Affordability and Preventive Public Health Policy

Affordability pressures increasingly shape health risk in the United States, influencing both the upstream conditions that sustain health and the downstream ability to access health promoting resources. Financial stability is a key driver of health, affecting patterns of health, health care use, and the tradeoffs people must make among competing needs. The economic policy landscape aimed at improving financial security for Americans is expansive, complex, and often difficult to organize, making it challenging to discuss how different policies influence financial resilience and population health. We propose the Earn–Keep–Grow framework as a practical way to organize and guide discussion of these policies in population health research and policy decision-making.

The framework categorizes policies around three financial mechanisms that shape household financial stability: earning income, retaining resources, and building wealth. While much literature on economic disparities and health has focused on income, we look beyond income to understand not only what households earn, but also what resources they are able to keep and grow over time. Figure 1 shows examples of policies in each category of the framework that could garner bipartisan support and lead to meaningful improvement in population health.

Figure 1. The Earn–Keep–Grow Framework for Financial Health and Population Health

Establishing financial health as preventive public health

Financial instability operates as a chronic stressor and a barrier to accessing medical care. Medical debt discourages future health care use and is associated with housing instability and psychological distress. Routine financial shocks like car repairs, rent increases, or unexpected medical bills disproportionately affect households with limited savings. Medical debt remains widespread, even among insured individuals, discouraging future care-seeking. While annual earnings have risen about 38% since 2017, these gains have been eclipsed by increases in essential costs, including rents (up 50%), food costs (up 32%), and premiums for the lowest cost Affordable Care Act Marketplace plans (up 41%).² These pressures help explain why economic growth has not translated into proportional improvements in population health.  

Public health policy has traditionally focused on expanding insurance coverage, regulating environmental exposures, and promoting healthy behaviors. These remain foundational. However, financial resilience itself also functions as preventive infrastructure. Households with savings and appreciating assets can avoid high-interest debt, maintain continuity of care, and invest in stable housing and education. A key premise of this framework is that wealth, not just income, shapes health risk by determining whether households can absorb financial shocks, maintain access to care, and invest in long-term stability. This framework emphasizes three mechanisms through which economic policies can prevent health deterioration by: (1) expanding the ability of households to earn income, (2) enabling them to keep the resources they generate, and (3) supporting the accumulation of wealth over time.

Earning income

Earning income remains the primary pathway through which most households build wealth.  Beyond financial returns, employment provides structure, social connection, and a sense of purpose. These factors are independently associated with better mental and physical health.

Policies that expand earning capacity, therefore, function as preventive public health interventions. Some of these policies create job training and placement programs while others focus on improving wages. Supported employment programs help people with mental illness retain competitive employment. Evidence-based individual employment plans have been successful in providing return on investment through higher tax revenues, reduced avoidable hospitalizations, and improved health outcomes for participants.⁵ In this sense, competitive employment is part of rehabilitation and recovery. It also has the added benefit of providing individuals with income that can help establish autonomy, agency, and control for people who otherwise may have difficulty gaining employment.

While debates continue over minimum wage and labor market effects, there is broad consensus that stable, adequately compensated employment promotes well-being. There is alignment on the left and the right that employment has health promoting benefits; further, there are promising conversations about refining benefit eligibility to allow people to earn higher income while maintaining essential benefits, particularly for people with disabilities. Framing employment policy as health policy elevates its preventive value and highlights opportunities for collaboration across labor, education, and health sectors.

Keeping resources

Earning income alone is insufficient if households cannot retain resources. The “keep” category addresses the erosion of assets through debt accumulation, risky financial practices, and avoidable expenses. In an era of rising consumer costs and expanding financial products, households need both financial education and structural protection to preserve assets. As increasing numbers of Americans, particularly young adults, use financial technologies such as Buy Now Pay Later loans and other credit products to purchase goods and services, the risk of accumulating unmanageable levels of debt has grown, making financial stability an increasingly important factor to address. Despite having rising high incomes, populations that have depleted savings may experience greater financial strain and be less capable of covering unexpected costs or planning for the future. Policies that help households retain earned income include financial education, which many states now require for high school graduation. To be sure, consumer protections against bad actors, risky loans, and misleading consumer products—all of which can lead to rapid debt accumulation—are also needed to ensure that populations have financial security. Financial literacy complements consumer protection and anti-fraud programs. Federal policy also requires that military service members have access to financial education to help protect them from financial exploitation during and after active duty. Financial literacy has broad support across political parties and could be an upstream approach to educating consumers to use products and services that allow them to retain more of their income, which can be leveraged into additional, longer term assets. 

Another set of policies that helps households retain resources, particularly during unexpected health events, focuses on reducing the risk of medical debt. These include stronger hospital financial assistance policies, clearer and more transparent medical pricing, consumer protections against aggressive billing practices, and guidance that helps individuals select insurance coverage that limits catastrophic out-of-pocket costs. Medical debt is linked with a flurry of negative health and asset outcomes, including subsequent housing instability. Medical debt relief programs are not always successful, suggesting that preventing medical debt in the first place may be more beneficial for population health. By combining financial literacy, consumer protections, and insurance coverage that limits exposure to catastrophic costs, policymakers can help households avoid financial shocks that erode savings and destabilize health. Expanding public health policy to include financial preservation recognizes that protecting household assets can reduce stress, maintain continuity of care, and prevent downstream health crises.

Growing wealth

Long-term financial security depends not only on income and preservation of resources but also on asset growth. Asset growth creates durable protection against stress, instability, and limited opportunity.  Appreciating assets provide intergenerational stability and a buffer against economic shocks. Baby bonds exemplify a policy approach that builds wealth from birth and aims to reduce gaps in wealth across different income groups. Connecticut became the first state to establish a Baby Bonds program. Beginning July 1, 2023, babies born into Medicaid-covered households receive publicly funded investment accounts initially valued at $3,200, projected to grow substantially by adulthood. These assets can be used for higher education, homeownership, entrepreneurship, or retirement savings. The Connecticut policy was backed by a bipartisan group of state and local officials, and as of this writing, a dozen other states are interested in pursuing iterations of a Baby Bonds program, with broad public support.

Other policies that can help families build and grow wealth include 529 college savings accounts, matched savings accounts, ABLE accounts, and programs that encourage and incentivize homeownership. Finally, means testing in the United States is appropriate to ensure fair allocation of limited resources. However, outdated asset and income limits that define eligibility for safety-net benefits may create disincentives to save. Phasing eligibility thresholds rather than imposing abrupt cutoffs could encourage greater savings and strengthen financial resilience. Finally, public health can endorse behavioral economics evidence-based interventions to increase savings such as through automatic enrollment for retirement savings and matching programs that incentivize savings behavior. By supporting wealth accumulation, particularly for low-income populations, public health policy can address differences in wealth that contribute to avoidable health disparities.

It should be noted that absent deliberate targeting, some wealth-building policies may widen gaps in wealth across income groups. Aligning goals of wealth growth and fairness requires ensuring that low-income households can access and benefit from these programs, including market-based and tax-preferred savings opportunities. Together, universal and targeted programs can ensure opportunities for all Americans to access build-building, with additional resources directed at groups who start life with less financial stability.

Leveraging Wealth to Build Health

Health and wealth are mutually reinforcing. Financial stability enables access to safe housing, nutritious food, education, and timely medical care. It reduces chronic stress and increases agency. The Earn–Keep–Grow framework is a way to focus public health policy on sustainable and bipartisan solutions to affordability in the United States. By strengthening households’ ability to earn income, retain resources, and build wealth, policymakers can address an upstream driver of independence, financial security, and population health.

Many of the policies described here already have bipartisan appeal and growing momentum at the state level. By aligning labor, education, financial, and social policy with public health objectives, policymakers can address affordability as a root cause of health disparities. Policies that strengthen household wealth are not peripheral to public health; they are essential infrastructure for improving population health.

Acknowledgements: The authors would like to thank Eyra Dordi for research assistance and Kevin Corinth for review of earlier drafts of this work. This work was supported in part by a JHU Nexus Award, a Lipitz Public Health Policy Awards, and the JHU-AEI Fellowship Exchange Program.

About the Author