Strengthening and Updating Social Security to Protect Our Nation's Health

  • Date: Nov 05 2013
  • Policy Number: 201315

Key Words: Health Services

Related APHA Policy Statements

APHA Policy Statement 200020 – Raising Income to Protect Health 

APHA Policy statement 2002-3 – Support of Healthy Aging through Health Promotion and Prevention of Disease and Injury

APHA Policy Statement 6101 – Financing of High Quality Health Services for the Aged

APHA Policy Statement 6413 – Improvements in State and Local Retirement Plans

APHA Policy Statement 6509 – Social Security Coverage for Health Workers

APHA Policy Statement 8328(PP) – Aging Women's Health Issues

APHA Policy Statement 9508 – Full Employment and Public Health


Social Security is one of our nation’s most effective anti-poverty programs. Millions of Americans rely on Social Security benefits for their health and well-being. However, with changing times and changing demographics, the program needs to be strengthened and updated. To strengthen Social Security and create a fairer, more progressive taxation system, we propose increasing or eliminating the current cap on taxable wages. To update Social Security, we propose adjusting eligibility to be more inclusive of women, people of color, and same-sex partners. Adjustments that strengthen and update Social Security, rather than adjustments that decrease benefits, are imperative to our nation’s health.

Problem Statement
Social Security was born in the midst of the Great Depression, at a time when Americans were most in need of social support. The program still offers financial stability for millions of people, with 90% of American older adults earning Social Security benefits.1 Social Security does not merely supplement income; it is the primary source of income for the majority of older adults. It offers a safety net for some of our country’s most vulnerable populations, including people of color, low-income older adults, and people with disabilities.1 According to the United States Census Bureau, without Social Security, 45% of older adults would live below the poverty line.

However, because of Social Security, only 10% of older adults fall below this line.2 The program exemplifies some of our country’s closest held values: equality, fairness, respect for older adults, and benefits for years of hard work. It remains one of the most impressive achievements in US history.

Social Security’s role in improving the public’s health: The American Journal of Public Health has published substantial evidence supporting the correlation between income and health. More specifically, low income predicts poor health within the older adult population.3–5 As income decreases, morbidity and mortality increase among those 65 years and older.6

Many factors contribute to the correlation between income and health, including health care access, physical and social environments, health behaviors, and chronic stress.7 As a result, on average, low-income older adults suffer worse health outcomes and die sooner than middle- to high-income older adults. These findings illuminate the pressing need for income security among older adults.

In addition to documenting the role of Social Security in keeping older adults out of poverty, other studies have focused more directly on the relationship between Social Security benefits and health. Mortality rates among older adults fell in the 1930s when workers began receiving Social Security benefits. Rates fell again in the 1970s when benefits were indexed to better match the rate of inflation. Those 75 years and older experienced the largest reduction in mortality.8

Even seemingly small-scale reductions in benefits can have drastic health consequences. In the late 1970s, Congress adjusted the benefit calculation for new beneficiaries such that an individual born in 1917 had a 7% to 10% reduction in benefits relative to an individual born in 1916.[9] Five-year mortality rates after the age of 65 among both men and women grew significantly in the group receiving lower benefits.9 Given these findings, Social Security, both in its advancement of income equality and in its direct relationship to older adults’ health, is an effective public health policy.

In addition, Social Security and other old-age benefit programs allow older adults to live independently. If families had to provide monetary support for their older adult family members, they would face greater financial restraints and higher levels of stress.10

Raising the full retirement age by just 1 year reduces benefits by a median of 6.5%.11 Reduction at this scale is associated with increased morbidity and mortality in older adults.9 Such cuts in benefits could cause workers to work more hours through retirement, even as they reach their 70s and 80s.12 Working longer may not be an option for those in physically demanding jobs or for those who cannot find work.13 In 2011, more than 45% of workers older than 58 years held jobs that could be considered physically demanding.14 Some members of Congress have proposed increasing the Social Security retirement age in response to increased life expectancy, but this increase is not consistent across all groups. Since 1982, life expectancy has increased by 5 years among high-income men but by only 1.1 years among low-income men, and life expectancy has actually declined among low-income women.14 Lowering or eliminating guaranteed income for older adults and their dependents reduces protective factors against poverty, increases negative health outcomes, and contributes to mortality.8,9,15

Reliance of vulnerable populations on Social Security: Old-age benefits provided under the Social Security Act are the single largest poverty-protective factor for older Americans.[16] Between 1976 and 2000, approximately 90% of the older adult population received Social Security, and benefits continue to make up between 30% and 40% of older adults’ aggregate income.17 Many older adults rely on income from other sources, including assets, pensions, public assistance, and earnings, but these sources fluctuate with the market and are related to one’s education and health status.16,18 Low-income workers and their families are less likely to have significant contributions from assets and pensions.19

Although Social Security is largely successful in protecting people from poverty, some older adult populations are less economically secure than others. African Americans and Hispanics have higher unemployment rates, lower wages, and less accumulated wealth; thus, they rely more heavily on Social Security benefits in old age.20 Women from all racial and ethnic backgrounds have lower annual and average lifetime earnings and are less likely to have a secure retirement than men.21–23 Unmarried women are especially likely to depend heavily on Social Security.24 Given these findings, Social Security is particularly valuable for the health and well-being of populations that are disproportionately vulnerable to morbidity and mortality.

The future of Social Security: Social Security is especially important to the American people today; the older adult population is growing, pensions are declining, and job insecurity is high. The population 65 years and older is projected to grow over the next 4 decades as the baby boomer generation enters retirement and health advances prolong the life span. Within the 65 and older age group, one in 6 women and one in 10 men are currently older than 85, and these numbers are expected to grow to almost one in 4 women and one in 5 men by 2050.25 These “oldest of the old” require the most resources and care.26

The popular narrative is that this demographic shift will bankrupt Social Security, but such a view is unfounded. Much of the political discourse has focused on the “disappearing” Social Security Trust Fund, a surplus of payroll tax revenue intentionally stockpiled in the 1980s for baby boomer retirement benefits.[13,27] Even without the surplus, after the trust fund is spent down, three-quarters of benefits could still be paid out of annual payroll tax revenue until the 2030s without any additional reforms in terms of benefits, eligibility, or tax policy.27 Despite political threats and characterization of the program as “broke,” the structure of Social Security is in reality quite sound.13,27 Small policy changes now can prevent large cuts in the future.

The need to update Social Security: Social Security eligibility and benefits criteria have remained unchanged since the early 1990s. Meanwhile, familial responsibilities, workplace roles, and lifestyle changes have resulted in a growing number of people who are either not eligible to receive benefits or receive fewer benefits than necessary to protect them from severe poverty. As a consequence, Social Security does not provide adequate benefits for all Americans and exacerbates existing disparities. Addressing the gaps in eligibility and benefits criteria identified below ensures that Social Security will continue to provide a safety net for all Americans.28

Social Security has 2 primary requirements for retirement benefit eligibility. First, an individual must be at least 62 years old. Second, he or she must have earned “credits,” which reflect time in the workforce.29 Individuals must earn at least 40 credits over a lifetime to qualify.29 To earn credits, individuals contribute to Social Security through payroll taxes. In 2011, a participant received one credit for every $1,130 of taxed income, up to a maximum of 4 credits per year.30 Because eligibility criteria reflect outdated social mores, the current credit system allows some particularly vulnerable populations to fall through the cracks.

For many of those 65 years and older, Social Security benefits surpass income from any other source. Despite this, nearly 4% of the population may never become eligible for benefits.17 These “never beneficiaries” are a small group within the aging population but are noteworthy owing to their high poverty rates, distinct demographics, limited sources of income, and few assets.

Never beneficiaries are made up of 2 important categories of Americans: late-arriving immigrants and infrequent workers. Together, these 2 groups make up nearly 90% of the population 62 to 86 years of age who do not receive any Social Security benefits.31 Significant proportions of never beneficiaries are women (67.2%) and/or immigrants (67.3%).31 A third of never beneficiaries are infrequent workers who have insufficient earnings to qualify for Social Security; 99% have fewer than half of the credits required to qualify for Social Security benefits.31 Infrequent workers include unpaid caregivers who care for children, adults with disabilities, and older adults. These caregivers are most often women. Women spend twice as much time on average as men caring for others in their households and perform three-quarters of all unpaid caregiving for older adults.32,33 Overall, the poverty rate among never beneficiaries is 44.3%, as compared with 3.7% among beneficiaries.32

The overrepresentation of women as never beneficiaries is particularly alarming. Not only are women nearly twice as likely to be impoverished as men during their retirement years, but women also tend to live longer than men.34–36 Eligibility requirements must be updated to address this disparity.

Although most individuals qualify for Social Security benefits by meeting the age and credit requirements, others qualify through marriage via spousal or widow/widower benefits. Most spouses or former spouses qualify for benefits if they are currently married or were married for at least 10 years.37 Although qualifying for Social Security through spousal benefits served women well when they were primarily homemakers in long-term marriages, declines in marriage rates and increases in divorce rates have resulted in decreased eligibility for spousal benefits.24 In addition, a greater proportion of those who are ineligible have never married (15%) relative to those who are eligible for spousal benefits now or projected to be eligible in the future (3.7%).31 Eligibility standards also do not address disparities among women of color, as Black and Hispanic women are less likely to marry than White women and therefore less likely to qualify for spousal or widow benefits.31,38

Current Social Security eligibility does not address disparities based on sexual orientation. Social Security Administration rules reflect federal law in recognizing same-sex unions only in states in which gay marriage is legal. With the recent Supreme Court decision to overturn the federal Defense of Marriage Act, the issue of equal Social Security benefits for same-sex partners remains unclear.24

The current Social Security benefit calculation uses the adjusted average income from a worker’s 35 highest-earning years. Any years under the 35-year threshold are counted as zeroes in the benefit calculation, lowering the benefits for workers who have spent fewer than 35 years in the workforce. This system penalizes 2 large populations: those who stay out of the workforce as a result of family caregiving responsibilities (disproportionately women) and those who experience high rates of unemployment (disproportionately low-wage men).14 On average, women have a total of 32 years of paid work, as compared with the male average of 44 years.14

The need to strengthen Social Security: To address the Social Security inequities stemming from anachronistic eligibility criteria, APHA supports strengthening Social Security’s revenue streams to create a more stable and enduring financial structure. Since the inception of Social Security, Congress has revisited and updated its financing structure multiple times. It is currently due for an update that strengthens its revenue streams rather than cuts its benefits.

The majority of Social Security revenue comes from payroll taxes.39 Most of the payroll taxes collected from today’s workers are used to pay benefits to today’s recipients.39 This structure is sound but is also unnecessarily regressive in 2 ways: (1) taxing only payroll income and (2) the payroll tax cap. First, high-income earners have large sources of income not taxed by Social Security (e.g., capital income, capital gains, and business income).40 Low-income earners are more likely to have taxable wages as their primary source of income. Because Social Security revenue is pulled from wages rather than all income, low-income earners pay a greater proportion of their income into Social Security.

Second, any income above the “contribution and benefit base,” or the limit on taxable income (hereafter referred to as “the tax cap”), is not subject to Social Security taxation and does not contribute to Social Security revenue (the tax cap in 2013 was $113,700).[41,42] Therefore, as an individual’s income increases, the proportion he or she pays into Social Security decreases. This tax cap results in an inequitable, regressive tax structure wherein the “richest 1 percent of American families pay a smaller proportion of their income in payroll taxes than the poorest 20 percent of families.”43

Over the past 3 decades, the income gap between the rich and the poor has widened. In 1983, 91% of earnings fell below the tax cap; in 2009, however, only 83% of earnings fell below the tax cap.44 With income increasingly concentrated among top wage earners and a declining portion of this income subject to Social Security taxation, there are fewer political opportunities to expand benefits and improve beneficiary health. The Social Security tax cap fails to take advantage of an important revenue stream and places a greater burden on low-income individuals.

Social Security was established to provide income security to those who can no longer support themselves financially. It provides the main source of stable income to the majority of American older adults and is critical to the health and well-being of vulnerable populations, particularly low-income older adults, people of color, and people with disabilities. Research clearly links income to individual and population health outcomes.4,7,25,36 Social Security retirement benefits allow older adults and people with disabilities to focus on their health rather than on the chronic stress of financial insecurity.

Proposed Recommendations Statement
Updates to Social Security eligibility criteria and benefits would reduce disparities that result from the current system. Strengthening Social Security financing would support these updates and ensure that the system is sustainable for future generations.

Updating Social Security to be more equitable: To address the inequities in the credit-based Social Security eligibility system that perpetuate poverty and ill health in vulnerable populations, APHA recommends expanding eligibility criteria and increasing benefits for Social Security so that vulnerable populations receive income protection in old age. Ideally, the expansion of eligibility outlined below would be paired with a change in the benefit formula to increase benefits.

This policy statement supports rewarding caring for dependent family members by establishing caregiver credits and recommends broadening the definition of “work” to include unpaid caregiving. These updates would ensure that caregivers are not at disproportionate risk for poverty and ill health when they reach old age. Caregiver credit systems are functioning successfully in other Organization for Economic Co-operation and Development countries and have been proposed by a number of US advocacy organizations as well as congressional leaders through the Social Security Caregiver Credit Act.28,32

This policy statement supports reduction of the credit requirement for Social Security eligibility. The United States Senate Special Committee on Aging and the National Academy of Social Insurance, among others, describe the benefits of reducing the minimum requirement to as low as one credit, greatly reducing the number of people who are entirely excluded from benefits.27,45 Decreasing the number of credits necessary to qualify for Social Security would improve the financial security and health of our country’s already vulnerable populations.

This policy statement supports reduction of the number of years of marriage required for eligibility as well as addressing the geographic inequities exacerbated by the landmark United States v. Windsor Supreme Court decision striking down the federal Defense of Marriage Act. By allowing all spouses, including domestic partners in states where same-sex marriage is not yet legal, to qualify for benefits regardless of the length of marriage or gender, Social Security eligibility would better reflect the current American population.

Increasing the Social Security retirement age is considered to represent a decrease in benefits, and APHA opposes any decrease in Social Security benefits.

Finally, this policy statement supports proposals to lower the threshold for the number of highest-earned years used to calculate Social Security retirement benefits to 30 rather than 35 years.

Strengthening Social Security for future generations: To update Social Security coverage, expand eligibility, and maintain benefits, this policy statement supports strengthening Social Security’s revenue streams to create a more stable and enduring financial structure.

Increasing the payroll tax cap would improve Social Security’s solvency. Increasing the tax cap such that it encompasses 90% of earnings would eliminate 43% of the Social Security Trust Fund’s long-range shortfall and extend solvency for an additional 11 years.40,46

Eliminating the tax cap entirely and levying the Social Security payroll tax on all taxable income is a more sustainable option. The Congressional Budget Office estimates that this proposal would extend the ability to pay 100% of projected benefits to 2083.44 Removing the tax cap while maintaining a cap on benefits for the highest earners would make Social Security more equitable while greatly extending solvency past the 75-year period the Social Security Administration uses to project funding estimates.44 This policy statement supports proposals eliminating the tax cap for Social Security payroll taxes and maintaining the benefit cap for high earners.

Either option is likely to lessen economic inequality in the United States by reducing the burden of regressive taxation. Income inequality has a deleterious influence on health, and not just among low-income populations but also among wealthy Americans. This was demonstrated in the 2013 Institute of Medicine and National Research Council report U.S. Health in International Perspective: Shorter Lives, Poorer Health. Moreover, the more stable funding structure that would result from eliminating or increasing the cap could create political opportunities to increase benefits, which in turn could have a nearly immediate effect on poverty rates.

Opposing Arguments
Proponents of privatizing or eliminating Social Security would likely oppose increases in eligibility requirements or benefits. These proposals would undermine Social Security’s success in preventing Americans from falling into poverty.

Many critics of Social Security are ideologically opposed to any expansion of Social Security. Opponents claim that policies promoting greater equity, such as caregiver credits, could be a disincentive for individuals to return to work after caregiving. However, France, Germany, and Sweden have successfully implemented caregiver credit systems that address disincentives by establishing limitations of caregiver credit distribution (child care versus older adult care) and length of time allowed, which encourage caregivers to return to the workforce.32

Other critics suggest that piecemeal proposals such as caregiver credits, lowering the threshold of highest income years, and modifying spousal benefits would not have a wide-reaching effect on overall poverty because they do not adequately address populations in need. However, well-crafted policies can and would target historically disadvantaged groups, which are a growing proportion of the American population.47 A caregiver credit design, such as the one we propose, would provide credits to caregivers who remain in the workforce and thus produce greater distributional equity.48 By combining multiple reform proposals, APHA’s package of proposals would not only redress long-term inequities but also have a direct effect on poverty among vulnerable groups.

Some rhetoric asserts that Social Security is financially unstable and calls for drastic measures such as raising the retirement age to avoid insolvency. These arguments overstate the problem and actually constitute masked attempts to dismantle Social Security.

Proposals to eliminate the tax cap face opposition from those who advocate for reducing taxes across the board, as such a change would reduce the benefit to tax ratio for the top quintile of household income earners.44 However, the current payroll tax structure is inherently regressive, and thus high earners pay a smaller proportion of their total income in payroll income tax than the lowest earners. In 2009, the highest-earning 1% of the population paid only 1.4% of their wages in payroll taxes, while the poorest 10% of the population relinquished 23%.16 The removal of the payroll tax cap would decrease some of this advantage for the highest earners and distribute the tax burden more equitably across all income brackets.

Some claim that an increase in the retirement age is necessary because of increased longevity among beneficiaries.49 While it is true that, with the depletion of the trust fund, Americans’ increased life spans may contribute to a drawdown on the Social Security purse, this position is predicated on the assumption that longevity will not result in older adults working longer owing to good health. The repercussions of such a policy are devastating: raising the full retirement age by only 1 year reduces benefits by a median of 6.5%.11 This seemingly minor reduction would impose additional barriers to self-sufficiency on older adults, resulting in heightened morbidity and mortality.10

Alternative Strategies
There are many promising options for strengthening and updating Social Security, including those described below.

Benefits: Other types of benefits have been proposed to improve income and savings support for retired workers. One such alternative would be implementing a tax credit similar to the 1976 federal Earned Income Tax Credit (EITC) to offset regressive taxes on retired workers who rely on Social Security as their primary source of income. The EITC is associated with decreased rates of infant mortality, childhood poverty, and use of other government assistance in low-income individuals and families and could similarly be used to benefit older adults.50–53

Another plan is to establish a system in which every worker can voluntarily participate in a retirement security account that encourages savings for workers. About half of working individuals do not have access to retirement plans through their employers.54 Portable retirement plans would be tied to the worker and not the workplace. This would serve to supplement, but not supplant, the existing Social Security infrastructure.

Eligibility: Some have suggested reinstating previously abolished benefits such as those for college-aged students whose parent or parents are deceased. This would allow the children of deceased parents to remain eligible up to the age of 22 years provided they are enrolled in college.13

Financing: Approximately 4.7% of workers are not covered by Social Security, the majority of whom are state and local government employees.31 Therefore, some have suggested instituting a payroll tax on this group of employees. Including state and local workers in the program will inject new payroll tax revenue into Social Security, which could alleviate a portion of the anticipated financial strain.55

Action Steps
The American Public Health Association urges the United States Congress to revise the Social Security Act to:

  • Expand the definition of work so that it awards retirement benefits to those who provide uncompensated care for children, older adults, and people with disabilities.
  • Reduce the minimum credit requirement for eligibility.
  • Allow all spouses to qualify for benefits, regardless of length of marriage, and redress geographic disparities among committed same-sex couples exacerbated by the Supreme Court decision to overturn the federal Defense of Marriage Act.
  • Amend Section 230, which delineates the formula for the tax cap, such that the maximum contribution is increased or eliminated. 

In addition to the United States Congress, the American Public Health Association urges the president of the United States, the Social Security Administration, the Social Security Trust Fund Board, and particularly the United States secretary of the treasury to:

  • Oppose legislation that would reduce benefits for Social Security beneficiaries through overall reductions in benefits, reductions in the cost-of-living adjustment, increases in the age of eligibility, privatization, or other means.
  • Communicate the realities of Social Security’s sound, rather than broken, financial structure.
  • The American Public Health Association urges the Department of Health and Human Services to: Fund research investigating the link between income security and improved health outcomes for older adults and other Social Security beneficiaries.


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