Letter to the Editor: Temporal Changes in Cost-Related Medication Nonadherence by Race/Ethnicity and Medicaid Expansion: The Behavioral Risk Factor Surveillance System Survey

Management of chronic disease requires long-term use of multiple medications. However, adherence to medications is often suboptimal, with cost often reported as a major barrier.¹ Racial disparities and socioeconomic factors have been well described, with minorities often bearing a high burden of morbidity and mortality.² Since 2014, prescription drug prices have increased by 33%, and this may affect racial minority groups disproportionately. Cost-related medication nonadherence (CRMNA) may be offset by improving access to health care. For example, expanding Medicaid as part of the Affordable Care Act (ACA) can help mitigate CRMNA. We found that social determinants of health, including CRMNA, are associated with a high burden of comorbidities among individuals with cardiovascular disease.³ In the present study, we evaluate the prevalence of CRMNA over time for each race/ethnicity, stratifying by Medicaid expansion status.

We used cross-sectional data from the Behavioral Risk Factor Surveillance System survey (BRFSS; 2016–2018), a nationwide telephone-based survey of a random sample of US adults. All variables were self-reported. CRMNA was defined by answering “Yes” to the question “Not including over the counter (OTC) medications, was there a time in the past 12 months when you did not take your medications as prescribed because of cost?” We classified states as having expanded Medicaid if they had done so by the year 2020. Appropriate Centers for Disease Control and Prevention-provided survey weights were used for all analyses to account for the complex survey design of BRFSS and to ensure representativeness to the US population. The prevalence of CRMNA was calculated for each race/ethnic group for the years 2016 to 2018 and stratified by Medicaid expansion status. Analyses were conducted using Stata Statistical Software, version 16.1 (StataCorp LLC, College Station, Texas).

The study population consisted of 1,329,129 individuals; 21% aged ≥65 years, 51% women, 63% White, 12% Black, and 17% Hispanic. Prevalence of CRMNA in the overall population was 10%. A total of 69% reported living in a state that had undergone Medicaid expansion. Prevalence of CRMNA did not differ substantially between 2016 and 2018 for any racial/ethnic group among participants who did not live in Medicaid expansion states. However, there was a trend toward decreasing prevalence of CRMNA among those living in Medicaid expansion states, which was more pronounced for minority groups; from 2016 to 2018 the prevalence of CRMNA decreased from 14.3% (95% CI 12.3%–16.5%) to 11.6% (95% CI 9.6%–14.0%) for Blacks and 14.3% (95% CI 11.7%–17.3%) to 10.1% (95% CI 8.8%–11.6%) for Hispanics.

This study demonstrates that CRMNA has decreased among racial/ethnic minority groups who often have the highest burden of comorbidities and are the least able to afford health care. CRMNA tended to decrease in states that had undergone Medicaid expansion and the magnitude of this decrease tended to be more pronounced among racial/ethnic minority groups. With recent legislative battles surrounding the ACA, these results provide evidence that the provisions afforded by Medicaid expansion as part of the ACA have tangible societal benefits, especially for those who are most vulnerable.⁴

Author Disclosure Statement

Dr. Virani reports: research support from the Department of Veterans Affairs, World Heart Federation, and Tahir and Jooma Family; and honorarium from the American College of Cardiology (Associate Editor for Innovations, acc.org). The remaining authors declare that there are no conflicts of interest.

Funding Information

No funding was received for this letter.