Document Type


Publication Date


Publication Title

Journal of Primary Care & Community Health


Advanced access published


primary care, supply of physicians, poverty, health insurance, breast cancer, breast cancer care, health care policy, health care reform, Patient Protection and Affordable Care Act, Obamacare


Background: Better health care among Canada’s socioeconomically vulnerable versus America’s has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care. Methods: We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy. Results: Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access. Conclusions: Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America’s system of primary care will probably be the best way to ensure that the Affordable Care Act’s full benefits are realized.



Funding Reference Number

The work was supported by a grant from the Canadian Institutes of Health Research (Grant no. 67161-2).

Creative Commons License

Creative Commons Attribution-Noncommercial 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial 3.0 License