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Mortality in the United States is 18% higher than in Costa Rica among adult men and 10% higher among middle-aged women, despite the several times higher income and health expenditures of the United States.
Comparing health and mortality in these two countries may help to identify pathways for improving health even under suboptimal economic circumstances, as well as help to improve targeting of health interventions in high-income settings.The purpose of this article is to contribute to explaining why Costa Rica outperforms the US in life expectancy at older adult ages, which are the ages in which Costa Rican health achievements are most impressive (2).The article focuses on economic inequality, smoking, and obesity as important explanatory factors in this comparison, following related research that has shown that these are strong factors related to the relatively poor performance of life expectancy in the United States compared with other high-income countries (3).Costa Rica is one of a handful of middle-income countries in which the availability of data allows this type of more striking comparison.It is well established that economic development brings about higher life expectancy to countries (6).Costa Rica, with a life expectancy at birth of 78.5 y, is a clear health overachiever given its GDP-PPP of $9,200, an income level at which the norm is a life expectancy of about 72 y according to the prediction curve and according to what is observed in countries such as Iran or Romania. 1 are Vietnam, Israel, and Japan, whereas South Africa, the Russian Federation, and Kuwait are examples of clear underachievers.
The life expectancy in Costa Rica is at a level expected for economies with a GDP of about $40,000, closer to the United States, which slightly underachieves expectations with a life expectancy of 77.4 y, 1 y lower than Costa Rica (Fig. The outstanding health indicators of Costa Rica have been known for decades.
Particularly interesting are those countries whose health indicator substantially outperforms expectations—those above the prediction line in Fig.
1—in contrast with underachievers below the prediction line.
The Costa Rican Gini is also higher than the US Gini of 0.40, which itself is higher than in most high-income countries such as Sweden (0.25), Germany (0.30), or Japan (0.32) (13).
In contrast to the low financial access and fragmented health care for low socioeconomic status (SES) adults under age 65 in the United States (after age 65, essentially all US residents are covered by Medicare insurance), Costa Rica has a single national health insurance system that covers the vast majority of residents.
Costa Rica is one of a handful of middle-income countries with data to conduct this comparison.