Executive Summary
Healthcare spent three decades learning a lesson that financial services has not yet absorbed. Health outcomes are not determined solely by clinical care. They are shaped by structural forces: housing stability, food security, education access, social support, and neighborhood environment. These Social Determinants of Health (SDOH) now drive billions in investment, mandatory CMS screening, and a fundamental restructuring of how healthcare measures success.
This paper argues that financial wellbeing in retirement operates under the same logic. A person's ability to deploy their financial resources with confidence is not determined by how much money they have saved. It is determined by five structural forces: Spending Confidence and Access, Financial Literacy and Cognitive Load, Social Identity and Role Continuity, Advisor Trust and Planning Continuity, and Health and Financial Navigation.
Together, these five forces constitute the Social Determinants of Financial Wellbeing (SDOF™). They explain why married retirees with over $100,000 in savings withdraw at just 2.1% annually, why 64% of Americans fear running out of money more than death, and why financial stress produces a 60% higher mortality risk than having had a previous heart attack.
What healthcare got right.
Before 2010, American healthcare measured success by volume: how many procedures were performed, how many patients were seen. The system treated patients as clinical problems with clinical solutions. Then researchers documented that 30% to 55% of health outcomes are attributable not to clinical care but to social and environmental factors.53
A scoping review of 41 U.S. studies found that 79% of outcome measures showed improvement from SDOH interventions.3 CMS mandated SDOH screening in all hospital inpatient quality reporting programs starting in 2024, covering five domains: food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.2
CMS has set a target of 100% of Traditional Medicare beneficiaries in accountable care relationships by 2030.4 HHS has concluded that some SDOH interventions both improve outcomes and decrease healthcare costs.6
If your neighborhood has no sidewalks, you walk less, regardless of your personal motivation to exercise. If your retirement has no spending confidence, you spend less, regardless of how much you have saved.
The great transfer: from pensions to paychecks.
For most of the twentieth century, retirement income was an institutional problem. Employers provided defined benefit pensions. The individual's role was to show up, work for thirty years, and leave with a guaranteed monthly check. That world is gone. In 1980, 38% of private-sector workers participated in a defined benefit pension plan. By 2024, that number had fallen to 15%.7
The transfer was not just financial. It was psychological. Pensions provided income certainty, decision simplification, and institutional responsibility. A retiree with a 401(k) faces all three questions simultaneously, every month, for the rest of their life. Only 4% of retirees claim Social Security at the most financially optimal time, costing $3.4 trillion collectively.9
Seventy-nine percent of Americans agree the country faces a retirement crisis. Eighty-three percent believe all workers should have access to a pension.11
The mass affluent paradox.
A 72-year-old woman with $800,000 in savings needs a medically necessary adjustable bed that costs $10,000. She refuses to buy it. Not because she cannot afford it, but because she has no confidence that spending $10,000 today will not leave her short at age 88. Her financial advisor has shown her the projections. But projections do not replace confidence. She sleeps in pain. Her mobility declines. Her health costs increase. Financial anxiety produced a health outcome that no amount of savings could prevent.
Forty-two percent of retirees with more than $2 million in assets spend less than $100,000 per year.13 From 2000 to 2008, the financial assets of wealthy retirees still continued to increase during retirement.15
Sixty-four percent of Americans now say they are more worried about running out of money than about dying.14 The behavioral science explains why: losses feel approximately twice as painful as equivalent gains.17 In retirement, every withdrawal is framed as a loss.
The five social determinants of financial wellbeing (SDOF™).
The SDOH framework works because it names the structural forces that shape health outcomes beyond individual behavior. The SDOF™ framework applies the same logic to financial wellbeing in retirement.
Fifty-one percent of retirees with money remaining in their defined contribution plan worry about running out, up from 30% less than a decade ago.18 Twenty-seven percent of Vanguard retirees over 60 took zero withdrawals during their first five years of retirement.19
Thirty-six percent of Americans say financial pressures force them to sacrifice aspects of their health.21 One-third of financially vulnerable individuals did not receive healthcare they needed due to cost.22
Retiring in America in 2026 requires making more simultaneous, irreversible, and interconnected decisions than at any other point in adult life. Medicare enrollment, Social Security claiming, COBRA transitions, RMDs, Roth conversions, long-term care insurance, estate documents, pension elections.
People without social identity and role continuity make worse financial decisions. They panic-spend to fill the void. They refuse to spend because spending feels like confirming that retirement is really happening. Identity disruption produces financial paralysis.
SDOH says: if your community has no social support, your health declines. SDOF™ says: if your identity has no structure beyond work, you cannot make confident financial decisions about a life you cannot picture.
Social isolation in retirement is not just a loneliness problem. It is a financial risk factor. Isolated people are more vulnerable to scams, lack sounding boards for major decisions, and lose access to informal financial knowledge.
The Connection Loop: SDOF™'s central contribution.
The five determinants do not operate in isolation. At the intersection of Health and Financial Navigation and Spending Confidence, a self-reinforcing cycle emerges.
The Connection Loop is not theoretical. It is measurable, predictable, and, with the right interventions, interruptible.
Why this matters now.
CMS mandated SDOH screening in 2024 because the evidence was overwhelming. The evidence in this paper is equally overwhelming that savings adequacy alone cannot explain financial wellbeing in retirement.
Measuring what matters: from assessment to action.
SDOH screening works because it asks questions that clinical assessment does not. SDOF™ assessment applies the same principle.
Organizations can begin measuring SDOF™ today by adding five questions to their existing retirement readiness assessments, one for each determinant.
Implications for employers, advisors, and policymakers.
Measure what matters. Not just what is easy to count.
Healthcare spent three decades discovering that health outcomes are shaped by forces that clinical care cannot see. They called them Social Determinants of Health. They invested $2.5 billion. They mandated screening. They changed outcomes for millions.
This paper has named five forces that shape financial wellbeing in retirement: Spending Confidence and Access, Financial Literacy and Cognitive Load, Social Identity and Role Continuity, Advisor Trust and Planning Continuity, and Health and Financial Navigation.
These five forces constitute the Social Determinants of Financial Wellbeing: the SDOF™ framework. They explain why people with enough money cannot spend it. Why financial anxiety produces a 60% higher mortality risk. Why 30 million retiring Americans need more than a savings plan.
The framework exists now. The question is who will use it first.
Ready to measure what matters?
My Plan Keeper's Retirement Wellness Assessment measures all five SDOF™ determinants. Our platform, powered by Grace Intelligence, provides personalized assessments, decision-sequencing tools, and population-level analytics for HR teams, financial advisors, and benefits platforms.
A practical framework with 23 cited research findings for HR leaders implementing retirement wellness programs. Read the whitepaper →
A data-driven analysis with 47 cited research findings. Introduces the RAP (Retiree Assistance Program) model. Read the whitepaper →
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Disclaimer: This white paper is published for informational and educational purposes. It does not constitute financial, legal, tax, or investment advice. Statistical figures cited represent publicly available research data and are provided for illustrative context. Organizations should consult qualified professionals for guidance specific to their workforce. © 2026 My Plan Keeper. All rights reserved.
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