The Secret of Costa Rica’s Successful Health Care System
By making public health central to their health care system, Costa Rica has achieved a higher life expectancy than the US for a fraction of the cost. How did they do it? The New Yorker’s Atul Gawande investigates.
Life expectancy tends to track national income closely. Costa Rica has emerged as an exception. Searching a newer section of the cemetery that afternoon, I found only one grave for a child. Across all age cohorts, the country’s increase in health has far outpaced its increase in wealth. Although Costa Rica’s per-capita income is a sixth that of the United States — and its per-capita health-care costs are a fraction of ours — life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.
People who have studied Costa Rica, including colleagues of mine at the research and innovation center Ariadne Labs, have identified what seems to be a key factor in its success: the country has made public health — measures to improve the health of the population as a whole — central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades.
The Covid-19 pandemic has revealed the impoverished state of public health even in affluent countries — and the cost of our neglect. Costa Rica shows what an alternative looks like. I travelled with Álvaro Salas to his home town because he had witnessed the results of his country’s expanding commitment to public health, and also because he had helped build the systems that delivered on that commitment. He understood what the country has achieved and how it was done.
In the US, the pandemic has revealed a public health system that is underfunded, underutilized, undervalued, and disconnected from the largely private health care system. As with many other aspects of American life, private individuals who can afford it get access to better lives, at the expense of everyone else.
The concern with the U.S. health system has never been about what it is capable of achieving at its best. It is about the large disparities we tolerate. Higher income, in particular, is associated with much longer life. In a 2016 study, the Harvard economist Raj Chetty and his research team found that the difference in life expectancy between forty-year-olds in the top one per cent of American income distribution and in the bottom one per cent is fifteen years for men and ten years for women.