The Impacts of Individual and Household Debt on Health and Well-Being

Abstract
Unsecured debt (debt owed by individuals or households that is not secured by an item of value) has been rising since 2004 and increasingly threatens the public’s health. The adverse health impacts of unsecured debt include stress, anxiety, depression, and high blood pressure. Some people with unsecured debt have been victims of unfair lending practices, such as repayment terms that consume a substantial percentage of their income and lack of transparency related to interest rates and fees. Unfair lending practices are more likely to disadvantage Black, indigenous, and people of color; women; people with disabilities; and rural residents than White and suburban residents. There is emerging evidence demonstrating health and well-being improvements when unsecured debt is canceled or reduced. Also, there is well-established evidence that more income is associated with better health among low- and moderate-income people. Unsecured debt reduces income available to meet basic needs and ensure financial stability. Financial literacy and coaching can be important components of a comprehensive set of corrective actions but will not adequately address the problem on their own. Stronger policies are needed to protect consumers from high-cost unsecured debt and increase access to affordable credit and financial support. These reforms could improve both the financial well-being and physical health of individuals, families, and neighborhoods. Providing fair access to low-cost loans and reducing reliance on loans as a pathway to securing basic needs are important anti-racist policies needed immediately to improve health equity, address centuries of racist lending policies, and contribute to a resilient economic recovery from the COVID-19 pandemic.

Relationship to Existing APHA Policy Statements

The following policy statements are relevant to the current statement:

• APHA Policy Statement LB20-04: Structural Racism is a Public Health Crisis: Impact on the Black Community
• APHA Policy Statement LB20-05: Advancing Public Health Interventions to Address the Harms of the Carceral System
• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 20179: Reducing Income Inequality to Advance Health
• APHA Policy Statement 20167: Improving Health by Increasing the Minimum Wage
• APHA Policy Statement 20166: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 201210: Promoting Health Impact Assessment to Achieve Health in All Policies
• APHA Policy Statement 20062: Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births

Problem Statement
Definition of unsecured debt: Debt is money owed by one party to another in the form of a loan or credit.[1] Credit is extended when a person owns an item without paying fully for it and then pays for it over time.[2] Loans and credit are characterized by their purpose (e.g., housing or automobiles), whether the loan is secured by a physical object of value, the interest rate, the annual percentage rate, the amount borrowed, and the length of time for repayment. Secured debt is backed by an item of value that can be seized by the lender if loan payments are not made, while unsecured debt is extended without the collateral of a physical item of value (such as a house or an automobile). While some types of loans, such as affordable home mortgages, can help individuals build assets and wealth, unsecured debts often can be financial burdens, especially when high interest rates, penalties, and fees make them difficult to repay.

Growth in unsecured debt: Household debt in the United States has almost doubled since 2004, rising from $8 trillion in that year to $15 trillion in 2021 (an 88% increase, twice the rate of inflation of 44%).[3] In 1980, the ratio of debt to disposable income for a typical American household was 65%; by 2020, that ratio had risen to 95%.[4] In 2019, 77% of U.S. households reported holding some type of debt.[4] Home mortgages initially played a large role in that increase; however, since the housing crisis in 2008, mortgage debt has remained stable in the United States and unsecured consumer debts have continued to rise.[3]

Types of unsecured debt: There are several types of unsecured debt, including student loans, medical debt, credit card debt, high-cost credit, legal financial obligations, and child support debt. Seventy percent of college graduates have student loan debt.[3] Total student borrowing has risen from $590 billion in 2007, when 47% was borrowed from the federal government, to $1.7 trillion in 2020, when 25% was borrowed from the federal government. Private student loan lenders typically charge higher interest rates and higher fees than federal lenders.[5] After inflation, this represents a more than doubling in student loan debt for the U.S. population from 2007 to 2020. In 2020, the average student with loans owed about $37,000 in student loans.[5]

Medical debt also is common among U.S. households. About 20% of Americans report not being able to pay medical costs at the time they received care and therefore receiving charity care and/or having medical debt.[3] The average amount of medical debt was $429 in 2020,[6] down from a peak of $827 in 2010.[6]

Forty percent of Americans have credit card debt. In 2021, credit card debt was $790 billion,[3] with an average debt of about $6,000.[7]

Many Americans also use riskier, typically unsecured loans classified broadly as high-cost credit and also referred to as “predatory” as a result of their very high interest rates.[8] Predatory loans take many forms, including payday loans, pawn shops, rent-to-own services, tax refund anticipation loans, and auto title loans. Predatory loans are often used to obtain small sums of money.[9] In 1996, there were an estimated 2,000 payday loan stores in the United States. In 2019, this number had grown to 23,000 stores.[10] The volume of payday loans increased from $5 billion in 1995 to $45 billion in 2013. The growth accelerated from the late 1990s through 2021 as smaller payday lending operations consolidated and parent companies secured loans from commercial banks, public pensions, and private equity funds.[11] As the economy shifted online, so did payday lending. Online payday lender loan volume increased 25% per year from 2016 to 2019, although it fell 35% in 2020 during the COVID-19 pandemic.[12] Although use of nonbank credit fell from a high of 8% of the population in 2015 to 5% in 2019, more than 13% of low-income, young (18 to 24 years of age), Black, and American Indian individuals and people with disabilities reported having loans from nonbank lenders.[13]

Legal financial obligations (LFOs)—fees, fines, and other monetary sanctions imposed by a court in addition to a criminal sentence—are another important source of unsecured debt.[14,15] After the 2008 recession, many state and local governments increased the number and levels of fines and fees imposed on constituents for minor traffic and municipal code violations, misdemeanors, and felonies as they attempted to fill budget gaps.[16] When fines and fees were not paid, they became debts that many courts turned over to debt collection agencies. Civil courts have issued arrest warrants for thousands of borrowers who failed to provide their personal financial information to debt collectors.[17] Debtor prisons were outlawed in the United States in 1833, but hundreds of people have been arrested and jailed on contempt of court charges after failing to appear at court proceedings to answer financial questions from debt collection agencies.[17] Many who were incarcerated stated that they were not aware of their court date or that they were required to disclose financial information to debt collectors. The increased use of monetary sanctions and their associated debts threaten to permanently penalize and marginalize the poor, particularly women and people of color.[16] National data show that 6% of Americans report having unpaid legal expenses, fines, fees, or court costs.[18] Relatedly, child support is legally mandated by courts, and complex rules for collecting child support payments have led to more debt and exposure to debt collectors in recent years.[19]

Scientific issues: Substantial epidemiological evidence shows that having unsecured debt is a risk factor for poor health, including depression and depressive symptoms[20–25]; anxiety, poor psychological well-being, and other mental disorders[21,24,25–30]; poor self-rated health[8,24,31,32]; high blood pressure[24,29]; obesity[29,33,34]; inflammation/high C-reactive protein[29]; self-reported physical and sexual symptoms[29]; child behavior problems[35]; lower life expectancy[36]; higher mortality[31]; and forgone medical care.[37] While some studies suggest a dose-response relationship, such that higher amounts of unsecured debt (either as an absolute value or in relation to income or assets) are associated with worse health,[22,31–33,35,36,38] others have shown that simply being in an indebted state (carrying any unsecured debt or subjectively reporting debt difficulties) is associated with poor health.[20,21,23–27,29] 

Altered health behaviors resulting from debt, such as skipping medical care and cutting back on food and utility usage to help pay bills, are one potential mechanism through which unsecured debt may impact health.[37,39,40] Psychosocial stress is another likely pathway, since stress is a known risk factor for several chronic diseases[41–44] and both qualitative[45] and quantitative[24,29]findings suggest that being in debt is a source of stress. Unsecured debt, which often carries high interest rates and punitive repayment structures, is likely to be especially stressful.[21,25,29] Indeed, borrowers describe being in debt as causing intense feelings of personal failure, shame, depression, and anxiety.[46] This pathway could be a form of institutional betrayal (developed from betrayal trauma theory), which occurs when a trusted institution mistreats an individual. Institutional betrayal is associated with measurable psychological and physical harms.[47]

Studies show that in addition to overall levels of unsecured debt, specific forms of debt such as student loans,[30] medical debt,[48] credit cards,[32,49] high-cost credit (e.g., payday loans),[8,29] legal financial obligations,[50,51] and child support debt[52] are predictors of poor health. Student loan debt has a negative impact on not only student borrowers’ sleep duration,[38] substance use, and mental health[30,53] but also the health of their parents.[54] Among college students, credit card debt over $1,000 (in 2004 dollars) was associated with insufficient physical activity, being overweight, sedentary behavior, fast food consumption, binge drinking, substance use, and other risky behaviors.[49] Medical debt is the leading cause of personal bankruptcy and also is associated with the risk of becoming homeless.[37] Several studies have shown that medical debt reduces access to health care services and often results in delayed care.[48] One study of Arizona adults revealed that those with medical debt had six times the odds of forgoing needed medications and five times the odds of forgoing care.[55]

Research shows that LFOs can have an adverse effect on health outcomes of debtors and their family members who are often relied upon to pay.[50,56] LFOs also are associated with longer periods of homelessness.[51] Several studies have shown negative financial impacts of child support debt on children and mothers, as well as on fathers’ labor force participation and their involvement with children.[57,58] One study revealed that fathers who owe child support are more likely to report mental health problems than those who do not.[52]

Ethical, economic, and political issues related to racial inequities and disproportionate effects on other marginalized populations: Debt is not distributed equitably among U.S. residents. White residents have greater access to low-cost loans and credit from mainstream banks, which can provide economic opportunities, while Black, indigenous, and other people of color (BIPOC) disproportionately bear the burdens of high-cost loans and credit and overindebtedness, which can have adverse effects on health and well-being (as described above).[18] Ninety percent of White applicants for low-cost loans earning $100,000 or more received the loan they sought in 2020, as compared with only 70% of Black applicants and 79% of Hispanic applicants in the same income category. While 58% of White applicants earning less than $40,000 received loans, only 38% of Black applicants and 52% of Hispanic applicants with similar incomes did.[18] While 87% of White adults have a credit card, which offers convenience, longer payback periods, and lower interest rates than payday loans and other forms of predatory credit, only 72% of Black and 76% of Hispanic adults have credit cards from a mainstream bank.[18]

Four years after graduation, Black graduates have nearly $25,000 more student loan debt than White graduates: $52,726 on average, as compared with $28,006 for the typical White graduate.[59]  Sixteen percent of U.S. adults had medical debt in 2020.[18] Black adults have 2.6 times higher odds of having medical debt than White adults.[60] Black adults incur more medical debt than Whites and are more likely to be contacted by a debt collection agency because of medical debt.[60] In one study of adults over 65 years old and eligible for Medicare, about 7% of White respondents indicated having medical debt, as compared with 21% of Black respondents.[60] Medical debt also was higher among Americans living in the South than in the Northeast and higher among those living in low-income zip codes.[6] 

The rate of payday loan use varies by gender, disability, income, race/ethnicity, rural/urban location, and state of residence. Slightly more than half of those using payday loans are women (52%), and people with disabilities are twice as likely as the general population to use payday loans (12% versus 6%). Black people are three times more likely to use payday loans than White people. Urban and rural residents are twice as likely as suburban residents to use payday loans are.[9] Black and Hispanic women are more likely to use payday lenders as a last resort, since these women are more likely to lack a mainstream bank account than other groups. Lacking a bank account is also known as being “unbanked” or “underbanked.”[18] 

Privately run national credit reporting agencies assign numbers to consumers[61] and are more likely to assign high numbers to White residents who have had generations of greater access to home ownership and other financial assets.[62] With a low or no credit score, lower-income Black and Hispanic residents cannot access lower-interest credit cards or other low-cost loans.[63] Black and Hispanic residents with low incomes live in neighborhoods with more payday loan stores.[64,65]

Mainstream banks provide lines of credit to payday loan companies and financially benefit from the racially inequitable financial system they have collectively created.[66] National credit reporting agencies, and the algorithms they use, play a role in perpetuating the racist impacts of lending and credit systems.[67]

Legal financial obligations and associated court debt are more likely to be experienced by people with low incomes: 10% of those earning less than $40,000 report having court debt, as compared with 3% of those earning more than $100,000. Court debt is more likely to be imposed on Black and Hispanic people. In 2019, 12% of Black adults and 9% of Hispanic adults had court debt, while 5% of White adults had such debt. Court debt often adds to other financial burdens faced by people with low incomes; 43% of those with court debt also have unpaid medical debts.[18]

Almost one third (29%) of U.S. adults have unpaid debt in collections.[68] Twenty-four percent of White residents and 39% of people of color have debt in collections, a disproportionality that contributes to the perpetuation of the racial wealth gap.[68] People living in the South are more likely to have debt in collections than those living in northern parts of the United States.[68]

Evidence-Based Strategies to Address the Problem
The evidence base for strategies to address the growing levels of unsecured debt is grounded in three related rationales. First, there is growing evidence showing that reducing unsecured debt can lead to improved health. Second, strategies that reduce the need for individuals to take out unsecured loans (e.g., providing public benefits) have been associated with improved health outcomes. Third, a well-established research literature shows that more income, which also reduces the pressure to take out loans, is associated with better health. As components of the third rationale, job training programs that lead to higher incomes can reduce debt levels and future pressures to take on unsecured debt. Similarly, wealth-building strategies such as individual development accounts have been associated with improved health outcomes.

Health effects of reducing or eliminating unsecured debt: Researchers have studied how chronic debt affects behavior by measuring how a large unanticipated debt-relief program affects psychological functioning and economic decision making. A charity provided households with low incomes debt relief worth up to three months of household income. Having the debt paid off improved cognitive functioning and reduced anxiety by 11% and increased levels of hope for the future by 10%.[69] The researchers hypothesized that chronic debt impaired behavior because the mental costs of having debt consumed mental bandwidth.[69] Case studies on students in graduating classes that have had student loans canceled have shown that canceling debt can improve health and well-being.[70] Family well-being measures have improved when child support debt is reduced.[71]

Some argue that reducing access to payday lenders is detrimental to the well-being of individuals with lower incomes since they may face challenges covering unexpected expenses. However, after payday lenders have been banned in different states, there have not been increases in loan sharks, and new businesses have moved into previous payday loan storefronts.[72,73]

Public benefit expansions are associated with improved health outcomes and lower levels of debt. Strengthening social welfare programs (e.g., Earned Income Tax Credit [EITC], Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, and other programs), increasing the minimum wage, testing conditional and unconditional cash transfer programs, expanding government-sponsored health insurance (to reduce medical debt), offering free community college (to reduce student loan debt), and increasing labor protections could reduce the population’s demand for and exposure to short-term high-interest loans.[74] Given space constraints, comprehensive evidence of all of these safety net policies cannot be provide here, but a few examples are offered for reference. Medicaid expansions and higher state minimum wage laws have been associated with lower demand for short-term high-cost loans.[8] Medicaid expansions also have been associated with lower levels of medical debt over time.[6] A “natural experiment” took place during the COVID-19 pandemic when the combination of moratoriums on debt, child tax credits, and stimulus payments was associated with a reduced volume of payday lending.[12] Much research has focused on the health impacts of the minimum wage, the EITC, and unconditional cash transfer programs. Studies have shown that higher minimum wages are associated with improved mental health,[75,76] EITC generosity is linked to a reduction in suicide attempts,[77] and unconditional cash transfers during pregnancy are associated with improved birth outcomes.[78]

Health improvements are associated with higher incomes: A robust literature shows that income is strongly associated with better health outcomes across the income distribution.[79] Income influences health through clinical, behavioral, social, and environmental mechanisms. Policy initiatives that supplement income and increase access to higher incomes by improving educational opportunities, housing stability, and economic mobility have been shown to reduce poverty and lead to corresponding health improvements for low- and middle-income people.[80] Excessive debt repayments effectively reduce incomes and counteract the goals of these policy initiatives.

Vocational or job training programs that lead to higher incomes and more secure employment can reduce debt levels and future pressures to take on unsecured debt. Vocational training, an intervention for unemployed and unstably employed workers, has been shown to improve employment outcomes for this vulnerable group. Although studies have not linked vocational training directly to reductions in debt, research has shown increases in earnings and employment rates for those who completed vocational education.[22,32,35,36] For example, a study of students attending the Tennessee College of Applied Technologies revealed a 13% to 19% increase in earnings relative to before enrollment and an approximately 11% higher employment rate, while a study of California community colleges showed a 14% to 45% increase in earnings, with health care programs exhibiting the strongest return on earnings.[35]

Training programs that provide support services, such as child care or financial compensation, have been shown to be more successful than those that do not. For example, the comprehensive Quest program in San Antonio, Texas, provided students with financial assistance to cover the costs of tuition, books and fees, remedial math and reading instruction, academic and personal counseling, referrals to safety net organizations for assistance with child care, utility bills and food, weekly meetings to build life skills, and job placement assistance.[32]

Wealth-building strategies can reduce unsecured debt: Child and individual development accounts (IDAs) have been associated with improved savings and improved health outcomes. IDAs are matched savings accounts designed to help poor people build assets. When individuals make withdrawals for buying a home, pursuing education, or starting their own businesses, their savings are matched by a government or community-based entity. An evaluation of IDA programs showed modest gains in savings among low-income program participants.[81] Evidence is stronger for the health impacts of Child Development Accounts (CDAs). These are matched savings programs established for children to pay for future educational expenses. In a randomized controlled trial, a decline in maternal depressive symptoms and an improvement in social-emotional development among young children were found in families with CDAs (relative to those without CDAs).[82,83]

Many well-designed studies have demonstrated that unsecured debt can have adverse effects on mental and physical health, so immediate interventions are called for. Additional interdisciplinary research is needed to expand the evidence base on how to relieve debt burdens and prevent future burdens and on how these strategies can improve health outcomes.

Opposing Arguments/Evidence
Opposing argument 1: Overindebtedness can lead to material burdens and poor mental and physical health outcomes, but the authority to implement solutions is outside the purview of public health. Public health is underfunded in the United States and should focus resources on current policy priorities.

Response: The social determinants of health shape health outcomes, and in the United States loans are often a way to secure access to social determinants such as transportation, housing, and education.[84] A health in all policies approach supports public health leaders who consider the health effects of financial instruments such as loans.[85] Unsecured debt can be a barrier to economic stability, which contributes to good health. Public health and health care sector leaders can be important partners for consumer protection organizations, community development agencies, and asset-building leaders seeking to reduce overindebtedness because they can provide health-related reasons to increase access to low-cost loans and protect individuals from high-cost unsecured loans. Similarly, consumer protection organizations can provide public health organizations information on policy and grassroots organizing, creating a synergistic relationship to identify and implement interdisciplinary policy solutions for individuals and communities.

Opposing argument 2: Debt taps into strongly held values and has deep historical meaning, its etymology referring to “what is owed” and “duty.” Debt is sometimes perceived as a moral obligation to fulfill at any cost.[86]

Response: Research has shown that the moral obligation of debt is in fact one of the mechanisms through which it may exert its adverse impact on health; many people feel a deep sense of shame about their indebtedness, which in turn is associated with poor emotional, physical, and subjective health.[87] The psychological meaning of debt has been exploited by some lenders to create circumstances approaching indentured servitude in the United States.[86] In many places, city and county courts and sheriff’s offices have become adjunct arms of debt collectors.[17] Loans can be a social construct devised by those who have gained substantial financial benefit, and ill-gotten gains do not necessarily need to be repaid.[86] The United States has normalized going into debt for basic needs (e.g., health care and education) that could alternatively be publicly funded.[88] In some phases of history, every seven years loans were forgiven in a jubilee year.[86] Canceling debt could provide more hope for the future and resources to improve people’s lives rather than feeding feelings of futility and exposing individuals to the health risks of overindebtedness.[89]

Opposing argument 3: People are not forced to take on debt, and they must pay what they owe.

Response: In many cases, people actually are forced to take on debt, or at least they feel that way.[90] Since the 1970s, neoliberal economic policies have effectively funneled Americans, especially poor ones, into debt.[91,92] Through deregulation and “democratization” of credit industries, consumer debt has become widely available at the same time real wages have declined, leaving many in a position in which credit is their only option for meeting basic needs, such as rent or food, or paying an unexpected expense.[93,94] In addition, many families have no choice but to incur debt to pay down medical debt in the absence of comprehensive health insurance. Predatory lenders can be deceptive, and they target Black, indigenous, and people of color in different ways than White people, such as through the locations of retail stores, marketing, and spokespeople.[64] Systematic underinvestment in communities of color has created many disadvantages for residents, including greater exposure to predatory lending.[95]

Opposing argument 4: Regulating payday lenders and other high-interest short-term credit offered by online and in-person alternative financial service providers will deprive people with low incomes of small dollar loans for unexpected life emergencies and will lead to illegal lending.

Response: Before the 1980s, high-interest payday loans were not legal in the United States, and they are currently not legal in 18 states and the District of Columbia where interest rates are capped, typically at 36%. There has been no evidence of increased illegal lending in states with interest rate caps.[72] Rather than legalizing payday lending, more constructive public policy options are reducing the demand for high-cost loans, making other safe low-interest loans available on terms that can reasonably be paid back, and providing public benefits so that the demand for unsecured debt is lowered.

Alternative Strategies
Financial literacy and financial coaching: Some have advocated that additional consumer financial education is enough to address unfair lending practices by banks, other lenders, and alternative financial service institutions.[96] Financial literacy places the onus on the individual and does not change larger systemic issues that create the environment for overuse of debt.[97] Financial coaching programs meet clients where they are and provide tailored resources and advice.[98] However, these programs often suffer from low participation rates.[99] Financial literacy and coaching are beneficial but insufficient strategies that could be components of a comprehensive set of strategies.[100,101]

Community-based financial services: To reduce predatory lending and address the exclusion of low-income communities from mainstream banking, lending circles and community development financial institutions (CDFIs) can offer benefits.[102] With their roots in Latin American and Asian cultures, lending circles provide an opportunity for members to gain access to loans at no interest and with no additional fees. The Mission Asset Fund in San Francisco has developed innovative lending circles, and, through reporting of lending circle contributions to credit agencies, participants are able to build credit while also receiving no-cost loans.[103] CDFIs are committed to economic development in low-income communities and provide flexible loans and other financial services (e.g., financial education and credit counseling). Their approach is investment focused with a goal of increasing the flow of capital to historically neglected communities.[100] CDFIs have important roles to play in comprehensive approaches to reducing unsecured debt burdens.

Action Steps
To ensure that Americans have fair and just access to the resources they require for basic needs and are protected from the financial drains and health harms of unsecured debt, APHA recommends that:

1. The federal government take several coordinated actions to reduce current levels of unsecured debt and improve protections of consumers from overexposure to unsecured debt.

• The federal government and Congress should act when possible to cancel student, medical debt, and other types of excessive debt for lower-income people, people of color, and other groups who have been harmed by unsecured debt in the past.[104]
• The Consumer Financial Protection Bureau (CFPB) should require that payday loans and similar high-interest loans take the applicant’s ability to pay into account and limit repeat borrowing. Interest rates should be limited to 36% or lower, as is done for members of the military.[92] 
• The CFPB also should provide more monitoring, enforcement, and regulation of online lending and financial technology companies that offer unsecured debt and credit. 
• The Federal Reserve Banks should work speedily to make affordable loans more available to all of those who have been excluded from low-cost credit and loan markets in the past, especially Black, indigenous, and people of color; women; low-income people; disabled individuals; and gender nonconforming consumers. 
• All bank regulating entities in the federal government, including the Federal Deposit Insurance Corporation, the Federal Reserve Banks, and the Office of the Comptroller of the Currency, should act in alignment to make high-quality and affordable banking products available more equitably.[105] 
• Federal regulators should demand greater transparency from lenders to consumers. Consumers have the right to know how loan decisions are made so that they can be assured that lending practices are not racist, sexist, or ableist. 
• Federal and state regulators should require lenders to make the terms of loans and credit clear to borrowers, should not be allowed to offer add-on products, and should provide documents in the borrower’s preferred language.

2. State governments take actions to protect their residents from overexposure to unsecured debt.

• The 32 states that have not done so should join the 18 states that have passed a cap of 36% or lower on interest rates to lessen or eliminate payday lending.
• All states should establish and maintain usury limits to reduce the harms of high-interest short-term loans. 
• States should require health impact assessments for consumer financial products, including loans and credit. 
• States and territories should offer public banks to increase access to affordable financial services, as is done in North Dakota and American Samoa.[106] 
• States should reinstate key provisions of Uniform Small Loan Laws to protect residents from predatory unsecured small loans. 
• State health officers, boards of health, and Medicaid directors should evaluate and publicly report how overexposure to unsecured loans is associated with population health. 
• States should review and reduce the role of their court systems in enforcing predatory unsecured loan contracts. 
• States should remove or limit city and county court authority to impose harmful legal financial obligations and fund court systems directly through general tax revenues.[107] 
• States should review and reduce their use of child support debt and other forms of debt that disproportionately affect low-income people and people of color. 
• States should conduct greater oversight of debt collection agencies and monitor their impacts on population health. 
• States should increase investments in consumer financial education and financial coaching as part of a comprehensive unsecured loan reduction strategy.

3. City and county governments protect local residents from unsecured debt by using zoning laws and other policy interventions available to them to reduce the burdens of unsecured debt, including reducing the density of payday loan storefronts in low-income neighborhoods.[108]

• Cities and counties should financially support historically underresourced low-income communities.[93]
• Cities and counties should publicly report and reduce or eliminate their use of fines, fees, restitution, and associated debt. 
• City and county courts should review and reduce their roles in the debt collection process. 
• City and county courts should cancel court debt more than one year old, reduce child support debt, and eliminate or reduce the use of fines and fees that create disproportionate burdens for low-income and BIPOC communities.[109] 

4. State and local health departments increase their capacities and participation in multisector partnerships that measure, evaluate, and intervene in financial policies and products’ effects on mental and physical health outcomes.

• Health departments should adopt policies to reduce exposure to predatory lending and unsecured debt in their community health improvement plans, as has been done in Kansas City, Missouri.[110] 
• Health departments should make use of health impact assessments for financial policies, as Minnesota has done for payday loan reforms.[64]

5. Federally regulated banks make affordable financial products available to all U.S. residents, including the 8% who have low credit scores and the 11% who do not have a credit score, so that all residents have alternatives to high-cost short-term credit.[111]

• Banks should reduce fees for consumers with low incomes.
• More banks should offer low-cost financial products with fees but without interest to be accessible to Muslim individuals and members of other religious groups that do not permit borrowing.[112]
• Banks should not "create" markets for payday lenders by declining to serve low-income consumers and then extending corporate financing to payday lenders and other alternative financial service companies.[19]
• Banks and lenders should publicly share information about how loan decisions are made to assure the public that lending practices are not racist, sexist, or ableist.
• When offering loans, banks should ensure that the terms of the loans are clear to borrowers and are offered in their preferred language.

6. Credit unions and community financial development institutions make low-cost savings and loan products more available to those who lack affordable banking options. These options include payday alternative loans and credit builder loans.[113]

7. National credit reporting agencies provide greater transparency about the formulas and algorithms they use, including algorithms that employ artificial intelligence, to demonstrate whether low-income people, women, people of color, disabled individuals, and gender nonconforming people have fair access to credit. Artificial intelligence and machine learning based on historical lending data are likely to replicate past sexist and racist practices and should be intentionally designed to counteract past biases. Credit reporting agencies should increase the use of variables in their algorithms to be more inclusive of renters and utility payers.

8. Hospitals and other health care providers not own or invest in debt collection agencies.

9. Health care providers take additional steps to reduce the potential health harms of unsecured debt.

• Health care providers should reduce the levels of medical debt they impose on patients. 
• Health care providers should not take patients’ assets into consideration when collecting medical debt.
• Health care providers should confidentially screen for overindebtedness as a risk factor for patients while ensuring that privacy protections are in place, and they should make referrals to legal aid organizations that can negotiate lower debt levels and to public benefit programs so that patients can reduce their debt levels. 
• Health care providers should work at the policy level to protect their communities from predatory lenders and overexposure to unsecured loans.[114]

10. Schools of public health create programs in partnership with business schools, public policy experts, asset-building nonprofits, and other financial experts to teach about and build the evidence base on the relationships between financial policies and health. 

11. Community organizers and advocates launch more state-level initiatives to curtail predatory lending when such issues are elevated by community members and partner with public health leaders.

12. Faith-based leaders continue to advance fair lending practices and partner with health care and public health leaders to protect the health and well-being of community members by reducing exposure to unsecured debt and unfair lending practices.

13. Employers offer financial education and low-cost short-term loans to employees as long as safeguards such as ability to pay assessments, limits on repeat borrowing, and flexible payback periods are used.

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