Researchers who have been looking for a way to quantify the health toll of ACEs in dollar terms, now have an example in a newly-released study of California. ACEs exacted a toll costing an estimated $113 billion annually, according to the study in the journal PLOS One that was commissioned by the Center for Youth Wellness.

ACEs-associated cardiovascular disease was the condition that lead author Ted Miller dubbed “the giant in the room.” It accounted for $29.6 billion in spending, more than three times higher than the next ACEs associated condition, depression, which accounted for $7.8 billion, followed by COPD at $6.1 billion, arthritis at $5.9 billion and asthma, which accounted for $401 million in spending among adults, according to the study.

What makes the PLOS One study unique? “To my knowledge, it's the first study of the health-related cost of ACEs,” said Miller, a senior research scientist with the Pacific Institute for Research & Evaluation (PIRE). His coauthors include California Surgeon General and Cofounder and former Director of the Center for Youth Wellness Dr. Nadine Burke Harris. Researchers looked at chronic diseases that studies have shown are linked to ACEs, the health spending associated with those diseases and the DALY’s – (Disability Adjusted Life Years lost, which translates to years of healthy life lost to disease, plus years of life lost to death from the disease) for the year 2013.

“Year by year we understand more about how adverse childhood experiences damage children and consequently how those affected can follow a course for poor health throughout their lives,” said Mark Bellis, the director of the World Health Organization Collaborating Center on Investment for Health and Well-being, and the author of ACEs-related research. “This paper helps expose how such ACE-impacted life courses also come with a huge financial cost both to the individual with a history of ACEs and those in the families and communities around them.”

The release of the study on ACEs health-related costs in the state comes just a month after California began a statewide program to encourage universal trauma screening of Californians. Since the beginning of 2020, doctors can be paid $29 for each of the 13 million patients in the state’s Medi-Cal program that they screen for ACEs, making California one of the first states to put trauma screening front and center.

Researchers analyzed prevalence data from the Behavioral Risk Factor Surveillance System (BRFSS) in California and 13 other states, a total of 132,000 surveys, according to Miller. The BRFSS is an annual survey that asks about chronic conditions such as asthma, heart disease, arthritis, and depression. It also asks about obesity, alcohol consumption and cigarette smoking.  Forty-two states and the District of Columbia have included questions about ACEs in at least one year since 2009, according to the Centers for Disease Control.

Miller and his colleagues  looked at existing research that showed a dose-dependent relationship between the number of ACEs and the risk of chronic health conditions, which was first brought to light in the seminal  CDC-Kaiser Permanente Adverse Childhood Experience Study of more than 17,000 adults, beginning in 1998. It linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs— including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys.

The ACE Study found that the higher someone’s ACE score — the more types of childhood adversity a person experienced — the higher their risk of social, economic, health and civic consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4 or higher. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information about how this works and about the full complement of ACEs science, go to ACEs Science 101. To calculate your ACE and resilience scores, go to: Got Your ACE Score?)

Indeed, in the PLOS One study found that higher ACE scores of 4 or more accounted for 36 % of health care related costs in California. But researchers found that even lower ACE scores translate to significant cost. “I was surprised at how important having just one ACE was in terms of the portion of the total cost. Having one ACE causes substantial health care problems across a number of different areas of health,” said Miller, who put that total of health-related cost of 1 ACE at $28 billion.

One of the barriers to understanding the extent of the risk of diseases associated with ACEs in prior research, the authors suggest, was the lack of clarity about the extent to which the relationship between ACEs and specific diseases was mediated by health risk factors, such as smoking, heavy drinking and obesity.

For example, “With COPD (chronic obstructive pulmonary disease) we know that you have a greatly elevated risk of COPD if you smoke,” said Miller. “The question is if we take account of that do nonsmokers have a higher risk relative to other nonsmokers with ACEs? Do smokers with ACEs have a higher risk relative to other smokers [without ACEs]? He explaines that they factored out those kinds of questions to get at what smoking, heavy drinking and obesity cost on their own.

Researchers found that ACEs exposure accounted for 19% more cases of lifetime smoking; 15% more heavy drinking and 7.0 % more obesity.

One of the limitations of the study, Miller said, is that it relies on data from self-reported surveys. “Because we haven’t taken a cohort of people and tracked them from their childhood, but rather have taken people and asked them what happened in their childhood. and there’s always inaccuracies in recall,” he said.

One big takeaway from the study is the need for prevention. “For a lot of these [health-related] problems, there is no system set up to assure that kids when they’re exposed to an ACE don’t develop toxic stress, or to reduce the likelihood that they’ll develop toxic stress. I think that’s a challenge that we need to face as a society and start a dialogue about,” said Miller.