Burden and consequences of financial hardship from medical bills among nonelderly adults with diabetes mellitus in the united states

César Caraballo, Javier Valero-Elizondo, Rohan Khera, Shiwani Mahajan, Gowtham R. Grandhi, Salim S. Virani, Reed Mszar, Harlan M. Krumholz, Khurram Nasir

Research output: Contribution to journalArticlepeer-review

47 Scopus citations


BACKGROUND: The trend of increasing total and out-of-pocket expenditure among patients with diabetes mellitus represents a risk of financial hardship for Americans and a threat to medical and nonmedical needs. We aimed to describe the national scope and associated tradeoffs of financial hardship from medical bills among nonelderly individuals with diabetes mellitus. METHODS AND RESULTS: We used the National Health Interview Survey data from 2013 to 2017, including adults ≤64 years old with a self-reported diagnosis of diabetes mellitus. Among 164 696 surveyed individuals, 8967 adults ≤64 years old reported having diabetes mellitus, representing 13.1 million individuals annually across the United States. The mean age was 51.6 years (SD 10.3), and 49.1% were female. A total of 41.1% were part of families that reported having financial hardship from medical bills, with 15.6% reporting an inability to pay medical bills at all. In multivariate analyses, individuals who lacked insurance, were non- Hispanic black, had low income, or had high-comorbidity burden were at higher odds of being in families with financial hardship from medical bills. When comparing the graded categories of financial hardship, there was a stepwise increase in the prevalence of high financial distress, food insecurity, cost-related nonadherence, and foregone/delayed medical care, reaching 70.5%, 49.4%, 49.5%, and 74% among those unable to pay bills, respectively. Compared with those without diabetes mellitus, individuals with diabetes mellitus had higher odds of financial hardship from medical bills (adjusted odds ratio [aOR], 1.27 [95% CI, 1.18-1.36]) or any of its consequences, including high financial distress (aOR, 1.14 [95% CI, 1.05-1.24]), food insecurity (aOR, 1.27 [95% CI, 1.16-1.40]), costrelated medication nonadherence (aOR, 1.43 [95% CI, 1.30-1.57]), and foregone/delayed medical care (aOR, 1.30 [95% CI, 1.20-1.40]). CONCLUSIONS: Nonelderly patients with diabetes mellitus have a high prevalence of financial hardship from medical bills, with deleterious consequences.

Original languageEnglish (US)
Article numbere006139
Pages (from-to)e006139
JournalCirculation: Cardiovascular Quality and Outcomes
Issue number2
StatePublished - Feb 2020


  • Diabetes mellitus
  • Expenditures
  • Healthcare systems
  • Insurance
  • Prevalence
  • Age Factors
  • Financing, Personal/economics
  • Humans
  • Middle Aged
  • Income
  • African Americans
  • Cost of Illness
  • Male
  • Young Adult
  • United States/epidemiology
  • Adult
  • Female
  • Cross-Sectional Studies
  • Risk Assessment
  • Comorbidity
  • Risk Factors
  • Medically Uninsured
  • Diabetes Mellitus/diagnosis
  • Health Expenditures
  • Health Services Accessibility/economics
  • Health Care Costs
  • Adolescent
  • Food Supply/economics
  • Patient Compliance
  • Health Care Surveys

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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