Why Does Costa Rica Outperform the United States in Life Expectancy? A Tale of Two Inequality Gradients

William H. Dow, University of California, Berkeley
Luis Rosero-Bixby, Universidad de Costa Rica

Mortality in the United States is 18% higher than in Costa Rica among adult men and 10% higher among middle-age women, despite the several times higher income and health expenditures in the U.S. This simultaneously provides striking evidence of the potential for substantially lowering mortality in other middle-income countries, and highlights the U.S.’s embarrassingly poor health performance. The U.S.’s underperformance is strongly linked to its much steeper socioeconomic (SES) gradients in health. Although the highest SES quartile in the U.S. has better mortality than the highest quartile in Costa Rica, U.S. mortality in its lowest quartile is markedly worse than in Costa Rica’s lowest quartile. High SES-driven inequality in the U.S. persists in all broad cause of death groups and risk factors such as smoking, high blood pressure, and obesity, but Costa Rica’s overall mortality advantage is explained largely by two causes of death: lung cancer and heart disease.