passed such laws.

Phil Dougherty, senior executive officer of the Wisconsin Association of Health Plans, said many employers are troubled by the rising cost of health insurance. Covering bariatric surgery would increase rates, he said.

In January, Dean Health Plan started covering bariatric surgery for any of the 6,000 employees of Dean Health System or St. Mary's Hospital who qualify.

Patients are being evaluated, and some will undergo the surgery beginning in July, said Dr. Tom Hirsch, chief medical officer for Dean Health Plan.

The pilot project will help give St. Mary's bariatric surgery program the volume it needs to receive an important national accreditation, Hirsch said.

The effort also is designed to gather data on the cost effectiveness of the surgery, which might encourage other Dean customers to add the coverage, he said.

Though bariatric surgery can cause complications, including blood clots in the lungs and bypass leaks, the procedures result in few problems at qualified centers, Hirsch said.

"When done by the right people, bariatric surgery is safe and effective," he said.