Breast Cancer among Socioeconomically Vulnerable Women in Vulnerable Places: Historical Evidence of Better Care in Canada than in the USA

Better health care outcomes among Canada’s most socioeconomically vulnerable versus America’s have not been fully explained. We examined the pre-Affordable Care Act (ACA) effects of poverty, health insurance and physician supplies on breast cancer care among 7,250 women in Ontario or California between 1995 and 2010. Cancer registry data were joined to census tract-level income data via Statistics Canada and the US Census Bureau, and to county-level data on primary care and specialist physician supplies via Canadian Institute for Health Information and American Medical Association databases. Canadian women were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (standardized rate ratio [RR] = 1.65) and communities that lacked specialist physicians [RR = 1.33). Canadian advantages were completely explained by better health insurance coverage and greater access to primary care. These protective effects of Canadian health care suggested ways to maximize the ACA's protections. Ensure that the newly insured, public and private, are indeed, adequately insured, without having to bare exorbitant out-of-pocket costs for medically necessary care. Expand Medicaid across all 50 states in ways that are consistent with the ACA’s legislative intentions. Bolster the supply of primary care physicians and allied primary health care professionals.