Following implementation of the Affordable Care Act (ACA), cost-related medication nonadherence significantly decreased among adults who survived stroke, according to a study published in JAMA Neurology.

Study investigators examined temporal trends in health insurance coverage status and cost-related nonadherence by age. The study sample included 13,930 survivors of stroke who responded to an annual in-person household survey of the noninstitutionalized US population conducted by the National Center for Health Statistics. Study investigators stratified the data according to age group: respondents 45 to 64 years (38.1%) vs respondents over 65 years (61.9%).

Time was treated as both a continuous and a categorical variable, divided into 4 time periods: historical control (2000-2005), economic recession and peak unemployment (2006-2010), before ACA implementation (2011-2013), and after ACA implementation (2014-2016). The primary self-reported outcome was cost-related nonadherence, which was defined as the inability to afford prescription medications in the past year. Multivariable logistic regression models were used to estimate the association between cost-related nonadherence with temporal trends and ACA implementation.

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Among stroke survivors aged 45 to 65 years, Medicaid coverage increased significantly after ACA implementation from 24% (95% CI, 21%-27.2%; P <.001) between 2011 and 2013 to 30.8% (95% CI, 27.3%-34.6%; P <.001) between 2014 and 2016, while uninsurance decreased from 13.7% (95% CI, 11.3%-16.4%; P <.001) to 6.8% (95% CI, 5.3%-8.8%; P <.001) in the same period. In the same age cohort, cost-related nonadherence steadily increased before ACA was implemented, from 18.6% (95% CI, 16.5%-20.9%; P =.01) between 2000 and 2005 to 23.8% (95% CI, 20.7%-27.3%; P =.01) between 2011 and 2013, and decreased to 18.1% (95% CI, 15.4%-21.3%; P=.01) after ACA implementation.

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In stroke survivors over 65 years, cost-related adherence rates were relatively stable over time. After adjusting for sociodemographic and clinical factors, the period of time after ACA implementation was associated with lower odds of cost-related nonadherence for survivors of stroke aged 45 to 65 years (odds ratio, 0.63; 95% CI, 0.47-0.85), but not for survivors older than 65 years.

Limitations of the study included the use of self-reported data, including stroke history, and not measuring potential confounders, such as severity of stroke and medication use. In addition, the results are not generalizable to all survivors of stroke as the population only included noninstitutionalized respondents.

After ACA implementation, health insurance coverage increased and a reduction in cost-related nonadherence was demonstrated among stroke survivors aged 45 to 65 years. These results suggest that improved access to health care via expansion of Medicaid coverage may be associated with favorable outcomes for adult stroke survivors.

This study was supported by grants from the National Institutes of Health.


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.