By Lisa Rapaport

(Reuters Health) – With increased access to insurance under the Affordable Care Act (ACA), known as Obamacare, fewer middle-aged stroke survivors are skipping medications that they previously might have struggled to afford, a U.S. study suggests.

Stroke survivors take an average of 11 medications a day, researchers note in JAMA Neurology. Half of stroke survivors under age 65 spend at least 10 percent of their disposable income on health care, and these middle-aged people are more likely to be uninsured than older people who qualify for Medicare.

The new study focused on four periods: 2000 to 2005 as a historical control group; 2006 to 2010 during an economic recession and peak unemployment; 2011 to 2013 before ACA implementation; and 2014 to 2016 after ACA implementation.

The proportion of stroke survivors who didn’t take medications as prescribed due to cost rose steadily during the first three periods, from about 19 percent to almost 24 percent. However, after the ACA was implemented, that proportion fell to 18 percent.

“It was harder for younger stroke survivors to afford medications before the ACA because many were uninsured,” said study leader Dr. Deborah Levine of the University of Michigan Medical School in Ann Arbor. “After implementation of the Affordable Care Act, health insurance coverage, namely Medicaid, increased and skipping medications due to cost decreased among younger stroke survivors.”

From the period right before ACA implementation, 2011 to 2013, to the period after the law took effect, the proportion of stroke survivors receiving Medicaid benefits rose from 24 percent to almost 31 percent as many states made Medicaid available to adults who might not have qualified in the past.

Even after researchers accounted for health insurance, the ACA implementation was still associated with 24 percent lower odds that people would fail to take prescribed medicines.

Stroke survivors who skip or delay refilling medications or who take smaller than prescribed doses are at risk for another stroke, Levine said by email.

“Repeat strokes are more deadly, disabling, and costly than first strokes,” Levine said. “Stroke survivors who skip medications due to cost are more likely to have uncontrolled blood pressure, diabetes, and cholesterol that in turn increase their risk for stroke.”

The 13,930 stroke survivors in the study were 56 years old on average, ranging in age from 45 to 64.

The study wasn’t a controlled experiment designed to prove whether or how the ACA directly influenced medication compliance among younger stroke survivors. Researchers also relied on study participants to report any history of stroke, and this wasn’t verified with medical records.

Still, the results offer fresh evidence of the potential for expanded Medicaid coverage under the ACA to reduce hospitalizations of uninsured people for strokes and other major cardiovascular problems, said Dr. Joseph Ross, a professor of medicine and public health at Yale University in New Haven, Connecticut, who wasn’t involved in the study.

“It is no surprise, but reassuring to see, that after the ACA was enacted and Medicaid expanded in many states, that rates of uninsured hospitalizations declined among stroke survivors, as did rates of cost-related non-adherence as patients now had insurance, enabling them to afford the costs of the medications prescribed after their stroke,” Ross said by email.

Before the ACA, people without insurance who had a stroke or other major health event would likely be uninsurable afterward because of their pre-existing conditions, said Stacie Dusetzina, a researcher at Vanderbilt University School of Medicine in Nashville, Tennessee, who wasn’t involved in the study.

“Those individuals . . . would likely have a large number of medications prescribed to them to prevent subsequent strokes or treat other conditions, and they would likely have to pay out-of-pocket for the full price of those medications,” Dusetzina said by email. “Alternatively, if individuals were able to access Medicaid after the ACA they could have new access to medications at very low out-of-pocket prices.”

SOURCE: JAMA Neurology, online August 27, 2018.