Cost and transportation barrier trends related to Affordable Care Act among cancer survivors and atherosclerotic cardiovascular disease patients

Abstract

The Affordable Care Act (ACA) included major coverage expansions implemented in 2014. However, its association with cost‑related barriers among people with chronic disease remains incompletely described. We analyzed trends in cost and transportation related barriers to care between cancer survivors and adults with atherosclerotic cardiovascular disease (ASCVD) in relation to ACA implementation and expansion. National Health Interview Survey (NHIS) data from 2004-2024 for adults ≥18 years reporting a history of cancer or ASCVD without cancer were obtained. Primary outcomes were overall cost‑barrier and transportation barrier. We used survey weighted interrupted time series analysis (ITSA) with prespecified policy breakpoints and survey weighted modified Poisson regression to estimate associations between policy periods and barriers, adjusting for sociodemographic covariates. The analytic sample included 106,947 respondents: 63,505 cancer survivors and 43,442 adults with ASCVD without cancer. Overall cost barriers were reported by 8.1% of cancer survivors (n = 5,264) and 10.6% of adults with ASCVD without cancer (n = 4,772; p < 0.001). In adjusted models, the prevalence of overall cost barriers in 2022–2024 was lower than in 2004–2009 among both cancer survivors (aPR 0.63; 95% CI: 0.56-0.71) and adults with ASCVD without cancer (aPR 0.73; 95% CI: 0.65-0.82). In ITSA, cancer survivors had an immediate decrease in overall cost barriers at the 2022 breakpoint (-1.98 percentage points; p = 0.006). No substantial 2022 level change in overall cost barriers was observed among adults with ASCVD without cancer. Transportation barriers were higher in the post-pandemic period among years with available data, particularly among adults with ASCVD without cancer, but transportation ITSA findings were exploratory since data were unavailable in 2019–2021. Overall cost related barriers declined among U.S. cancer survivors and ASCVD patients, with the largest improvements observed in the most recent period. Nevertheless, increases in transportation-related delays underscore persistent structural barriers and highlight the need for targeted interventions to improve care accessibility.