Document Type


Publication Date


Publication Title

Social Work Research


breast cancer, health care reform, health insurance, Patient Protection and Affordable Care Act, poverty, single-payer system


This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multipayer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high-poverty neighborhoods in Ontario and California between 1996 and 2011. Women in Canada experienced better care, particularly as compared with women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60), and hormone therapies (RR = 1.78). Women living in high-poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the United States. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study’s 15-year time frame 31,500 late diagnoses, 94,500 suboptimum treatment plans, and 103,500 early deaths were estimated in high-poverty U.S. neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of U.S. health care, are discussed.




This is a pre-copyedited, author-produced PDF of an article accepted for publication in Social Work Research following peer review. The version of record is available online at: