title: Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places.
abstract: 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.
authors.affiliation: 1 University of Windsor, Windsor, Ontario, Canada.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Gorey
authors.affiliation: 2 Western University, London, Ontario, Canada.
authors.forename: Caroline
authors.initials: C
authors.lastname: Hamm
authors.affiliation: 2 Western University, London, Ontario, Canada.
authors.forename: Isaac N
authors.initials: IN
authors.lastname: Luginaah
authors.affiliation: 2 Western University, London, Ontario, Canada.
authors.forename: Guangyong
authors.initials: G
authors.lastname: Zou
authors.affiliation: 3 University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Holowaty
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000628:therapy*; D002140:California; D005260:Female; D006801:Humans; D008507:Medically Underserved Area; D008875:Middle Aged; D009864:Ontario; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012959:Socioeconomic Factors; D035862:Vulnerable Populations
keywords: Patient Protection and Affordable Care Act; breast cancer; health care policy; health care reform; health insurance; poverty; primary care; supply of physicians