Stroke Survivors in the US Face Steep Gaps in Care, Mobility and Mental Health

Stroke remains one of the most feared medical events in modern life, and for good reason: it strikes suddenly, often without warning, and can rewrite a person’s future in a matter of minutes. But surviving a stroke is only the beginning of a much longer story. A new national analysis of US survey data reveals that the years after a stroke are marked by sharply elevated rates of emergency department visits, severe difficulty walking or climbing stairs, and depression, along with a troubling pattern of unmet medical needs that concentrates among middle-aged and uninsured survivors. The findings, drawn from more than 118,000 adults surveyed between 2019 and 2023, offer one of the most detailed contemporary portraits yet of what life looks like for the millions of Americans living with the aftermath of stroke.

The study, published in BMC Public Health by Wenlong Wang, Defu Yu and Minghui Zhu of The First People’s Hospital of Changzhou, pooled four waves of the US National Health Interview Survey, a large, nationally representative household survey administered by the National Center for Health Statistics. The researchers combined data from 2019, 2021, 2022 and 2023, a period spanning the COVID-19 pandemic and the survey’s methodological redesign, yielding a pooled sample of 118,652 adults, of whom 4,355 reported having had a stroke. Because the survey uses a complex multistage sampling design, the team applied survey weights and statistical procedures that account for clustering and stratification, ensuring that their estimates reflect the entire noninstitutionalized US adult population rather than just the people who happened to be interviewed.

The headline numbers are stark. After adjusting for age, sex, race and ethnicity, income, insurance status, comorbidities and other demographic and health factors, stroke survivors were 43 percent more likely than adults without stroke to have visited an emergency department at least once in the preceding year, and 61 percent more likely to have made two or more such visits. Repeated emergency visits are widely recognized in emergency medicine as a signal of fragmented care, inadequate outpatient follow-up, or complications that spiral into crises, so this pattern suggests that many survivors are cycling through hospital doors rather than receiving stable, preventive management of their conditions.

Functional disability emerged as perhaps the most dramatic disparity. Stroke survivors were 81 percent more likely to report severe difficulty walking or climbing steps compared with adults who had never had a stroke. This single measure captures the physical toll of stroke in a way that clinical scales often miss: the struggle to climb a staircase, cross a parking lot, or simply move through one’s own home. Stroke damages the brain’s motor pathways, and the resulting weakness, spasticity, balance problems and fatigue can persist for years. The finding underscores that stroke is not merely an acute cardiovascular event but a chronic condition that reshapes daily life long after hospital discharge.

Mental health told a similar story. Ever-diagnosed depression was 31 percent more prevalent among stroke survivors than among the general adult population, even after full statistical adjustment. The relationship between stroke and depression is well documented in clinical literature and is thought to involve both biological mechanisms, such as inflammatory and neurochemical changes following brain injury, and psychological responses to sudden disability, loss of independence and altered life circumstances. The persistence of this association in a large, nationally representative sample reinforces the argument that mental health screening should be a routine component of post-stroke care rather than an afterthought.

Unmet care needs, defined in the survey as medical care that a person needed but did not receive or delayed because of cost, showed a more complicated and revealing pattern. In the crude, unadjusted comparison, stroke survivors were only modestly more likely to report unmet needs, with a prevalence ratio of 1.19. But once the researchers adjusted for age and sex, the ratio jumped to 1.77, a nearly 80 percent elevation. The reason lies in the unusual age distribution of unmet needs among survivors: the disparity was concentrated at ages 45 to 64, where the prevalence ratio reached 1.87, and ages 65 to 79, where it climbed to 2.13, while it was not significantly elevated among the youngest adults or those aged 80 and older.

This non-monotonic age pattern carries important policy implications. Middle-aged stroke survivors often fall into a coverage gap: too young for Medicare, yet frequently unable to maintain stable employment-based insurance because stroke-related disability limits their ability to work. Older adults aged 80 and above, by contrast, are nearly universally covered by Medicare, which may explain why their unmet needs did not differ from those of their peers without stroke. The authors also found that unmet needs were inversely associated with age 80 and above among survivors themselves, further supporting the insurance interpretation. In other words, the American health insurance architecture appears to leave a visible fingerprint on who gets care after a stroke and who goes without.

The strongest correlate of unmet need, however, was insurance status itself. Among stroke survivors, those with insurance were dramatically less likely to report unmet needs than the uninsured, with an adjusted prevalence ratio of 0.23, meaning insured survivors had less than a quarter of the unmet-need prevalence of their uninsured counterparts. Unmet needs were also associated with higher emergency department use, with a prevalence ratio of 1.24 for at least one visit and 1.36 for two or more visits, as well as with fair or poor self-rated health and depression. This constellation of associations paints a coherent picture: when cost barriers prevent survivors from obtaining timely medical care, their conditions worsen, and they end up in emergency departments, the most expensive and least effective setting for managing chronic post-stroke needs.

The researchers also examined whether these disparities were changing over time, comparing fully adjusted prevalence ratios across the four survey waves from 2019 to 2023. The year-specific estimates fluctuated without a consistent direction, and the confidence intervals overlapped for every outcome examined, meaning the data cannot demonstrate either improvement or deterioration across this period. That stability is itself notable: it suggests that the burdens carried by stroke survivors, in emergency use, disability and depression, are not transient artifacts of the pandemic era but persistent features of the American health landscape. Sensitivity analyses, including those excluding proxy respondents and the 2019 wave, and those adjusting how comorbidities such as dementia and cancer were counted, supported the robustness of the main findings.

For clinicians and policymakers, the study identifies concrete, actionable targets. Transitional-care interventions, structured programs that bridge the gap between hospital discharge and stable outpatient management, could reduce the emergency department burden by ensuring that survivors receive timely follow-up, medication management and rehabilitation. Expanding insurance coverage for middle-aged adults with disabilities, and strengthening cost protections for the uninsured, could directly attack the unmet-need problem at its source. And routine screening for depression and mobility limitations could ensure that the mental and functional consequences of stroke are treated with the same urgency as its cardiovascular precursors. As the population ages and stroke survival improves, the number of Americans living with post-stroke disability will only grow, making the question of who receives care, and who falls through the cracks, one of the defining health policy challenges of the coming decade.

Subject of Research: Health care use, unmet needs and functional disability among US stroke survivors

Article Title: Health care use, unmet needs, and functional disability among US stroke survivors: a pooled cross-sectional analysis of the National Health Interview Survey, 2019–2023

Article References: Health care use, unmet needs, and functional disability among US stroke survivors: a pooled cross-sectional analysis of the National Health Interview Survey, 2019–2023. (n.d.). https://doi.org/10.1186/s12889-026-29952-z

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29952-z

Keywords: stroke, health care utilization, unmet health care needs, emergency department, functional disability, depression, National Health Interview Survey, insurance coverage, health disparities, public health, prevalence ratio, transitional care