This study supports previous research observing correspondence between a higher ACE count and a greater burden of disease6,8,9,14 as well as previous findings of a high ACE-associated adult health economic burden in studies using similar cross-sectional PAF methods in Europe and North America,6,7 the UK,8 and California.9 Medical spending represents financial costs to specific, identifiable payers (including individual persons, health insurance payers, and employers), but most of the economic burden presented herein comes from healthy life-year losses based on the value of statistical life estimates. The value of what is lost in quality and number of life-years is not completely identifiable through financial transactions and thus not as visible as direct costs, such as medical spending or employer costs from lost work productivity. This study valued reduced quality and number of life-years in monetary terms based on recommended US estimates, which are higher than common alternatives, such as 1 to 3 times per capita gross domestic product.6,7 An alternative DALY valuation using 2019 US gross domestic product per capita ($65 000) with this study’s data would yield an economic burden estimate of $1.7 trillion (8% of 2019 US gross domestic product).31
