Exploring why Costa Rica outperforms the United States in life expectancy: A tale of two inequality gradients

Abstract

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. This comparison simultaneously shows the potential for substantially lowering mortality in other middle-income countries and highlights the United States' poor health performance. The United States' underperformance is strongly linked to its much steeper socioeconomic (SES) gradients in health. Although the highest SES quartile in the United States has better mortality than the highest quartile in Costa Rica, US mortality in its lowest quartile is markedly worse than in Costa Rica's lowest quartile, providing powerful evidence that the US health inequality patterns are not inevitable. High SES-mortality gradients in the United States are apparent in all broad cause-of-death groups, but Costa Rica's overall mortality advantage can be explained largely by two causes of death: lung cancer and heart disease. Lung cancer mortality in the United States is four times higher among men and six times higher among women compared with Costa Rica. Mortality by heart disease is 54% and 12% higher in the United States than in Costa Rica for men and women, respectively. SES gradients for heart disease and diabetes mortality are also much steeper in the United States. These patterns may be partly explained by much steeper SES gradients in the United States compared with Costa Rica for behavioral and medical risk factors such as smoking, obesity, lack of health insurance, and uncontrolled dysglycemia and hypertension.

Keywords: Costa Rica; United States; adult mortality; inequality; socioeconomic status.

Fig. 1.

Life expectancy by per capita GDP. World’s countries 2003–7. Data from ref. .

Fig. 2.

Mortality by age and sex, population, and NLMS-sample estimates. United States and Costa Rica 1995–1999. Continuous lines show the rates in the population (data from refs. and : vital statistics and population estimates). Points, with 95% CIs, show NLMS sample rates.

Fig. 3.

Mortality rates by SES quartiles and regression-estimated SES gradients. United States (US) and Costa Rica (CR) in the 1990s. RII, relative inequality index. Dashed lines connect the age-adjusted rates per SES quartile and their 95% CIs. Straight, continuous lines smooth out the SES-rank effect and the corresponding shadow areas show their CI. Data from refs. and .