Following the implementation of the Affordable Care Act (ACA) in 2014, which provided health insurance to low-income adults, cost-related nonadherence (CRN) with medication decreased in stroke survivors, according to a study in JAMA Neurology.
Data recorded in the National Health Interview Survey between 2000 and 2016 were collected and reviewed. A total of 13,930 people who survived a stroke and who participated in the survey were enrolled for analysis, with outcomes compared between patients age 45 to 64 years (n= 4926) vs those age 65 years or older (n=9004).
Self-reported CRN, which was characterized as the inability to purchase (ie, afford) medications within the past 12 months, comprised the primary outcome. A total of 4 time periods (in years) were used to compare outcomes: 2000 to 2005 (historical control), 2006 to 2010 (economic recession and peak unemployment), 2011 to 2013 (prior to implementation of the ACA), and 2014 to 2016 (post-ACA implementation).
Medicaid coverage increased from 2011 to 2013 (24.0%; 95% CI, 21.0%-27.2%) through 2014 to 2016 (30.8%; 95% CI, 27.3%-34.6%), an increase that was considered statistically significant (P <.001). Additionally, the investigators observed a significant reduction in uninsured people with previous stroke age 45 to 64 years from 13.7% in 2011 to 2013 (95% CI, 11.3%-16.4%) to 6.8% in 2014 to 2016 (95% CI, 5.3%-8.8%; P <.001).
In patients age 45 to 64 years, there was an observable increase in CRN prior to ACA implementation. Specifically, the investigators found an 18.6% increase in CRN rates between 2000 and 2005 (95% CI, 16.5%-20.9%), a 22.6% increase in 2006 to 2010 (95% CI, 19.7%-25.9%), and a 23.8% increase in 2011 to 2013 (95% CI, 20.7%-27.3%).
An 18.1% decrease in CRN was found after implementation of the ACA between 2014 and 2016 (95% CI, 15.4%-21.3%; P =.01). Following adjustment for year, sociodemographics, and clinical factors, there were lower odds of CRN directly after ACA implementation (odds ratio, 0.63; 95% CI, 0.47-0.85). Additional adjustment for health insurance coverage attenuated this difference (odds ratio, 0.76; 95% CI, 0.56-1.03).
The reliance on self-reported stroke history data as well as the lack of measurement of stroke features and other potential confounders are likely limitations of the study.
Findings from the analysis suggest that further ACA expansion “is likely to be advantageous for survivors of stroke in those states.”
Levine DA, Burke JF, Shannon CF, Reale BK, Chen LM. Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act [published online August 27, 2018]. JAMA Neurol. doi: 10.1001/jamaneurol.2018.2302