Financial toxicity is a construct increasingly used in health services research to capture the distress associated with the costs of medical care. It goes beyond simple out-of-pocket spending to encompass the psychological weight of bills, the coping behaviours people adopt to manage them, and the ripple effects on household finances. Although the concept has been extensively studied in cancer therapy, where it is now recognised as a genuine side effect of treatment, its application to chronic diseases like diabetes has been limited. The new study, led by Stanley John Njattumkalayil with colleagues Michael Donnelly, Ciaran O’Neill and Tran Thu Ngan, set out to fill that gap by examining the experience of financial toxicity among type 1 and type 2 diabetes patients in the United States and identifying the factors associated with both vulnerability to it and its severity.

The research team recruited a total of 337 diabetes patients who completed an online cross-sectional survey in July 2024. Each participant answered the COST questionnaire, a validated instrument for measuring financial toxicity that produces a score reflecting both the likelihood and the depth of cost-related distress. The survey also collected information on a range of covariates, including sex, income, employment status, marital status, living arrangement, insurance status, and whether the participant lived in an Affordable Care Act Medicaid expansion state or a non-expansion state. The researchers then conducted logistic regression and ordered logistic regression analyses, separately for each diabetes type, to evaluate the relationships between financial toxicity and these covariates.

The headline finding was unambiguous. The prevalence of financial toxicity was significantly higher in the type 2 diabetes group compared to the type 1 diabetes group, at 77.45 percent versus 56.86 percent respectively, a difference that was statistically significant at p less than 0.001. In crude terms, the odds that a type 2 diabetes patient experienced financial toxicity were 2.61 times higher than the odds for a type 1 diabetes patient, with a 95 percent confidence interval of 1.58 to 4.28. That means a person with type 2 diabetes in this sample was roughly two and a half times more likely to report cost-related distress than someone with type 1 diabetes, before any adjustment for other characteristics.

The researchers were careful to note that this is a crude comparison, and that the two groups differ in ways that could shape the experience of financial distress independently of the disease label itself. Type 1 diabetes typically begins earlier in life and is managed with insulin from diagnosis, while type 2 diabetes is more common in later adulthood and is often accompanied by additional health conditions and medications. The survey data allowed the team to look beyond the crude odds ratio, and with respect to the covariates, distinct patterns emerged across the models, indicating that the factors associated with the likelihood of financial toxicity differ across the two diseases. Socio-economic variables, including income, living arrangement and insurance status, were significant predictors of financial toxicity, and the role of financial vulnerability was more readily discernible in the type 2 diabetes group.

The significance of these socio-economic predictors is consistent with what the COST instrument was designed to detect. The questionnaire does not simply ask whether someone has high medical bills; it probes whether costs have forced people to cut back on necessities, whether they worry about paying for care, and whether financial strain interferes with their treatment decisions. The finding that income, living arrangement and insurance status were significant predictors suggests that the experience of financial toxicity in diabetes is not evenly distributed across the population but clusters among those with fewer resources and less protection. The researchers also examined residence in Affordable Care Act Medicaid expansion versus non-expansion states, reflecting the policy landscape in which state-level decisions about Medicaid expansion have shaped insurance coverage for millions of low-income Americans since 2014.

The study’s conclusion emphasises that a distinct patterning of financial toxicity is evident among those with type 1 diabetes and those with type 2 diabetes, indicating that the findings are consistent with the COST instrument’s ability to detect variations across different patient populations. This is an important methodological point. The COST questionnaire was originally developed and validated in oncology, and demonstrating that it discriminates meaningfully between two chronic disease populations strengthens the case for its broader use in diabetes research. The researchers note that financial toxicity was more prevalent and more severe among those with type 2 diabetes, and that further research with respect to both groups and the factors that impact the experience of financial toxicity is warranted.

The implications for clinical practice and policy are considerable. Diabetes is one of the most common chronic diseases in the United States, affecting tens of millions of people, and its management involves ongoing costs for medications, monitoring supplies, and regular clinical review. If more than three-quarters of people with type 2 diabetes in this sample experienced financial toxicity, the aggregate burden of cost-related distress across the diabetes population is likely to be enormous. Financial distress is not merely a nuisance; it can influence whether patients fill prescriptions, attend appointments, or adhere to treatment regimens, and it can compound the psychological burden of living with a lifelong condition. The study’s identification of income, living arrangement and insurance status as significant predictors points to concrete levers, from coverage policy to targeted financial counselling, that could reduce the depth of distress among the most vulnerable patients.

The research was supported by Queen’s University Belfast and the Wellcome Trust, with the funders having no role in study design, data collection, data analysis, data interpretation, or writing of the report. The study was carried out in accordance with the ethical standards of the Helsinki declaration and received ethical approval from the Faculty of Medicine, Health and Life Sciences Research Ethics Committee at Queen’s University Belfast, with informed consent obtained from all participants, each of whom was compensated three dollars for their time upon completion of the survey. The authors declare no competing interests, and the article is published open access under a Creative Commons Attribution 4.0 International License.

As financial toxicity moves from the oncology clinic into the broader landscape of chronic disease care, this study offers one of the clearest quantitative portraits yet of what cost-related distress looks like in American diabetes care. The divide between type 1 and type 2 diabetes, and the clustering of distress among those with lower incomes, less secure living arrangements and weaker insurance protection, suggests that financial toxicity in diabetes is as much a socio-economic phenomenon as a medical one. The researchers call for further research into both patient groups and the factors that shape the experience of financial toxicity, work that could inform how clinicians, insurers and policymakers respond to a burden that is increasingly recognised as a genuine and measurable consequence of chronic disease in the United States.

Subject of Research: Prevalence, severity and predictors of financial toxicity among people with diabetes in the United States

Article Title: Prevalence, severity and predictors of financial toxicity among people with diabetes in the United States

Article References: Njattumkalayil, S. J., Donnelly, M., O’Neill, C., & Ngan, T. T. (2026). Prevalence, severity and predictors of financial toxicity among people with diabetes in the United States. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15862-8

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15862-8

Keywords: Prevalence, severity, predictors, financial, toxicity, people, diabetes, United, States, scientific research