Learning from Costa Rica

Summary: Atul Gawande writes a compelling New Yorker report of how Costa Rica melded medicine and public health to greatly reduce disease and lengthen life. If the U.S. is to learn from this inspiring example, we’ll need universal coverage with no cost barriers, robust health data, and strong primary care. Single payer will help pave the way.

Costa Ricans Live Longer Than Us. What’s the Secret?, The New Yorker, August 23, 2021, by Atul Gawande

“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. …

As the pandemic ebbs, countries will be assessing what went wrong with their public-health systems. A fundamental failure has been the separation of public health from health-care delivery. Getting that right, across the globe, could present our greatest opportunity to secure longer and better lives.”

Comment:

By Isabel Ostrer, M.D.

Atul Gawande’s captivating article about Costa Rica’s robust public health system describes a framework for how to improve health outcomes — one that a single payer healthcare system can facilitate. In fact, I contend that a unified health system is a prerequisite for implementing this type of comprehensive delivery.

Gawande recounts the three principal elements of Costa Rica’s universal approach to care: 1) merge public health services with hospital- and clinic-based care, 2) collect and integrate household-level demographic data with medical records to drive national health priorities, and 3) emphasize local primary care delivery.

Single payer provides the prerequisites for this transformation by:

1) Facilitating marginalized communities’ access to care: For the Costa Rican model to work, everyone needs excellent access to care. In the U.S, 33 million Americans are uninsured and nearly ⅓ of insured adults are inadequately insured. Single payer would eliminate barriers to care by ensuring every American has health insurance, with no point of care costs (premiums, co-pays, and deductibles) which discourage care seeking.

2) Creating a unified electronic health record: Electronic health records (EHR) are clunky and disparate, and don’t communicate with each other. A 2018 report revealed that fewer than half of office-based physicians were able to exchange health information with providers outside their organization electronically. A single payer system would prioritize a single EHR that allows easy exchange of information among medical providers. This foundation could be expanded to include public health data, mirroring the Costa Rican system Gawande describes.

3) Prioritizing a primary health workforce: Greater primary care is associated with lower mortality, lower costs, and higher quality of care. But the number of primary care physicians (PCPs) decreased from 46.6 to 41.4 per 100,000 people between 2005 and 2015. This is unsurprising given that the median PCPs’ income is just 60% of specialists’. The Medicare for All Act of 2019 establishes an Office of Primary Health Care to expand the primary care workforce and ensure greater access to care, particularly in underserved areas. Moreover, primary care compensation would increase through two mechanisms. First, a single payer system would compensate previously unreimbursed care. Second, it would free up time previously spent on administrative work for reimburseable direct patient care.

Gawande writes that as countries assess how they could have better responded to the Covid-19 pandemic there will be more focus on public health infrastructure. Indeed, this moment of reflection is an opportunity to fundamentally rethink how we deliver care with emphasis on universal coverage as a foundation to “braid together public health and individual health.”