Why do Costa Ricans outlive Americans?

Which country in the Western Hemisphere has the longest life expectancy?

Unsurprisingly its Canada, at 82.2 years (pre-Covid).

But which country in the Americas comes in second?

Surprisingly, its Costa Rica at 80.8 years.

Source

The United States, by far the richest country in the Americas, had a life expectancy of 78.4 years that was falling even before Covid.

How is it that Costa Rica outperforms not only the much richer United States, but also other somewhat richer countries like Panama, Mexico, Argentina, and the Dominican Republic?

Clearly they don’t do it by outspending us- Costa Rica spends the equivalent of $1600 dollars per person per year on health care, compared to nearly $12000 in the US (7.3% of their GDP goes to health care vs 16.8% for the US).

Source

So what exactly is Costa Rica doing right? Atul Gawande tackles this question in his latest article for the New Yorker.

He argues that the key has been Costa Rica’s investment in primary care and public health. The US might may have many more of the world’s best (and most expensive) hospitals, but the easiest and cheapest health benefits come from keeping people out of hospitals in the first place.

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.

In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis. Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.

The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States.

Gawande goes on to describe how every Costa Rican gets a home visit from a health care worker at least once per year. This is quite the contrast to the US, where even getting primary care doctors to let you see them in their office can be a fight. I moved to Rhode Island last year and this week finally tried getting a primary care doctor here. I looked through the list of doctors covered by my insurance that my insurer said were accepting new patients and started making calls (by the way, why calls? do any doctors book appointments online?). 2 said that they actually weren’t taking new patients. 9 never answered the phone. The 12th doctor I tried, one farther away and lower-rated than I’d like, finally agreed to see me- in 3 months.

For anyone with less free time, determination, or insurance coverage, it would be natural to just give up after the 5th or the 10th “no”. Clearly many Americans do, leading manageable conditions like diabetes or high blood pressure to turn into acute health crises and expensive hospital visits.

I do think individual doctors could do better here by thinking through their appointment process from the patient’s perspective. But at its core this is simply a numbers issue- we don’t have enough primary care doctors to go around. We actually have fewer doctors per capita than Costa Rica, and relatively high share of specialists means that we have even fewer primary care doctors to go around. More medical school spots, more primary care residency spots, and fewer restrictions on immigrant doctors could go a long way way toward helping to US catch up to…. Costa Rica.

That, or their secret is just the volcanoes. This is surprisingly plausible- the US state with the longest life expectancy is also the one best known for volcanoes, Hawaii.

Institutions Getting Smarter on Covid

Two weeks ago I argued for 4 non-coercive anti-Covid policies I thought were under-rated. I haven’t generally been impressed by the institutional response to the pandemic, and so I wasn’t expecting the policies I mentioned to get traction any time soon. But some did!

I argued for:

  1. Full vaccine approval
  2. Emergency vaccine approval for children
  3. Ventilation
  4. Outpatient treatments that work

Since then, the big news is that the FDA fully approved the Pfizer vaccine. This seems to have increased the pace of new vaccinations.

I really wasn’t expecting the FDA to move that fast- they have generally learned to be slow because Congress has been much more likely to complain about them approving a bad drug than about them denying or slow-walking a good drug. But Congress itself seems to be changing in response to Covid, with 108 House members pushing the FDA for a timeline on approving vaccines for 5 to 11 year-olds.

I don’t know of a good way to gauge progress on ventilation overall, but I was pleased to see HEPA filters show up in the classrooms at Providence College:

Likewise, I don’t know if Fluvoxamine prescriptions are up in the weeks since a good sized study showed it reduced Covid hospitalizations 31%, but the popular press articles about it keep coming (don’t be deterred by “Vox”, the linked article is by Kelsey Piper and its excellent).

So some institutions seem to be getting smarter, and perhaps coincidentally, we seem to be at the peak of the Delta wave. According to Covidestim.org, Rt is now below 1 in 31 states, and falling in 45 states, including all of the Southern states hit hardest by Delta. Barring a new twist (another worse variant? Winter Delta wave in the North?), things just get better from here.

Remote Work vs Employer Power: Why I’m Not Sweating Tenure

When there’s only one employer in town who hires for jobs like yours, they have labor-market power, and can pay less and have worse working conditions than a competitive firm would. Economists call this “labor market monopsony” but I like the term “employer power”, which is simpler and makes sense when there are a few employers as well as when its literally just one. This keeps down the wages of machinists at the only factory in town, nurses at the only hospital in town, and professors at the only university in town.

Of course, workers in this situation could always move and get a better job elsewhere, and this does put some limits on employer power, but many workers have strong preferences to stay in their home, which means the balance of power is with the employers- or at least, it has been.

The growth of remote work means that workers can get jobs all over the world (or at least all over nearby time zones) without having to leave their town. Which means that monopsony is over, at least for jobs where remote work is possible.

I’m going up for tenure at my college soon, meaning that by next June they will tell me either that I have a job for life or that I’m fired. This “up or out” system naturally causes a lot of anxiety for professors. Partly this is because many professors’ identities are wrapped up in our jobs to an unnecessary and unhealthy extent, and so we take it as a judgement on our worth as human beings. But partly there was always the very practical problem that failing tenure almost certainly meant you would either need to move, accept a substantially worse job, or both.

The thinness of the academic labor market means that unless you live in a major city, its probably the case that no university nearby is hiring tenure-track academics in your subfield this year; and even if you are in a major city, there are probably only 2-3 searches in your field, and they will be so competitive that you almost certainly won’t get the job. To have a real chance at another good academic job, people need to apply nationwide (when I got my first job I sent out 120 applications all over the country to get 1 offer). Getting another job locally generally means taking a job with much worse pay, worse conditions, or both- like high school teacher, adjunct professor, or entry-level business analyst. Those in relatively practical fields like economics were able to get decent jobs outside of academia (PhD economists in private sector and government jobs typically earn better salaries than academics, at the cost of working more hours with less freedom), but such jobs were plentiful only in a few major cities (DC, SF, NYC, Boston), which usually still meant moving. Even in a mid-sized state capital like Providence, I don’t think I’d have an easy time finding something here- or I didn’t think so, until remote work became ubiquitous last year.

Now I won’t be losing any sleep over the possibility of losing my job next year. Partly I think my odds of getting tenure are good, but even a 1% chance of losing my job would have been worrisome in the pre-remote world. Now instead of worrying I just think about the huge range of opportunities in tech, finance, consulting, business, think tanks, and even government. Remote also addresses one big reason I ignored those jobs in the first place and only applied in academia- flexibility. I didn’t want to be stuck in an office 40+ hours/wk; I wanted to be able to pick my kids up from school. Now flexible hours and the ability to be evaluated on output rather than time spent at the office seem to be increasingly common.

To the extent that remote work puts a dent in employer power we would expect to see higher employment, higher wages, and fewer people feeling trapped in their jobs. We’ve seen all of these in 2021- quits in particular are at an all-time high, a good sign that workers don’t feel trapped- though much this could simply be due to the rapid economic recovery. The real test will come when we see how much this is sustained past the initial recovery, and whether it is mainly in remote-able jobs or is a broad improvement.

Anti-coercive ways to fight Delta

Two weeks ago I predicted that Covid cases would continue to spike for at least two weeks due to the Delta variant, but argued against general shutdowns as a way to combat this spike. Two weeks later cases have indeed spiked, and while localities and organizations have been mandating masks and vaccines, we have largely avoided new lockdowns, at least in the US (Australia is reverting to its roots as a prison). In the last post I mostly said what we shouldn’t do to fight Delta, so today I want to show what a better response looks like.

The tendency of authorities to reach first for coercive solutions is a natural product of their incentives, but I’ve been disappointed to see the same tendency among the chattering classes. I think this is due to polarization- people are most interested in debating solutions that are identified with a specific side in politics or the culture war. Masks became blue-coded, so many reds oppose them even though they probably work. Likewise with vaccines, even though they definitely work well and funding them early was the greatest achievement of the Trump presidency. Meanwhile certain medications became red-coded, leading blues to oppose them before the evidence even came in. But many of the best non-coercive and anti-coercive solutions barely get discussed because they have no political valence, or a mixed one.

Fully Approve the Vaccines Already!

The Covid vaccines are still being distributed under an emergency use authorization. This lack of full approval is a source of vaccine hesitancy. More concretely, it also means that pharmaceutical companies aren’t allowed to advertize their vaccines, even though they are much more effective than the typical pharmaceutical you see advertized. The randomized control trials testing the vaccines have been complete for months, we are just waiting on the FDA to do their job.

Authorize Vaccines for Kids

The FDA still bans children under 12 from receiving the vaccine, saying they are waiting for more trial data. Last week, the American Academy of Pedicatrics argued that we have enough data to justify an Emergency Use Authorization for children aged 5-11 given, you know, the emergency. The government is going to make my 5 year old wear a mask to kindergarden won’t allow me (or my physician wife!) to get him a vaccine which would protect him and others much better than a mask.

Ventilation

Opening windows, modifying HVAC systems to bring in more outside air, and using air purifiers is about as effective as requiring masks and is definitely less of an imposition on people. But we don’t talk about it, partly because people took so long to recognize that Covid is spread through the air more than through droplets, and partly because it is less of an imposition on people and so never became a culture-war debate. Ventilation might be too boring to advocate but I think staying alive is very exciting.

Outpatient Treatments that Work

Repurposing existing drugs to fight Covid is a great idea that has not yet lived up to its promise, aside from the widespread use of Dexamethasone for inpatients with severe cases. The core problem is that it takes large randomized controled trials to really prove that a drug works, and these are expensive. Worse, pharmaceutical companies don’t want to pay for these expensive trials once their drug has gone off patent. This means that many promising treatments have been ignored, while a few have been over-promoted on the basis of observational studies and tiny RCTs (and worse, still promoted once large RCTs showed they probably don’t work). But the British government stepped up to fund the large trials that found Dexamethasone effective last year, and private donors have funded mid-size trials that just found Fluvoxamine reduced Covid hospitalization by 31%. This is excellent news because Fluvoxamine is a cheap and relatively safe anti-depressant that people can take at home. There are other promising treatments that have yet get funding for large RCTs; this is exactly the sort of thing that NIH should be throwing money at. While we’re waiting on compentent government, you can ask a doctor about outpatient treatment if you do get Covid.

Overall, many of our best tools for fighting Covid are being ignored despite, or perhaps because of, the fact that they maintain or increase our freedom.

Generous Health Insurance Makes Employees Stay

The idea of “job lock” is well established in the academic literature- employees leave firms that don’t offer health insurance more often than they leave firms that do. But this literature has always measured employer-provided health insurance as a simple binary: either they offer it or they don’t. In fact employers vary widely in the generosity of their plans, both in the quality of the insurance and in how much of the cost is paid by the employer. Some employers pay all of the premiums, some pay none, and most pay part:

Data are from the Current Population Survey, which uses top-coding to protect privacy (values greater than 9997 are reported as 9997)

In an article published last week in Applied Economics Letters, my colleague Michael Mathes and I combine two supplements of the Current Population Survey to test whether employers who contribute more towards health insurance see their employees stay longer. Perhaps not surprisingly, we find that they do. We run lots of regressions to establish this, but this simple fit plot tells the story best:

What we found more surprising was the magnitude of this effect: a thousand dollar increase in employer contributions to health insurance is associated with at least 83 additional days of job tenure, compared to less than 10 additional days for a thousand dollar increase in wages. We conclude that:

For employers trying to increase retention, increasing contributions to health insurance appears to lengthen employee tenure far more than increasing wages by a similar amount.

Why the difference? Probably employees rationally valuing $1000 in untaxed contributions to health insurance above $1000 in taxable wages. Why don’t employers shift more compensation away from wages and toward health insurance, given that employees seem to prefer it? Here I’m less sure, and they could simply be making a mistake, but one possibility is that they worry about increasing their costs as couples whose employers both offer insurance choose the more generous one for a family plan. Another is that while generous health insurance plans are better for retention, higher wages could be better for attracting new employees, who tend to be younger and for whom the salary number could be more salient.

Delta: Danger is Rising, but 2021 is not 2020

Covid cases are rising rapidly in the US thanks to the more contagious delta variant.

Based on the experience of 2020, this has many states, cities, and organizations considering a return to mask mandates and shutdowns. But our situation in the US has changed substantially since 2020 as we now have better knowledge, better masks, and above all abundant vaccines.

We can see this difference clearly when looking at countries hit by the Delta wave before us. It first devastated India, where less than 10% of the population was fully vaccinated, officially killing 400,000 people and unofficially perhaps 10 times that. In constrast the UK, where more than half the population was fully vaccinated, saw a major spike in cases that did not translate into a major spike in deaths:

The delta waves seem to come and go quickly, with cases rising more rapidly than previous waves, but also falling rapidly 6-8 weeks after they began to rise in India, the UK, and the Netherlands. Cases began rising in the US at the beginning of July, so if this pattern holds we have about 2-4 more weeks of rising cases before a rapid drop.

My worry is that a spike in cases just before the school year will lead schools to shut down just as the danger begins to recede, and when vaccines mean the danger was never as great as in previous waves. Externality-based arguments for shutdowns and mask mandates are now substantially less valid than in 2020 but I don’t know that policymakers have internalized this. The Biden admin actually does seem to get it, calling this a “pandemic of the unvaccinated“- i.e., if you’re worried, get vaccinated, and if other people don’t, that’s their problem. Even with delta the vaccines reduce covid’s danger to you by ~10x, and so also reduce the protection you gain from controlling others by ~10x.

The situation with masks has also changed. Cloth masks have limited effectiveness in protecting you from others, but decent effectiveness in protecting others from you, which meant there was a strong externality-based case for mask mandates. But now in 2021 high-quality KN-95 and even N-95 masks are easily available, and unlike cloth masks they offer excellent protection FROM others, as well as FOR others. Anyone who is vaccinated and wearing an N-95 really has nothing to worry about anymore, and little reason to force masks onto others.

The main externality-based arguments that could still work are for vaccine mandates and for restrictions in areas where hospitals are overwhelmed by unvaccinated Covid patients in a way that substantially worsens care for non-Covid patients. But outside of areas with low vaccination rates leading to overwhelmed hospitals, I no longer see a good case to impose mask requirements or restrictions on movement or events.

According to one set of projections, by the end of August adult ICUs (though not hospitals overall) will be over capacity in most low-vaccination states:

If you want to wear a mask and avoid crowds, you can, and in fact probably should do at least one of those during the Delta wave of the next month. But the externality-based case for restrictions is mostly gone, and governments would do better to focus on continuing vaccine rollout in the US and ensuring vaccines are available worldwide to help other countries and to prevent more variants from emerging and finding their way here. Personally I’m glad that my employer has a vaccine mandate but, at least currently, no mask mandate. For those who do still want Covid restrictions I ask- what are you waiting for? What event or number would make you say “ok, now we can go back to normal”? When do you expect that to happen? For me, what I was waiting for was vaccines available for everyone and now, at least in the US, we are lucky to have that.

Simone Biles and the Trojan War

When star gymnast Simone Biles decided to sit out the Olympics this week to ‘focus on herself’, both those praising her and those criticizing her seemed to treat this like a unique story that wouldn’t have happened in earlier generations. But it reminds me of one of the oldest recorded stories in the world, one that predates even the first ancient Greek Olympics of 776 BC- Achilles’ decision to sit out the Trojan War.

Here is Biles this week:

We also have to focus on ourselves, because at the end of the day we’re human, too… We have to protect our mind and our body, rather than just go out there and do what the world wants us to do.

Here is Achilles, greatest of the Greek warriors, thousands of years ago:

Him do I hate even as the gates of hell who says one thing while he hides another in his heart; therefore I will say what I mean. I will be appeased neither by Agamemnon son of Atreus nor by any other of the Danaans, for I see that I have no thanks for all my fighting. He that fights fares no better than he that does not; coward and hero are held in equal honour, and death deals like measure to him who works and him who is idle. I have taken nothing by all my hardships- with my life ever in my hand; as a bird when she has found a morsel takes it to her nestlings, and herself fares hardly, even so man a long night have I been wakeful, and many a bloody battle have I waged by day against those who were fighting for their women. With my ships I have taken twelve cities, and eleven round about Troy have I stormed with my men by land; I took great store of wealth from every one of them, but I gave all up to Agamemnon son of Atreus. He stayed where he was by his ships, yet of what came to him he gave little, and kept much himself….

Agamemnon has taken her from me; he has played me false; I know him; let him tempt me no further, for he shall not move me. Let him look to you, Ulysses, and to the other princes to save his ships from burning…. I will draw my ships into the water and then victual them duly; to-morrow morning, if you care to look, you will see my ships on the Hellespont, and my men rowing out to sea with might and main. If great Neptune vouchsafes me a fair passage, in three days I shall be in Phthia. I have much there that I left behind me when I came here to my sorrow, and I shall bring back still further store of gold, of red copper, of fair women, and of iron, my share of the spoils that we have taken; but one prize, he who gave has insolently taken away. Tell him all as I now bid you, and tell him in public that the Achaeans may hate him and beware of him should he think that he can yet dupe others for his effrontery never fails him.

As for me, hound that he is, he dares not look me in the face. I will take no counsel with him, and will undertake nothing in common with him. He has wronged me and deceived me enough, he shall not cozen me further; let him go his own way, for Jove has robbed him of his reason. I loathe his presents, and for himself care not one straw. He may offer me ten or even twenty times what he has now done, nay- not though it be all that he has in the world, both now or ever shall have; he may promise me the wealth of Orchomenus or of Egyptian Thebes, which is the richest city in the whole world, for it has a hundred gates through each of which two hundred men may drive at once with their chariots and horses; he may offer me gifts as the sands of the sea or the dust of the plain in multitude, but even so he shall not move me till I have been revenged in full for the bitter wrong he has done me. I will not marry his daughter; she may be fair as Venus, and skilful as Minerva, but I will have none of her: let another take her, who may be a good match for her and who rules a larger kingdom. If the gods spare me to return home, Peleus will find me a wife; there are Achaean women in Hellas and Phthia, daughters of kings that have cities under them; of these I can take whom I will and marry her. Many a time was I minded when at home in Phthia to woo and wed a woman who would make me a suitable wife, and to enjoy the riches of my old father Peleus. My life is more to me than all the wealth of Ilius while it was yet at peace before the Achaeans went there, or than all the treasure that lies on the stone floor of Apollo’s temple beneath the cliffs of Pytho. Cattle and sheep are to be had for harrying, and a man buy both tripods and horses if he wants them, but when his life has once left him it can neither be bought nor harried back again. 

My mother Thetis tells me that there are two ways in which I may meet my end. If I stay here and fight, I shall not return alive but my name will live for ever: whereas if I go home my name will die, but it will be long ere death shall take me. To the rest of you, then, I say, ‘Go home, for you will not take Ilius.’ Jove has held his hand over her to protect her, and her people have taken heart. Go, therefore, as in duty bound, and tell the princes of the Achaeans the message that I have sent them; tell them to find some other plan for the saving of their ships and people, for so long as my displeasure lasts the one that they have now hit upon may not be

In either case, economists aren’t surprised to see people stop showing up to work when they think the costs to them exceed the benefits, even when that work is itself unusual and could benefit their country.

Informational Diabetes

We all recognize that in the Internet Age, it is easy to communicate and to access information.

For the infovores, this is a cause for celebration.

Others worry that this leads to “information overload”, and to the spread of “disinformation” and “misinformation”. While this is clearly true, complaints about it typically seem to come from elites longing for the days when they had the only microphone, before the Revolt of the Public. Its hard to banish “misinformation” without screening out differences of opinion and correct contrarians even if you want to- and for some, such “collateral damage” would in fact be the main goal. But clearly something is wrong with the current information environment.

In a recent podcast appearance, Balaji Srinivasan used a metaphor I like better- Informational Diabetes:

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Cars Are Likely to Stay Expensive for Years

Yesterday Jeremy discussed what spiking car prices mean for overall inflation.

Today I’ll discuss the outlook for car prices themselves, based on what I heard at the Philly Fed’s conference on auto lending yesterday. Some (approximate) quotes:

The used market is red hot

Used prices are likely to stay elevated for a few years

Because used prices are so high, “If you can find the car you are looking for new right now, there’s a good chance it makes sense to buy it instead of going used.” But it could be hard to find that new car you want because inventories are so low, and even then you probably won’t be able to bargain the price down like you normally would- “75% of new cars now sell for MSRP or above, vs 36% last year”

The average new car now sells for $40k, partly because SUVs are increasingly popular, and partly to bother those who care about financial responsibility, like fellow Temple Econ PhD Adam Ozimek:

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Because of manufacturing disruptions from Covid and the chip shortage, “We’re at least a year out before we start to restock to normal dealer inventory levels” in the new market. Supply in the used market could stay low for 4-5 years because of the lower production of new cars and lower turnover of existing ones. Normally cars coming off lease & out of rental car fleets are a big sources of used cars for sale, but fleet purchases & leases are down from 40% of new car purchases to 25%. Reposessions, another source of used cars, actually decreased slightly through Covid despite the huge spike in unemployment.

All in all, its a good time to own a car and a bad time to try to buy one, and this state of affairs could persist for years absent an unexpected drop in demand or spike in supply.

Electric cars, though, seemed poised to take over much more of the market- the forecast was about 1/3 of new sales by 2030, driven by improvements in the technology, continued subsidies to new EV purchases & EV infrastructure, and car companies offering electric models in popular categories like SUVs and trucks where they are currently rare.

You Shouldn’t Be Writing (All the Time)

Many people get the idea that they should be working all the time. Certainly many academics do, which for us means a continuous internal reminder that “you should be writing”.

I thought this way in grad school but I don’t anymore. I now almost never work on nights & weekends, and often not on afternoons. Yet I get just as much work done, maybe more, and I’m much happier about it. How can this be?

This post from Ava provides a great explanation. Its very short and you should read it, but I think it illustrates best through its literal illustrations:

Today is a good example. I’m writing this at noon, having just finished the revisions requested by a journal after 3 hours of solid work. Now, rather than start revising the next article & doing a bad job of it, I’ll take the rest of the day off. Real original thought is hard- I know I can do it for about 3 hours on a typical day, I have no one to impress by pretending to work longer, and one way or another the output will speak for itself. As remote work grows, this ability to do the real work and then stop rather than fill time “working” should be available to more people outside of academics.