Better breast cancer care among extremely poor women in Canada than in the United States: Historical cohort support of a health insurance explanation

The most substantial reform of American health care since the 1960’s Great Society reforms, the Affordable Care Act (ACA), became law in the midst of the Great Recession. Advocates of Canada-like, single-payer reforms wondered about the act’s ultimate effects as it leaves the present multi-tiered health care system in the US essentially intact. This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multi-payer system that leaves many uninsured or underinsured by comparing breast cancer care among extremely poor women in Ontario and California between 1996 and 2011. The Canadian women were consistently advantaged particularly as compared to inadequately insured American women. They were diagnosed earlier (standardized rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48) as well as radiation (RR = 1.60) and hormone therapies (RR = 1.78). The Canadian women even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44). Consequently, the Canadian women were much more likely to survive longer. Regression analyses indicated that health insurance explained most of the Canadian advantages. Over this study’s 15-year timeframe 31,500 late diagnoses, 94,500 sub-optimum treatment plans and 103,500 early deaths were estimated among poor American women due to the relative inadequacy of their health insurance coverage. The ACA will probably reduce such inequities by half, while single-payer reform would probably completely eliminate them. Making high quality health care available to all Americans seems a necessary step toward a just society.