This article appears in November Family magazine.

For National Diabetes Month this November, here’s an eye-opener: Americans with diabetes are paying a steep price to stay alive. Between 2002 and 2013 the average list cost of insulin nearly tripled, according to the American Diabetes Association.

More than 30 million Americans have diabetes, and about 7.5 million of them rely on the drug insulin for treatment. There is no medication that can be substituted for insulin.

For the people who need it, “insulin is a matter of life and death,” Dr. William T. Cefalu, the American Diabetes Association’s chief scientific, medical and mission officer, said in a statement.

Diabetes is a chronic condition characterized by high levels of blood sugar resulting from the body’s inability to maintain normal levels of glucose. People with Type 1 diabetes are unable to produce insulin, while people with Type 2 diabetes may still be able to produce insulin early in the disease but the body may not respond to it.

In response to mounting costs, nearly 25 percent of Americans with diabetes are rationing insulin or doing without basic necessities to afford insulin, according to a study presented at the June conference of the American Diabetes Association. Rationing of insulin is a life-threatening practice and increases the risk of the complications of diabetes, including blindness, amputation, kidney failure, heart disease and stroke.

Diabetes isn’t just expensive for the people who have it. Current estimates rank it as the most expensive chronic disease in America, with diagnosed diabetes costing more than $327 billion in 2017, including $15 billion for insulin, according to the American Diabetes Association.

For diabetics struggling with the affordability of medication, the American Diabetes Association suggests that people discuss the costs of different insulin preparations. They should request the lowest-priced insulin required for safe and effective treatment, which may include human insulin, which is less expensive than synthetic insulin. Human insulins are available at the pharmacy for $25 to $100 per vial compared with synthetic, also called insulin analogs, at $174 to $300 per vial, according to the American Diabetes Association.