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. Author manuscript; available in PMC: 2025 Feb 1.
Published in final edited form as: Am J Gastroenterol. 2023 Aug 21;119(2):270–277. doi: 10.14309/ajg.0000000000002405

The Rising Costs of Alcohol-associated Liver Disease in the United States

Jovan Julien 1,2, Turgay Ayer 3, Elliot B Tapper 4, Jagpreet Chhatwal 1,2,5
PMCID: PMC10872874  NIHMSID: NIHMS1917636  PMID: 37463414

Abstract

Introduction:

Alcohol-associated liver disease (ALD) is rising in the United States because of an increase in high-risk drinking, but population-level ALD cost is unknown. Our aim was to project the direct and indirect costs associated with ALD in the US population through 2040.

Methods:

We utilized a previously validated microsimulation model of alcohol consumption and ALD with model parameters estimated from publicly available data sources, including the National Epidemiologic Survey Alcohol and Related Conditions-III, the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research, the Bureau of Labor Statistics, and published studies informing the impact of alcohol consumption on ALD severity in the United States resident population. The simulated scenario included current and projected ALD-associated costs.

Results:

From 2022-2040, the ALD is projected to cost $880 billion; $355 billion in direct healthcare-related costs and $525 billion in lost labor and economic consumption. The annual cost of ALD is projected to increase from $31 billion in 2022 to $66 billion (118% increase) in 2040. While the female population makes up 29% of these costs in 2022, by 2040 on a per annum basis, female costs would be 43% of the total annual expenditure.

Discussion:

Increased consumption of alcohol in the US population, especially in females, will cause a steep rise in the economic burden of alcohol-associated liver disease in the United States. These findings highlight the need for planners and policymakers to plan for the increased impact of liver disease in the United States.

Keywords: costs, substance use, high-risk drinking, alcohol use disorder, simulation

Introduction

As the third leading cause of preventable death in the United States (US), alcohol-associated mortality is a significant driver of disease burden and mortality in the US healthcare system.1 A recent series of nationally representative surveys in the United States measured increases in the overall population’s consumption of alcohol.2,3 Alcohol consumption increases are projected to substantially increase morbidity and mortality associated with alcohol consumption in the next two decades.4 Prior increases in consumption amongst young people, and particularly young women have led to increases in ALD mortality from 1999 to 20165. They are projected to lead to increases in ALD mortality and morbidity in coming years6. Global alcohol exposure is projected to increase (with abstinence decreasing while drinking and heavy episodic drinking increase) between 2017 and 2040.7 For example, from 2019 to 2020, age-adjusted mortality rates for ALD in the US increased by 23.4%8 and increases in consumption are projected to add 8,000 ALD deaths and nearly 19,000 decompensations over the next two decades.4

Besides the varied effects of alcohol on health across the lifespan, beginning with prenatal exposure through liver disease and mortality, alcohol consumption and their associated conditions have a significant economic and disease burden in the US.5,9,10 With alcohol-associated mortality rising over the previous decades and significant consumption increases during the COVID-19 pandemic, the economic burden of alcohol-associated liver diseases can be expected to grow.3,4,11 While economic burden has begun to be studied, current economic losses are unavailable.12 In addition, future trends in economic burden have yet to be fully evaluated. From 2012 to 2016, the total cost burden of ALD cirrhosis hospitalizations was $22.7 billion.13 Amongst individuals with chronic liver diseases in the US, total healthcare costs were $14,000 more than those without chronic liver disease; chronic liver disease was associated with lower employment, lost work, and greater psychological distress.14 Understanding the long-term implications of current patterns of alcohol use is critical to planners for planning and policy design.15 Such estimates and projections could inform appropriate policies to curb the rising disease burden and provide potential cost savings achievable by interventions that reduce the ALD burden. Therefore, our objective was to estimate the current and project the future economic burden of direct healthcare spending, productivity loss, and premature mortality due to ALD in the US population, while incorporating the impact of COVID-19 induced drinking changes.

Methods

Model Description

We extended a previously validated microsimulation model, Alcohol Policy Simulation Model (ALP-SIM) of alcohol-associated liver disease and alcohol consumption in the United States to conduct cost projections from the healthcare and societal perspectives.16 The ALP-SIM microsimulation model of ALD for US adults16 accounts for current age-cohort and sex-based drinking rates as collected by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 17, drinking trajectories in the US population18, fibrosis progression rates, and varying rates of alcohol consumption.19 The ALP-SIM model has previously been used to project morbidity and mortality changes in the US population due to drinking pattern changes.6 The model further accounted for changes in drinking consumption during the COVID-19 pandemic and their future impact on disease burden.4 In this study, ALP-SIM was expanded to incorporate direct and indirect costs of ALD.

At any given time, a patient occupies one of the states in the model, which is defined by a combination of their drinking levels and liver health stage. Individuals transition from one health state to another based on progression and regression rates that are dependent on drinking level and sex. Drinking levels change dynamically each year. The model was developed in R, version 4.2.2 (R Foundation for Statistical Computing).

Figure 1 depicts the mutually exclusive states occupied by individuals in the model. A patient is represented by the combination of one of the health states and one drinking state, shown here as rectangles and circles. Arrows between states represent annual transition probabilities. Competing-cause mortality, the probability of dying from other causes both related and unrelated to alcohol use, exists in every state, but are not shown in our diagram for simplicity.

Figure 1: State-transition model of the natural history of alcohol-related liver disease and drinking state.

Figure 1:

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A patient is represented by the combination of a drinking state and disease state, shown here as circles and rectangles, respectively. States H1–H5 represent tunnel states to simulate healthy liver pre-drinking states. As individuals progress from H1 to H5 the risk of their first drink increases until they commence drinking. We simulate the following levels of alcohol consumption: never having consumed alcohol (denoted H1 – H5 in the model), abstinence, low-risk (< 3 drinks per day), medium risk (3-4 drinks per day), high-risk (4-7 drinks per day), and very high-risk states (> 7 drinks per day). After drinking commences, transitions occur between every drinking level (abstinence, low risk, medium risk, high risk, and very high-risk drinking). States C1 and C2 represent the naturally occurring range of liver susceptibility of individuals in the US population by age and sex to ALD. Individuals who drink can develop ALD. The natural history of ALD in the model is represented by fibrosis stages (F1–F4) and the darker blue stages represent various complications of decompensated cirrhosis. Patients could develop hepatocellular carcinoma or die from liver-related mortality or background mortality. Competing-cause mortality, the probability of dying from other causes both related and unrelated to alcohol use, exists in every state, but are not shown in our diagram for simplicity.

Abbreviations: pre-drinking tunnel states (H1–H5), no fibrosis (F0), mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), compensated cirrhosis (F4), hepatocellular carcinoma (HCC)

Abbreviations: pre-drinking tunnel states (H1–H5), no fibrosis (F0), mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), compensated cirrhosis (F4), hepatocellular carcinoma (HCC)

States H1–H5 represent tunnel states to simulate healthy liver pre-drinking states. As individuals progress from H1 to H5 the risk of their first drink increases until they commence drinking. These states are calibrated to reproduce the distribution of the age at first drink for the US population as evidenced in the National Epidemiologic Survey on Alcohol and Related Conditions-III.

States C1 and C2 represent the naturally occurring range of liver susceptibility of individuals in the US population by age and sex to ALD. Susceptibility is modelled as a distribution of time during which the liver’s regenerative capacity can counteract the negative effects of alcohol until an individual transitions to the initial liver fibrosis stage.

We simulate the following levels of alcohol consumption: never having consumed alcohol (denoted H1 – H5 in the model), abstinence, low-risk (< 3 drinks per day), medium-risk (3-4 drinks per day), high-risk (4-7 drinks per day), and very high-risk states (> 7 drinks per day). After drinking commences, transitions occur between every drinking level (abstinence, low risk, medium risk, high risk, and very high-risk drinking) consistent with rates found in Barbosa et al., 2019. 18

Individuals who drink can develop ALD. The natural history of ALD in the model is represented by fibrosis stages defined as no fibrosis (F0), mild fibrosis (F1) moderate fibrosis (F2). F3 indicates septal fibrosis, F4 compensated fibrosis, and the darker blue stages represent various complications of decompensated cirrhosis. Patients could develop hepatocellular carcinoma (HCC) or die from liver-related mortality or background mortality. Further details about the alcohol-consumption natural history model can be found elsewhere 16 and transition probabilities between health and drinking states are available in the appendix (Appendix Tables 1-3).

Our model accounts for increased alcohol consumption during COVID-19. Alcohol consumption changes recorded from February to March 2020 in the US were durable through at least November 2020.3 As a model input, we consider changes in drinking level by age and sex as recorded by a national survey(n = 993) of a representative sample of the US population aged 21 and older.2,3 Individuals in the model remain at their current drinking level, transition to a higher drinking level, or lower drinking level with rates calibrated to the overall increase seen in the survey. Consumption increases are maintained for a one-year period.

Costs

The costs of care related to each state is based on the average cost of treatment in the US healthcare system for the health conditions associated with each health state in the model10. For individuals in pre-cirrhosis stages, we estimate only 10% of individuals are aware of their condition and will incur healthcare-related costs. For individuals having compensated cirrhosis and decompensated cirrhosis we assume all of them are aware of their disease and will incur healthcare-related costs. Costs are differentiated between the first year after diagnosis and each year thereafter, where necessary. See Appendix Table 4 for details.

Additional to the individual and healthcare sector direct health care costs described above, the model also captures indirect costs related to the impact of early mortality on society, which are defined by expected productivity losses in the labor market and annual economic consumption lost due to previous alcohol-associated cirrhosis deaths using a framework proposed by the Second Panel on Cost-effectiveness in Health and Medicine.20 To calculate losses in the labor market costs, we use sex- and age-based statistics on labor market participation and expected annual income in the civilian workforce to calculate productivity losses due to early mortality before the age of 77.21

We use a similar methodology to find the expected value of consumption from the time of death through age 77. Statistics on consumption used to conduct the analysis are sourced from the Bureau of Labor Statistics (BLS) reports on consumer spending that report mean annual expenditure by age group.22 In the context of the civilian work force, only non-healthcare expenditures captured by the BLS surveys are incorporated into the model ensuring a conservative measure of lost economic activity that does not double count the direct health expenditures on liver care.

Model Calibration and Validation

We calibrate the model with a calibration function for the C1 and C2 transition probabilities. These states represent the natural variation in the population susceptibility to liver disease. The associated transition probabilities are calibrated to reproduce mortality trends captured in the CDC WONDER database for 2010-2014 as described in the previous paper.16 All other natural history transition probabilities utilized in the model are sourced from published studies (Appendix Table 1 and 2).

Initial model validation was achieved by comparing model-predicted annual mortality from 2014 to 2018 for men and women against mortality captured in the CDC WONDER database (Appendix Figure 1 and 2). Additional validation was achieved by comparing model-estimated and reported prevalence of alcohol-associated cirrhosis in 2009 and 2015 (Appendix Table 5).10

Model Outcomes

Alcohol-associated liver disease imposes costs on the healthcare system and society. Model outcomes reported include annual direct healthcare and indirect societal costs associated with ALD from 2022 to 2040. Results are reported for the entire population, by sex assigned at birth and by age groupings. Direct costs are also reported by ALD sequelae.

Sensitivity Analysis

We determined uncertainty in our model projections using a probabilistic sensitivity analysis by joint uncertainty of model parameters, in particular natural history of disease, transition rates, and drinking distribution. Parameter uncertainty is defined using recommended distributions for different types of parameters (see Appendix Table 1).23 Parameter values are sampled 1000 times from these distributions and the model is run again to determine results. The populations used were 1/10th the size of the US birth cohort. We generated the 95% uncertainty intervals of model outcomes. .

Results

We estimated that the annual ALD costs in 2022 were $31 [95% UI $29 - $32] billion, of which $11 [$10 - $11] billion are associated with direct healthcare and $20 [$19 - $21] billion with indirect costs of lost labor and economic consumption. By 2040, the annual alcohol-associated costs are are projected to increase by 118% to $66 [$64 - $69] billion, of which $28 [$27 - $29] billion would be associated with direct healthcare and $38 [$37 - $40] billion with indirect costs. Over the next 18 years (i.e., between 2022–2040), indirect and direct ALD could sap the US economy $880 [$845 - $915] billion (Figure 2).

Figure 2:

Figure 2:

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Projected annual (A) and cumulative (B) cost in billions for alcohol-associated liver disease in the US from 2022 to 2040

Abbreviations: United States Dollars (USD)

In the female population specifically, annual alcohol-associated costs are projected to increase by 231% from $9 [$8 - $9] billion ($4 [$3 - $4] billion direct costs and $5 [$5 - $5] billion for indirect costs) in 2022 to $29 [$28 - $30] billion ($13 [$13 - $14] billion direct costs and $15 [$15 - $16] billion for indrect costs) in 2040. Between 2022–2040, ALD costs attribuatable to female populations would be $325 [$312 - $338] billion (Appendix Figure 3, Figure 3). In the male population, annual alcohol- associated costs are projected to increase by 72% from $22 [$21 - $23] billion ($7 [$7 - $7] billion direct costs and $15 [$14 - $15] billion for indrect costs) in 2022 to $38 [$36 - $39] billion ($15 [$14 - $15] billion direct costs and $23 [$22 - $24] billion for indrect costs) in 2040. Between 2022–2040, alcohol-associated liver disease costs attribuatable to male populations would be $555 [$533 - $577] billion (Appendix Figure 3, Figure 3).

Figure 3:

Figure 3:

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Annual (A) and cumulative (B) alcohol-associated liver disease costs by sex from 2022-2040 in the United States

Abbreviations: United States Dollars (USD)

In 2022, alcohol-associated costs in the female population were 29% of the total costs. However, by 2040, alcohol-associated costs in the female population would be 43% of the total costs. (Figure 3) The rising total costs in the female subpopulation is particularly evident in the convergent costs of care in the 65+ age group, where the percentage of costs associated to females are projected to increase from 31% in 2022 to 45% in 2040. Amongst those age 18-65, the percentage of total costs associated to females is projected to increase from 30% in 2022 to 44% in 2040 (Figure 4).

Figure 4:

Figure 4:

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Annual (A, C) and cumulative costs (B, D) for alcohol-associated liver conditions by age and sex

The increase in total care costs is largely predicated on increases in decompensated cirrhosis costs of care. The annual costs attributable to decompensated cirrhosis in 2022 was $6.2 [$5.9 - $6.5] billion, which is projected to increase by 185% to $17.7 [$16.9 - $18.5] billion dollars in 2040. The annual costs attributable to compensated cirrhosis in 2022 was $2.3 [$2.3 - $2.3] billion and is projected to increase by 157% to $5.9 [$5.8 - $5.9] billion in 2040. Annual direct healthcare costs for complications related to early liver fibrosis stages including F1-F3 are projected to rise from $1.1 [$1.1 - $1.1] billion to $2.2 [$2.2 - $2.2] billion, a 100% increase. HCC-associated costs are projected to increase from $730 [$690 - $770] million in 2022 to $1.8 [$1.7 - $1.9] billion in 2040, a 147% increase (Figure 5).

Figure 5:

Figure 5:

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Projected Alcohol sequelae cost: US 2022-2040

Abbreviations: mild fibrosis (F1), moderate fibrosis (F2), septal fibrosis (F3), hepatocellular carcinoma (HCC)

Discussion

Alcohol-associated liver disease accounts for significant health burden and costs in the United States.24 In recent years, the proportion of individuals with alcohol-associated cirrhosis has increased.13 With recent increases in alcohol consumption, the societal burden of ALD is expected to rise. We projected long-term cost implications of healthcare and labor losses related to extant health crises such as alcohol-associated liver disease. We found that annual ALD-associated costs could more than double from 2022 to 2040 rising to $66 billion dollars and could erase $880 billion dollars from the economy. Additionally, costs related to ALD in females could rise from 29% in 2022 to 43% in 2040 of the total ALD-associated costs.

ALD is both a health and economic crisis

Multiple studies have shown the impact of excessive alcohol consumption on ALD and associated mortality for working age adults mortality, for whom nearly 1 in 10 deaths in the United States attributable to excessive consumption from 2006 to 2010.25 ALD is also an economic crisis. ALD is already a significant cost driver in the American health care system. In 2015, a nationally weighted measure of privately insured individuals found that approximately $5 billion dollars of direct health care costs were accrued by patients with ALD-associated cirrhosis; $44,835 in per-person in the first year after diagnosis.10 As the cost of care rises exponentially with worsening of the stage of disease and liver transplantation costs exceed $500,000, the future cost of ALD-care poses a significant burden for policy makers and health planners.

Our study provides new data on the population-level cost of ALD in the US. We also project future trends in population-level ALD-associated cost because of changing alcohol consumptions in the US population, especially among females. We also provide one of the first data on ALD cost burden from societal perspective. A critical insight from our results is that current consumption patterns are a significant risk for workers in their economic prime, causing significant increased burden to the economy through the indirect impacts of lost labor and economic activity. These losses compound the burden of the additional costs that are also expected among those >65 years old. Diminished productivity and increasing care costs will have implications for public payers, programs, and policy makers as well as individuals and their families who pay significant portions of the health-related costs for advanced care in ALD.

Sex as a differentiator in healthcare costs

American females have traditionally had much lower rates of ALD than males at the population level despite higher susceptibility at the individual level5,26. Reasons for these differences have been postulated to have biological and behavioral mechanisms at work26-29. However, the sharp rise in high-risk drinking in female populations in the United States in the recent years is projected to lead to a substantial rise in morbidity rates in females, which will close the gap between males and females by 2040.4 As a consequence, the proportion of ALD costs attributed to females is projected to increase substantially. This change is not representative of an overall decrease in costs in the male population but rather a convergeence in behavior and risks between males and females.4,30 The health-related consequences of convergent drinking behaviors should be thoroughly understood, as societal level recommendations on health consumption are made.

Comparison of ALD cost with other liver diseases

Our study provides new data on the population-level cost burden associated with ALD in the United States. Previous studies have estimated the cost burden of hepatitis C and non-alcoholic fatty liver disease. We found that annual healthcare ALD costs – $11 billion – are higher than the peak estimated annual healthcare cost of chronic hepatitis C virus ($9.1 billion in 2024).31 The current annual cost associated with nonalcoholic fatty liver disease was $292 billion, which is substantially higher than the current ALD cost of $31 billion.32 However, by including the cost of undiagnosed NAFLD, especially the majority with early stages of NAFLD, the study may have substantially overestimated the cost associated with NAFLD.

Clinical impact

There are 2 main ways that these data should inform our practice. First, we must prepare. The workforce must upskill and retool to meet the needs forecasted by these data. This includes improving training for all clinicians in the management of alcohol-use disorders, especially for those who manage ALD during residency, fellowship, and in continuing medical education. Increasing familiarity and comfort with motivational interviewing and alcohol use pharmacotherapy could be repaid with improved outcomes.33 Beyond that, screening for ALD amongst those with alcohol-use disorders and linking patients with effective care is known to be high yield and feasible with widely accessible tools such as the AUDIT-C questionnaire and biomarkers of liver fibrosis.33,34 Second, Policies to curb alcohol consumption are challenging to implement but their cause is strengthened by these robust cost-estimates. By defining the costs of the future burden of ALD, these data can be used to advocate for strengthening of policies. Local efforts to reduce access to excess alcohol have been shown to reduce ALD mortality.35 National efforts to reduce consumption have both reduced healthcare utilization and mortality attributed to ALD.36

Contextual factors

Our results must be interpreted in the context of the study design. First, data on drinking transitions among the general population is limited. Accordingly, we use the best available evidence on consumption patterns in lifetime sufferers of alcohol use disorders and the natural history model of ALD to replicate mortality in the US population. Validation of our model outcomes with reported data allows for confidence in our projections of disease burden and mortality and therefore associated costs. Second, while we model the increases in alcohol consumption associated with the initial outbreak of the COVID-19 pandemic, we do not account for any future changes in disease progression due to endemic spread of COVID-19 which has been shown to negatively impact liver health.37

Conclusion

Our study estimates a substantial population-level cost burden of alcohol-associated liver disease in the United States and projects increasing trends in these costs faced by the US population and healthcare system in years to come. Our findings highlight the substantial economic and disease burden of current consumption patterns and the need for policy and cultural shifts to address the growing societal burden associated with alcohol-associated liver disease.

Supplementary Material

Supplementary File

Study Highlights:

WHAT IS KNOWN

  • Alcohol-associated liver disease (ALD) prevalence and mortality have risen significantly in the past decade across all age groups.

  • The largest relative increase was amongst those aged 25-34.

WHAT IS NEW HERE

  • The annual cost of ALD is projected to increase from $31 billion in 2022 to $66 billion (118% increase) in 2040.

  • The percentage of costs associated with female drinkers from 2022 to 2040 will increase by nearly 50%.

Acknowledgement:

Dr. Chhatwal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Julien, Ayer, Tapper, and Chhatwal each approve this draft for submission.

Financial Support:

This study was funded by the American Cancer Society Research Scholar (grant RSG-17-022-01-CPPB to Chhatwal), and the National Institutes of Health through the National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK117055 and U01DK130113 to Tapper). This manuscript was prepared using a limited-access data set obtained from the NIAAA and does not reflect the opinions or views of NIAAA or the US Government.

Footnotes

Conflicts of Interest: none

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