People who survive a stroke in their 40s, 50s or early 60s may still have decades to live. But that's only if they take blood thinners, blood pressure drugs and other medications that can reduce their risk of a second stroke.
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Without insurance and money to cover the cost of those medications, patients might stop taking them, increasing the risk of another stroke. And another stroke will probably cause much more disability than the first — and cost much more to treat than the medications that could have prevented it.
Now, a new study shows what happened when more young stroke survivors got access to health insurance after the federal Affordable Care Act (ACA) took effect. Much of the credit may go specifically to the decision by a majority of states to let more people enroll in Medicaid.
In all, the ACA and Medicaid expansion stopped a trend that had been climbing for years: more and more stroke survivors younger than 65 lacking insurance who reported they didn't take their medications because of cost.
After the ACA's insurance programs went into effect in 2014, both trends reversed rapidly, data show. The study is published in JAMA Neurology.
Where once nearly 1 in 4 younger stroke survivors said cost had gotten in the way of their medication use, the number dropped to 18 percent. Meanwhile, among stroke survivors over age 65 who had access to Medicare, not much changed in either insurance status or cost-related nonadherence, as it's called.
"What's exciting about these findings is that they show that the ACA was effective at increasing insurance and decreasing cost-related nonadherence to medication among stroke survivors younger than 65 in the United States, suggesting that further expansion of Medicaid to additional states would have a larger impact and help stroke survivors in those states," says Deborah A. Levine, M.D., MPH, who led the University of Michigan team in the analysis.
Progress being made
Levine runs a clinic for stroke survivors at U-M's Frankel Cardiovascular Center, part of Michigan Medicine. Her experience treating stroke patients in Michigan — which expanded Medicaid in spring 2014 — prompted her to team up with colleagues to study national data collected by the Centers for Disease Control and Prevention.
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"Before expansion, many of the younger patients who I saw after a stroke were unable to afford their medication — and that contributed to their first stroke," says Levine, also an associate professor of internal medicine and neurology at the U-M Medical School and a member of the U-M Institute for Healthcare Policy and Innovation. "So we would work hard to try to help them find ways to get affordable medication to reduce the risk of another stroke.
"Now, more of my patients are qualifying for Medicaid, and so have greater access to stroke-preventive medications."
In all, nearly 31 percent of stroke survivors ages 45 to 64 in the new study were covered by Medicaid in 2014 to 2016, up from 24 percent in 2011 to 2013.
We see that the ACA, while it didn't eliminate the cost issue, had a significant impact on helping younger stroke survivors afford their medications.Deborah A. Levine, M.D., MPH
Problems left to tackle
Still, Levine cautions that Medicaid expansion, which is under consideration in three states and not enacted in 14 states, will reduce but not solve the problem of stroke survivors being unable to afford medications.
Many stroke survivors still struggle to afford their medications because they don't have insurance or their insurance shifts more of the medication costs to patients. These patients are still vulnerable.
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"All stroke survivors need affordable insurance and prescription drug coverage," Levine says. "In addition, they need affordable drug prices and copayments to get the medications they need and prevent another stroke."
For younger stroke survivors, being able to afford medications can be a life-or-death matter.
"These are the years when they are working and raising families. We don't want them having more strokes, which we know are likely to be more fatal and disabling," Levine says. "Stroke survivors are at an increased risk of another stroke."
The good news: Much of that risk can be alleviated by controlling vascular risk factors through medication and lifestyle changes.
Adds Levine: "We see that the ACA, while it didn't eliminate the cost issue, had a significant impact on helping younger stroke survivors afford their medications."
Additional study authors from Michigan Medicine include James Burke, M.D.; Bailey Reale, MPH; and Lena Chen, M.D., M.S.