Jerry Madrigal's life is spent in medical offices.
What started as a small sore on the 49-year-old's foot has turned into a diabetes diagnosis and an endless series of pricey procedures and prescription medicines.
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No longer able to work, Madrigal, of Corpus Christi, Texas, lives on disability checks and his wife's part-time pay. He has no clue how much all of this costs; his medical bills are fully covered by government-funded Medicaid.
Diabetes' financial toll extends beyond those diagnosed, reaching into the pocketbooks of taxpayers and those with health insurance who pick up the tab for the uninsured or those on government-funded health care plans.
"I think that everybody bears the cost of diabetes and its complications resulting in disability, because much of that is paid for through our taxes," said Dr. Melissa Wilson, an endocrinologist who served on the Texas Diabetes Council.
The federal government estimated the total cost of diabetes at $51.3 billion in 2010. And diabetes often coincides with other health problems, such as stroke or kidney failure, making it difficult to pin down the exact cost of the disease.
Emergency room visits or conditions associated with diabetes, such as strokes and heart attacks, make the true costs of diabetes likely to be much higher.
And they continue to grow.
Nationwide, diabetes costs nearly tripled from $18.8 billion in 1996, according to the Agency for Healthcare Research and Quality. Medicare and Medicaid covered, on average, 42 percent, or $196 billion over 14 years, according to the agency. That's enough to pay the wages of a quarter-million teachers during the same time.
Still, while the costs of diabetes skyrocket, prevention has not kept pace
Self-management classes, widely regarded as one of the best ways to prevent the onset of expensive complications, have failed to live up to their potential. Corpus Christi's diabetes education programs in recent years, for example, have struggled to stay afloat as funding gets stripped away.
That leaves people like Madrigal dependent on the government.
Four years ago, Madrigal stepped on a nail but the wound refused to heal, eventually sending him to the hospital, where his diabetes was diagnosed.
In the past year, he's had four surgeries, including the amputation of his big toe. His kidneys are failing. He needs dialysis three times a week until he can get a kidney transplant. At his sickest, Madrigal took almost a dozen prescription pills a day.
Madrigal worked as a laborer for years. He earned $350 a week and didn't have health insurance.
Hospital social workers helped him enroll in the county's indigent care program. Funded by property tax dollars, the program covers health care for the county's poorest residents. He stayed on that plan until he was able to enroll in Medicaid.
Madrigal's situation is common in Texas, where Medicaid and Medicare paid for two-thirds of the state's diabetes-related hospital stays in 2010, according to the state's health department.
And those stays aren't cheap.
Diabetes hospitalizations on average cost about the same as a new Lincoln MKS luxury sedan: $48,720, or 50 percent more than hospitalizations not related to diabetes, according to state reports released in April 2012.
That's because people with uncontrolled diabetes are more prone to infections and have a tougher time fighting them, Wilson said. A spike in blood glucose levels, even temporarily, can paralyze white blood cells for up to two weeks, compromising a person's immune system, she said.
"There's more flu, more colds, more urinary tract infections," Wilson said. "A cut can easily become infected. Skin infections and yeast infections are very common."
People with diabetes also face hefty indirect costs, such as reduced productivity and increased absenteeism from work. A January 2012 in Health Affairs found that people with diabetes have harder times finding and keeping jobs and earn far less over their lifetimes than people without diabetes.
One health insurer's data provided to the Caller-Times show that the costs to treat diabetes have been expanding, even when adjusted for inflation.
Tricare, which provides health benefits for military personnel and retirees and their families, spent $76.5 million on diabetes care in Texas alone in 2011. That's up 14 percent from 2007, adjusted for inflation.
Pharmacy costs made up 44 percent, or $33.7 million in 2011, according to Tricare's reports.
For Madrigal, it's too late to prevent some of the debilitating long-term complications of diabetes, but he's doing all he can -- closely monitoring his diet, exercising on the stationary bike in his living room and following doctor's orders. He's lost 45 pounds. At his last checkup, his blood sugar had dropped to prediabetic levels.