Introduction
“Two years down the line, everything stopped, and they sent me a letter stating the fact that I owed $88,000,” (Mar, 2023) said Diane O’Brien in an interview with CBS Chicago. O’Brien was shocked after receiving a letter from the Social Security Administration (SSA) demanding money for overpayments made to her deceased husband. The SSA provides monthly cash benefits to “retired or disabled workers and family members of deceased workers” with sufficient working hours and SSA tax “credits” (Social Security Administration, n.d..). However, as exposed in recent news reports by 60 Minutes and KFF Health News, the SSA frequently overcalculates its payments and reprimands its beneficiaries to repay thousands of dollars (Lanza, 2015). Within the 30 to 60-day payback window (Social Security Administration, n.d.), the SSA also strips beneficiaries of ongoing benefits (Buckner, 2024). These payment overcalculations are due to a multitude of problems: outdated systems, improper or inaccurate beneficiary reporting (Li et al., 2024), insufficient staffing oversight (Social Security Administration, n.d.), errors in data entry, and the application of policy (House Committee on Ways and Means, 2023).
The SSA’s overpayment crisis, totaling over $72 billion from 2015 to 2022, disproportionately affects America’s poorest and most vulnerable citizens (Office of the Inspector General, 2024). In October 2024, a former SSA attorney claimed that Americans are being overpaid $9 billion in benefits (Malcolm, 2024). As in cases like O’Brien’s, the SSA is demanding $11.1 billion from two million unknowing beneficiaries (SSA, 2023). The problem lies not only in the SSA’s efforts to recover these overpayments but also in its approach of suspending all benefits until the debt is settled. Since low-income individuals have less access to healthcare services (Glei et al., 2022), strict repayment regulations likely force beneficiaries to de-prioritize health-related expenses and reduce their capacity to uphold social determinants (e.g. economic stability, food security, safe and sanitary housing, and quality health care access) (World Health Organization, n.d.). When social determinants are negatively impacted, the risk of adverse health outcomes such as chronic stress (Ward, 2023) and unhealthy lifestyle behaviors such as poor diet and cigarette smoking increases (Liu et al., 2024; Zhang et al., 2021). While rooted in financial mismanagement, the SSA overpayments have a broader impact on public health. The SSA must thus acknowledge and take responsibility for its potential role in exacerbating socioeconomic health inequities, contributing to mental and physical health declines among beneficiaries, and neglecting biomedical principles of ethics. Overall, the health implications of SSA overpayments serve as a reminder that social policy is health policy.
Socioeconomic Inequities
Health disparities arise from the manifestation of unjust, unnecessary, and avoidable systems (Ward, 2023). The National Health Expenditure Accounts reported that U.S. healthcare spending grew from 4.5 percent in 2022 to 7.5 percent in 2023 (Centers for Medicare & Medicaid Services, 2024). Today, 45 percent of American adults struggle to cover their medical bills (Witters, 2022) with a recent Census Bureau analysis revealing that 1 in 12 adults owe medical debt (Rakshit et al., 2024). Despite rising healthcare costs, 133 million Americans suffer from a chronic disease (e.g. heart disease, cancer, arthritis) (Centers for Disease Control and Prevention, 2023; Raghupathi & Raghupathi, 2018), and Americans live shorter lives and experience more injuries and illnesses than other high-income countries (Amaro, 2025; Peter G. Peterson Foundation, 2024; National Research Council, 2013). Inadvertently, the SSA’s large and immediate overcalculation payback program widens the health gap between the lower and upper class by further limiting the quality of health services beneficiaries can afford. While the SSA overpayment crisis poses a threat to people’s wallets, it ultimately leaves a negative mark on their health. SSA beneficiaries such as the elderly, disabled, and emotionally distressed family members (Lanza, 2015) represent America’s healthy and financially vulnerable population (Fong, 2019; Krueger & Chang, 2008; Froehlich-Grobe et al., 2016). Public health research and literature suggest that individuals with low incomes die sooner than those with higher incomes (Avanceña et al., 2021). Financially burdened individuals are also more likely to work high-demand, low-control jobs and face multiple sources of stress due to insecurities in food, shelter, and medical care (House, 2002; Liu et al., 2024; Zhang et al., 2021; Glei et al., 2022). Other studies have found that the duration of poverty matters for health, as well. “The longer the poverty spell, the worse one’s health is” (Lynch, Kaplan, & Shema 1997). In 2014, the Washington Post reported on a woman whose state and federal tax returns were seized to recover a 37-year-old overpayment made to an unknown family member (Fisher, 2014). As exemplified by the Fisher (2014) story, those in need of medicine and health services may encounter financial constraints due to overpayments they never benefited from. The long-term health consequences generated by the SSA overpayment crises extend beyond individuals and married couples, impacting entire generations. Without money, people cannot take care of themselves. Reinforcing the link between low income and limited health-promoting resources reduces the potential to alleviate generational health disparities. This is particularly problematic for an agency whose main responsibility is to provide “financial protection for our nation’s people” (Social Security Administration, 2023). Today, overpaid beneficiaries may struggle to afford health-sustaining resources and services as they bear the burden of government errors. The SSA overpayment crisis advances socioeconomic inequities, further widening the health gap.
Mental and Physical Health Decline
Americans preparing for retirement and investment are suddenly finding themselves indebted to the SSA, increasing their risk of mental and physical decline. Exposure to this kind of fear and uncertainty may trigger a stress response. If this response is constant and unrelenting, then human physiological systems can suffer from lifelong, irreversible effects (Ward, 2023). The persistent stress of sudden debt may trigger chronic physiological responses such as suppressed digestive function and weakened immune responses (Mayo Clinic Staff, n.d.). As overpaid beneficiaries struggle to maintain their expenses, the constant state of financial uncertainty prevents them from maintaining a stable and healthy life. Thus, the solution to addressing negative health reactions is not increasing payback windows from 30 to 60 days (Social Security Administration, n.d.; Social Security Administration, 2024) or waiving and reducing overpayments (Buckner, 2024; Social Security Administration, 2024), but not having these errors occur in the first place. Even if current debts were waived or reduced, the stress imposed on beneficiaries - between receiving the overpayment letter and getting an appeal or waiver request approved (Social Security Administration, n.d.) - may result in future negative health outcomes. Chronic stress that lasts weeks or months (Cleveland Clinic, 2024) is directly linked to heart disease, stroke, depression, obesity, sleep problems, and other illnesses and injuries (Ward, 2023). A systematic review of policy changes in high-income countries found associations with mental health outcomes, in which “social security benefits are associated with positive mental health outcomes and lower inequalities” whereas “policies that reduce or limit benefits tend to have negative effects” (Simpson et al., 2021). Fourteen of the twenty-one studies that examined expansionary policies found strong associations with positive mental health outcomes, including Golberstein (2015) which revealed that “$1,000 in additional social security income reduced the likelihood of depression among low-educated women by 24% (p < 0.01)” and DeSimone (2018) attributing a significant 9% drop in American male suicides (p < 0.01) with early retirement eligibility (Simpson et al., 2021). On the contrary, the probability of depression among U.K. women aged 60 to 64 significantly increased by 6.2 percentage points (p < 0.05) (Carrino et al., 2020) and Dutch male depression rates increased by 2.8 percentage points (Grip et al., 2012) when retirement eligibility requirements were tightened (Simpson et al., 2021). The SSA’s rapid money clawback, offering limited alternatives and resources, is a prime example of an “austerity-style reduction” policy (Simpson et al., 2021). The risk of chronic stress induced by SSA overpayments, in addition to everyday circumstances and prior traumas like the COVID-19 pandemic, can contribute to a range of mental health issues. For thousands of SSA overpayment beneficiaries, unrelenting stress and chronic health issues have become the new normal for thousands of SSA overpayment beneficiaries, however, many go unnoticed. SSA overpayments pose a greater health risk to beneficiaries as it not only impacts one's financial ability to afford health services and resources but also the sudden financial burden can have immediate health consequences on them. Overpaid beneficiaries are facing negative impacts on their well-being, highlighting the need for ethical consideration in resolving the crisis.
Biomedical Principles of Ethics
The SSA’s lack of transparency raises concerns about its alignment with biomedical principles of veracity (an obligation to tell the truth) and beneficence (a willingness to do good). In this regard, the SSA’s inadvertent disregard for biomedical principles necessitates an ethical approach to addressing the overpayment issue. KHH News reported, “The agency rejected a May 2022 Freedom of Information Act request for documentation of every overpayment notice” (Hilzenrath et al., 2023). Concurrently, the former SSA commissioner resigned in late November 2024, hurting already low staffing numbers and demonstrating a low commitment to positive agency change (Hilzenrath et al., 2024). While the agency has made several policy changes, the system remains highly flawed, with the burden remaining on beneficiaries to prove their innocence, continued poor customer service, increased withholding of benefits, and slow waiver requests and appeal approval turnarounds (Hilzenrath et al., 2024). Above all, overpayment errors persist. As previously mentioned, SSA beneficiaries make up America’s most health-vulnerable and low-income population (Fong, 2019; Krueger and Chang, 2008; Froehlich-Grobe et al., 2016). From the standpoint of biomedical ethical principles, it is inequitable to reprimand a financially insecure population for thousands of dollars, reducing the already limited health benefits they have. If beneficiaries feel ‘scammed’ and manipulated by an agency they are funneling their entire life savings into, then why should they trust any federal agency or program? The SSA’s hesitancy towards change and lack of transparency only makes beneficiaries feel unsure and unprotected. This is more than just an issue of SSA overpayments, it is an issue of trust between the government and its citizens. Negative experiences encourage people to alienate themselves from welfare programs that promote their health, including ones that meet public health standards. As a government agency, it is the SSA’s responsibility to regularly check payments and report inconsistencies – especially since many beneficiaries are incapable or struggle to properly self-report data (Hilzenrath et al., 2023). If these mistakes go unnoticed by bureaucrats and automated systems, beneficiaries are even less likely to detect them. A policy following beneficence principles would also grant its beneficiaries the same amount of time the overpayments were made for paybacks. The Social Security Act states that the SSA “cannot recover an overpayment from a person who is without fault” because it “would defeat the purpose of the benefits program or would be against equity and good conscience” 42 U.S.C. §404(b). However, the SSA is not abiding by the rules they implemented by themselves nor by the biomedical principles of ethics. When faced with a situation that involves competing moral solutions, only ethical analysis can provide a solution that results in more good than bad (Ward, 2023). In this case, the SSA must decide between immediately demanding money back, waiving payments altogether, or granting time for paybacks and sustaining benefits. Ethical analysis is done through a ‘consequentialist’ lens, in which the benefits and harms from our actions are weighed against one another. By upholding biomedical principles of ethics, a solution to the overpayment crisis can be constructed that is not at the expense of people’s health.
More Than Healthcare
The three public health concepts, including socioeconomic inequities, mental and physical decline, and biomedical principles of ethics, reinforce one conclusion: social policy is health policy. Social and economic factors account for 40% of determinants of health (Los Angeles County Department of Public Health, 2013). A systematic review found that “more generous welfare states” lead to better population health outcomes and lower inequities” (Naik et al. 2019). Disparities in social policy can lead to health issues, wherein financial insecurity leads to mental and physical well-being decline. A core principle of public health services is assurance, which means enabling equitable access to the beneficiaries and building a skilled workforce, aspects in which the SSA needs improvement. Nicole Tiggemann, a spokesperson for the administration, noted that the “SSA is developing a program to tap payroll data from outside sources,” which will be used “to automatically adjust the amounts it pays beneficiaries” (Hilzenrath et al., 2023). Congress authorized that project almost eight years ago, but the SSA has remained silent. Without action, the SSA cannot uphold efficient policies, plans, and laws to advance population health. SSA overpayments have been occurring for over a century, with news coverage dating back to 1975 (Hart & Rowan, 1975). For decades, millions of Americans have suffered mentally, physically, and emotionally due to SSA overpayments. Due to financial strain, beneficiaries and their family members may forego necessary medical treatment and health services. In a 1975 interview with Robert Bynum, the associate administrator of the SSA, he said, “I think that our efforts will tend to become less productive as we move along. There’s no way that an administration of a program of this size…[can] identify all the errors and we will continue to pick up errors in the future” (Hart & Rowan, 1975). Those words, despite being said 48 years ago, reflect our current state today. If the SSA is not willing to find solutions to the problem, then beneficiaries of the SSA should not be forced to pay back. Without an efficient social policy, what good is it to have a program that harms the general well-being of its beneficiaries?
Conclusion
While rooted in financial mismanagement, the SSA overpayments have a broader impact on public health. The SSA must acknowledge and take responsibility for its potential role in exacerbating socioeconomic health inequities, contributing to mental and physical health declines among beneficiaries, and neglecting biomedical principles of ethics. Overall, the health implications of SSA overpayments serve as a reminder that social policy is health policy. With a collaborative public health and multi-sectoral approach, the health of SSA beneficiaries can radically improve. This means involving healthcare professionals in congressional hearings and related legislation regarding the SSA and its changes. When developing evidence-based social policies, the health impacts must be fully considered so they promote or at least do not harm Americans (Simpson et al., 2021). Without a population health framework, the SSA cannot achieve its safety-net program goals while simultaneously promoting overall well-being.
When 60 Minutes, a CBS News program, covered the issue in November 2023, the SSA waived all overpayments of the beneficiaries featured in the report (Farmer, 2023). Negative publicity encouraged the administration to take action, showcasing their interest in maintaining their reputation and receiving money. Since news reports from late 2023, Congress has introduced the Social Security Overpayment Fairness Act (118th Congress - House of Representatives et al., 2024) and held a hearing before the House Committee on Ways and Means, Subcommittee on Social Security (House Committee on Ways and Means, 2023). These are significant improvements, but a work in progress nonetheless. Alongside congresspeople, population health experts can create a policy that helps the SSA recuperate a portion of losses, reduce the number of overpayment errors, and promote well-being - all the while keeping a good public image. In this way, both the government and citizens win. Encouraging congregational action, ethical consideration, and a population health perspective are vital to resolving this crisis and safeguarding the well-being of millions of Americans. Today, 70.6 million Americans receive SSA benefits (Social Security Administration, 2023), making them vulnerable to overpayment errors. This crisis affects not only beneficiaries but also their families with potential long-term health and financial consequences. Younger generations also face uncertainty regarding future benefits, as SSA funds are projected to be depleted by 2057 (SSA, 2010). Given the widespread impact on financial stability and well-being, there is no better time to address the SSA overpayment issue than now.