BETHESDA, MD – Military Health System patients tend to receive earlier diagnoses of colon cancer and other types of malignancies than members of the general U.S. population covered by insurance, especially Medicaid.
“The presented findings provide evidence that patients in the MHS had diagnosis of common cancers at an earlier stage, compared to various insurance types in the general U.S. population,” wrote researchers from Walter Reed National Military Medical Center, the Uniformed Services University of the Health Sciences, the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and the Uniformed Services University of the Health Sciences, all in Bethesda, MD. “ This difference was largest compared to the uninsured and Medicaid groups, while it was minimal for the SEER-insured groups.”
A key difference, according to the Cancer Medicine study, is that individuals, retirees, and their families have free care or minimal out-of-pocket costs in the MHS, while out-of-pocket insurance costs in the United States general population can vary substantially.1
Also, specifically with colon cancer, “reported rates of screening are higher among patients with military insurance, whereas screening is less common among patients with Medicaid and least common among uninsured patients,” the authors wrote.
For the study, patients were identified from the DoD Automated Central Tumor Registry (ACTUR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program. Using the categories “insured,” “insured-no specifics,” “any Medicaid,” and “uninsured,” tumor stage at diagnosis of colon, breast, prostate and lung during 2007-2013 was compared among ACTUR and SEER categories. Included in the analysis were 18,440 eligible patients identified from ACTUR and 831,959 patients identified from SEER.
“For all cancer types, patients in the SEER-insured/no specifics, Medicaid, and uninsured groups had significantly greater likelihood of late stage diagnosis compared to ACTUR patients,” according to the authors. “The adjusted ORs were greatest among uninsured and Medicaid patients.”
The researchers concluded that MHS patients with universal access to healthcare were diagnosed at an earlier stage than those in the general population, especially when compared to Medicaid and uninsured groups.
“Early detection of cancer results in decreased mortality, and in order for a malignancy to be detected and diagnosed, a person must have access to medical care,” the study pointed out. “At present, the United States remains without a means in which to provide effective healthcare for its entire population.”
The study team advised that annual premiums for a typical employer sponsored plan were more than $4,000 in 2012 and have increased since. In that year, about half of Americans were covered by an employer-sponsored plan, 18% received coverage through Medicaid, and 15% were uninsured. By 2019, the percentage of uninsured had decreased to 9% in 2019, while other categories increased. with commensurate increases in other categories.
The MHS provides primary care, cancer screening, diagnostic imaging, and cancer treatment. Beneficiaries include active duty members, retirees, and their family members.
“The MHS provides universal health care to its beneficiaries,” the authors noted. “Our previous studies showed that MHS beneficiaries had earlier stages of colon, breast, and lung cancers compared to the population in the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry. However, these studies did not subdivide the SEER population by insurance status category. Comparison of each insurance status to the MHS can offer more nuanced evidence of its association with stage at diagnosis.”
The researchers reported that their results showed a later stage at diagnosis for colon, breast, prostate and lung cancers in Medicaid and uninsured groups compared to the MHS, across age groups. A later stage at diagnosis for colon cancer with privately insured groups compared to the MHS was not identified, however.
While later diagnosis among Medicaid patients could not be explained by cost sharing, since those patients have very low out-of-pocket costs, “uninsured patients are often enrolled in and classified under Medicaid shortly after a new cancer diagnosis. This may also contribute to later stage diagnosis in this group,” the study noted.
Also contributing were factors such as time to initial presentation, time to specialist referral, time to diagnostic testing, and time to definitive treatment.
Another issue is screening, “an important path” to diagnosis for colon, breast and prostate cancers, the study authors wrote. “Higher utilization of screening services in the ACTUR population may contribute to earlier stage at diagnosis,” they explained. “While breast cancer screening rates may be similar among patients with military insurance and private insurance, screening rates are lower among patients with Medicaid and especially for uninsured patients.”
The authors also emphasized that their study was performed before the ACA eliminated out-of-pocket costs for cancer screening for those not previously covered.
- Flanary JT, Lin J, Shriver CD, Zhu K. Cancer stage at diagnosis: Comparison of insurance status in SEER to the Department of Defense Cancer Registry. Cancer Med. 2023 Oct 30. doi: 10.1002/cam4.6655. Epub ahead of print. PMID: 37902129.