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Brief Report
December 2018

Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act

Author Affiliations
  • 1Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Department of Neurology and Stroke Program, University of Michigan Medical School, Ann Arbor
  • 4formerly with Datacolor, Lawrenceville, New Jersey
JAMA Neurol. 2018;75(12):1538-1541. doi:10.1001/jamaneurol.2018.2302
Key Points

Question  How did cost-related medication nonadherence change among adult survivors of stroke after the implementation of the Affordable Care Act?

Findings  In this study of data from a nationally representative sample of 13 930 survivors of stroke in the United States, an absolute decrease of 5.7% in cost-related medication nonadherence among survivors of stroke aged 45 to 64 years was associated with the implementation of the Affordable Care Act.

Meaning  Expansion of Medicaid coverage in more states is likely to further improve medication affordability and adherence for adult survivors of stroke.


Importance  Among adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage.

Objective  To assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke.

Design, Setting, and Participants  This study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates.

Main Outcomes and Measures  The primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months.

Results  Among the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03).

Conclusions and Relevance  After the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.