(Reuters Health) – Many working-age U.S. adults with diabetes struggle to pay their medical bills, according to a study that suggests health insurance offers inadequate protection from financial hardship.

Among adults under age 65 with diabetes, 60% of those without insurance struggled to pay for care, as did 40% of people with coverage.

Overall, 41% of diabetics had families facing financial hardship due to healthcare costs, and 16% were unable to pay medical bills at all.

“Those that reported financial hardship from medical bills were more likely to experience high financial distress, cutting back on basic necessities – such as food and medications – and foregoing or delaying medical care due to cost,” said study coauthor Dr. Cesar Caraballo-Cordovez of Yale New Haven Hospital Center for Outcomes Research and Evaluation in New Haven, Connecticut.

“This situation is not fully prevented with insurance coverage,” Caraballo-Cordovez said by email.

Health costs related to diabetes have doubled over the past decade, from $116 billion in 2007 to $237 billion in 2017, accounting for one quarter of healthcare spending, the researchers note in Circulation: Cardiovascular Quality and Outcomes.

Average yearly spending by people with diabetes on out-of-pocket on care is over $1,800, the study team notes. And for nearly one in four diabetics, more than 10% of family income goes toward medical expenses.

To assess the financial toll of diabetes, researchers examined survey data from 165,000 working-age adults, including nearly 9,000 with diabetes, who represented about 13.1 million people with the disease nationwide.

People were more likely to struggle with medical bills related to diabetes when they were poor, uninsured, black, or dealing with multiple chronic diseases.

Compared to people without diabetes, adults with the disease were 27% more likely to have trouble affording food, 30% more likely to skip or delay checkups due to costs, and 43% more likely to skip or delay medication refills.

The study didn’t look at whether money struggles affected health outcomes. But previous research has found that people who delay or skip needed prescriptions or checkups are at higher risk for dangerously elevated blood sugar and complications like kidney failure, blindness and amputations.

Patients may not be able to stop their out-of-pocket costs from going up, but they can try to shop around for insurance that lowers their bills and they can also ask their health providers to take cost into account when prescribing drugs or recommending treatment plans, said Dr. Laura Hawks of Harvard Medical School, in Boston, and the Cambridge Health Alliance.

“Patients with diabetes will almost certainly have high healthcare costs, so choosing a plan that has a higher premium but lower deductible and good prescription coverage may lower financial burden in the long run,” Hawks, who wasn’t involved in the study, said by email.

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