Full Citation

Title: The Affordable Care Act and Stroke

Citation Type: Journal Article

Publication Year: 2014

ISBN:

ISSN:

DOI: 10.1161/STROKEAHA

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PMID:

Abstract: T he Patient Protection and Affordable Care Act (ACA) was enacted on March 23, 2010, and has important implications for stroke care. The ACA is a comprehensive reform, although the signature component is the expansion of health insurance primarily by expanding Medicaid eligibility and by providing subsidies for consumers to purchase private insurance in online marketplaces called exchanges. Although many ACA provisions went into effect with its passage or have been phased in during the past several years, the Medicaid expansion and insurance exchanges went into effect more recently in January 2014. In this article, we begin by describing the working-age stroke population. We then discuss the health insurance provisions of the ACA, which largely target the working-age stroke population, and implications for racial/ ethnic and geographic disparities. We then focus on how the ACA may affect stroke prevention, treatment, and postacute care (PAC). We conclude by discussing how health system reform under the ACA could affect patients with stroke. Stroke Among Working-Age Americans Working-age Americans, those aged 19 to 64 years, are experiencing stable or increasing stroke incidence even as overall stroke incidence is decreasing over time. 1,2 Although racial and ethnic stroke disparities are present overall, the largest disparities are found among working-age Americans. 1,2 To provide national estimates of stroke hospitalizations and insurance status among the working-age population, we used data from the Nationwide Inpatient Sample, a nationally representative sample of hospitalizations (for detailed methods, see online-only Data Supplement). In 2010, ≈230 000 or 37% of all stroke hospitalizations were among patients aged <65 years. Of the working-age stroke hospitalizations, 20% were among patients who had Medicaid and 14% were among uninsured. Disparities in stroke hospitalizations and insurance status, particularly among blacks, are striking. First, hospitalizations among the working age are more frequent in blacks (26.5%) than would be expected on the basis of their population representation in the under 65 population (12.5%; Figure 1). 3 Stroke hospitalizations in working-age blacks (10.1% of all stroke hospitalizations) comprise a greater proportion of all stroke hospitalizations than those aged >65 years (8.3% of all stroke hospitalizations), a striking finding given the increase in stroke risk with advancing age. In addition, racial and ethnic minorities comprise 60% of Medicaid hospitalizations and 54% of the uninsured hospitalizations among the working-age population (Figure 2). Among working-age blacks, 17% of stroke hospitalizations are among uninsured individuals and 27% are among Medicaid recipients. These proportions are similar in Hispanics where 18% of stroke hospitalizations are among the uninsured and 30% are among Medicaid recipients. Limitations to the race/ethnic comparisons should be noted given that 4 states or 11% of the hospitalizations do not provide race/ethnic data in the 2010 Nationwide Inpatient Sample and thus were excluded from the race/ethnic analyses. Using data from the 2012 National Health Interview Survey, similar patterns are seen among community-dwelling stroke survivors in the United States (for detailed methods, see online-only Data Supplement). Of the 3.17 million community dwelling adult stroke survivors represented in National Health Interview Survey, 1.29 million (41%) are <65 years of age. Sixty-six percent of working-age stroke survivors are non-Hispanic white, 24% are black, and 10% are Hispanic, whereas 16% are uninsured and 26% are Medicaid recipients. Disability is common among working-age stroke survivors. Fifteen percent of working-age stroke survivors need help with activities of daily living (bathing, dressing, eating, getting around inside their home), and 25% need help with instrumental activities of daily living (everyday household chores, doing necessary business, shopping, or getting around for other purposes). The ACA has important implications for all phases of stroke care, given that a significant proportion of working-age patients with stroke are uninsured at the time of their stroke and a significant proportion of stroke survivors remain uninsured. The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/

Url: http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.

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Authors: Skolarus, Lesli E; Jones, David K; Lisabeth, Lynda D; Burke, James F

Periodical (Full): Stroke

Issue: 8

Volume: 45

Pages: 2488-2492

Data Collections: IPUMS USA

Topics: Health

Countries: United States