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I. Healthcare
According to the Centers for Medicare and Medicaid Services, the US allocates about 17.7
percent of its GDP ($3.6 trillion) to healthcare, which is among the highest global figures.
The American healthcare system has both strengths and weaknesses compared to the
systems of Canada and western European nations. A strength is that the US carries out
more diagnostic and preventive procedures such as cancer screenings and scans than other
developed countries. More people who are diagnosed with diseases receive successful
treatment, and there are high survival rates. The US generally avoids the long waiting lists
that typify other Western nations. The fear of waiting lists and delays is a reason many
Americans oppose government takeover of healthcare.
There are also significant problems. It is argued that many people are still excluded from US
healthcare and that there is insufficient preventive care. The US is behind other comparable
Western nations on some medical conditions such as obesity, infant mortality, heart and lung
disease, sexually transmitted infections, and life expectancy.
US healthcare is divided into private, public, and voluntary sectors. Hospitals and clinics are
largely operated as private businesses, although some are community- or volunteer-run and
owned by the local government. The quality and availability of medical provision is variable.
Adequate care may depend upon the wealth, gender, ethnicity, location, age and insurance
coverage of patients. Healthcare has traditionally been driven by the private sector, with
workers, families and employers benefiting from health insurance policies that allow them to
access treatment. Many people under 65 have private health insurance, while those over 65
are covered by the federal Medicare program. Workers contribute to funding Medicare until
retirement. Medical treatment and insurance are expensive; some people buy additional
insurance, but others remain uninsured. It is estimated that 25 percent of senior citizens
declare bankruptcy due to medical expenses and that 43 percent are forced to mortgage or
sell their property to cover costs.
In 2010, it was estimated that about 84 percent of Americans (and their families) had private
health insurance or Social Security and Medicare. But the US Census Bureau reported that
51 million people, or 16.6 percent of the population, had no health coverage because they
could not afford it, did not sign up for Medicaid or saw no need for coverage. Many people
were without coverage for shorter periods. Others received public sector healthcare (often
emergency) from state hospitals, Medicaid facilities, voluntary nonprofit hospitals and the
Children’s Health Insurance Program. The Veterans Health Administration, which treats
millions of Americans, manages hospitals and treatment centers across the nation.
The state of the healthcare system led to debates about how it might be reformed in terms of
insurance, the right to healthcare, access, fairness and efficiency. Organizations like the
Organisation for Economic Co-operation and Development (OECD) argued that the US was
one of the few industrialized nations that did not guarantee healthcare for its population.
In 2010, the ACA made changes to health insurance. New procedures were introduced,
and hospitals and doctors had to achieve better healthcare results, lower costs, and
increased accessibility. The ACA was intended to reduce the uninsured rate by compulsory
insurance coverage. It introduced mandates (individual and company insurance), federal
subsidies for the poor to buy insurance and insurance exchanges (where insurance could be
bought). These had to cover all applicants, offer the same rates regardless of preexisting
conditions or gender, give coverage to children under 26 on their parents’ policies and
encourage people to choose cheaper healthcare plans. The ACA was President Barack
Obama’s most significant policy achievement. Obama involved Congress to a greater extent
than Bill Clinton had done. Obama would not have been able to pass the reform after 2010,
when the Democrats lost the majority in the House of Representatives.
The ACA is intended to restructure healthcare coverage and provide an improved system. A
main goal of the reform was to reduce the number of uninsured people and provide health
insurance for most Americans by 2019. Some 32 million citizens have taken out insurance
since 2014 when the system became active. Subsidies decrease as incomes increase, and
those earning a certain percentage of the poverty level receive no subsidy.
The ACA also expands Medicaid coverage to the poorest individuals under the age of 65
whose annual income is within federal poverty levels. For example, a family of four earning
less than $29,326 would be eligible for Medicaid. Still, expansion of Medicaid depends on
state approval, and states are not obliged to join the program. Some uninsured poor adults
may not gain access to Medicaid if states reject expansion, and they would not qualify for
exchange subsidies. However, if states decline to cover their poorest adults, they will not
lose federal aid for groups such as pregnant women and families with children.
Those who did not comply with the ACA would be fined, and the Supreme Court ruled in
2012 that the “individual mandate” should be treated as a tax and is therefore constitutional.
The individual mandate was repealed during the Trump presidency. Companies with more
than 50 employees will be fined (“the employer mandate”) if full-time employees lack
company coverage and require a government subsidy to purchase health insurance. The
exchanges are intended to control the implementation of the ACA and give advice to people
about health plans.
The implementation of the ACA, and its success or failure, has taken time to develop.
Despite repeated attempts to repeal the entire act, the ACA remains a major basis for public
health coverage. There has been little Republican support for the ACA, and some
Democrats argue that insurers were given too many benefits. The percentage of uninsured
people in the US increased during President Trump’s first two years in office. In 2018, about
8.5 percent of the people did not have health insurance. Since Medicaid and Medicare will
continue, the ACA should strengthen these programs and curb costs and fraud. Challenges
to the law continue from Congress, federal courts, state governments, labor unions and
small business organizations.
People’s anxieties about illness are still conditioned by high insurance premiums and the
cost of treatment, which can be very expensive for serious or chronic illness. There is often
criticism of the medical profession and drug companies, whom the public suspect of raising
medical and drug costs. Doctors and insurance companies constitute influential professional
interest and lobbying groups, many of whom are traditionally opposed to “socialized”
(government-controlled) medicine in the US.
Private hospitals and clinics are generally well-equipped, efficient, and run by a variety of
commercial organizations. Many of those in the public sector, financed by state and federal
funds, tend to lack resources and adequate funding. The US therefore has a range of high-
quality medical facilities but gaining affordable access to them is a problem for many people.
The percentage of GDP derived from private, public, and voluntary healthcare services
constitutes a major business sector and is larger than health spending in other countries.
Much of it is derived from incomes of the medical profession. Pharmaceutical companies
spend billions of dollars on research and development of new drugs. New medicines,
profitable as they are for the industry in the US compared to Canada and Europe, are very
expensive for the public, which contributes to policy debate. Hospitals and medical schools
also spend substantial amounts on research because new techniques and discoveries will
bring them prestige, patients and money while also benefiting many people. The result for
many consumers is improving quality and effectiveness of medical care but more expensive
treatment.
Critics say that many Americans are not receiving the full benefit of such expenditure
because medical costs vary. Compared with other countries, the US spends significantly
more on healthcare but helps fewer people. Affluent Americans can afford high-quality
healthcare, whereas Americans with incomes far below average cannot afford this. The main
reasons for low-quality US healthcare are inadequate access to healthcare and the variable
facilities on offer. It is alleged that, overall, the US still does not receive good value for its
healthcare investment.
Healthcare costs grow steadily. In an expanding compensation culture, there have been
more lawsuits by patients against doctors and hospitals because of alleged inadequate or
wrong treatment. Trial lawyers can profit considerably by fighting personal injury lawsuits on
a contingency fee basis (no win, no fee), and the rise in such cases forces doctors to insure
themselves against the risks of being sued. Medical care and vital decisions can be
adversely influenced by these considerations. Drug companies also have to pay high
compensation when medicines harm patients. Medicaid spending has had to cope with the
high healthcare costs involved in treating AIDS (acquired immune deficiency syndrome) and
HIV (human immunodeficiency virus) patients and others with acute and chronic illnesses.
Lawyers’ fees, insurance policies and higher drug prices increase the overall cost of
treatment, which passes to the patient or insurer, while both the public and private sectors
have to spend more to alleviate serious illness. Despite the ACA, healthcare coverage and
cost, for some critics, remain a major crisis facing the US.
II. Housing
Homes have traditionally been important for many Americans and their families and give a
sense of material satisfaction and personal identification. But the ideal of the home-owning
nuclear family unit has faded because of high divorce rates, single-parent households and
single-occupier properties.
Americans may move their home many times, and homeownership is associated with
socioeconomic mobility. A family will move frequently in the early years from apartments to
houses and up the rungs of the housing market. There may be further transfers from urban
locations to the suburbs in the same city, to new areas of the same state or to different
states.
Most Americans want to own their own homes after renting in their early adult years, and
two-thirds seem to prefer living in suburban areas. Ownership and mobility are affected by
income fluctuations, poverty, and unemployment. The housing market is consequently
divided between the private sector for those who are able to buy or rent and the public
sector, which is mainly for those who require assistance in obtaining low-rent property.
According to Statista, there were almost 140 million total housing units in the US in 2019. It
is more common to own a home than to rent one. The units include houses and apartments
and fixed trailers or RVs in trailer parks. Of the first type of housing units, a large percentage
were single-family houses, often of a detached type, usually having front and back yards.
The second type illustrates the traditional place of renting properties in the American market,
whether by choice or necessity. The housing industry grew strongly in the 1970s and 1980s,
when 35.8 million units were built, and later in the 1990s and early 2000s. But house prices
rose faster than incomes in the 1980s and prevented many people from buying homes. The
housing market suffered from an economic recession in the early 1990s, after which prices
and house construction increased again.
Most private houses and apartments were reasonably priced historically, but they are also
subject to price movements and market problems. They are often of a good standard, with
many amenities. Owners generally buy their properties by borrowing money (a mortgage or
loan), which is secured by the value of their house and income. In 2019, the median price of
a home was $226,800.
During his presidency, George W. Bush wanted to increase homeownership. Many
Americans with relatively low incomes received large loans to finance homes. This
contributed to the housing crisis of 2007–8, when the private housing market suffered
seriously from the subprime or credit crisis and the Great Recession. Owner-occupied home
rates declined to 67.4 percent in 2009 after the housing market crash in 2008. Individuals
overborrowed on loans and mortgages, and lenders overextended themselves. The market
collapsed when borrowers could not repay their mortgages and there was insufficient credit
available to maintain the system or provide loans. People lost their properties to foreclosures
(3.9 million in 2009), and house prices halved. In 2013, although the market was recovering
from recession, 12.9 million units (9.7 percent) were vacant and 4.1 million (3.1 percent)
were seasonal.
The US public sector housing is administered and subsidized by federal, state, voluntary and
local agencies. It provides for low-income Americans who are unable to buy property or
afford private rented accommodation. The supply of social housing has historically been
conditioned by the bias toward private provision. Individuals were expected to make their
own arrangements, rather than assuming that housing was a public responsibility, despite
economic and social conditions that caused poverty and homelessness. Millions of low-
income Americans lost their homes due to unaffordable mortgages during the Great
Recession. Currently, this is happening again because of job loss during the pandemic.
The growth of urban slums and substandard housing in the nineteenth century resulted in
social misery and threats to public health and led to the creation of the Federal Housing
Administration in 1934. This body (now the Department of Housing and Urban Development)
provided loans to organizations that built affordable accommodation for low-income and
needy people. Local and state governments also constructed public housing and
implemented stricter building and planning codes, health protection and public-sanitation
regulations to deal with slum conditions. It was argued that public housing should be priced
below current market rates and would allow people to live in locations that provided jobs and
stop the drift from cities to find lower rents. Public housing originally consisted primarily of
one or more concentrated blocks of low-rise and/or high-rise apartment buildings.
Subsidized apartment buildings, often referred to as housing projects, have a complicated
and difficult history in the US. While the first decades of projects were built with higher
construction standards, public housing increasingly became the last resort for the poor. In
many cities, housing projects suffered from mismanagement and high vacancy rates. They
have also arguably increased concentrated poverty in communities, resulting in high crime
rates, drug usage and educational underperformance. Attempts to create more low-cost
public housing with federal funds in the cities and other areas in the 1960s and 1970s were
often opposed by property owners and sometimes by state and local governments for
political, economic, racial, and religious reasons. Although racial and religious discrimination
in renting such housing has been curtailed, it still exists. While many states and cities have
imposed fair housing laws, some low-income people and minority groups in urban centers
live in barely habitable housing, and entry to low-cost housing for those who are unemployed
or on welfare can be restricted. Recently, there have been moves to exploit inner-city land
and replace inferior buildings with low-cost housing. People living in small towns and rural
areas also experience poor housing conditions.
Despite economic growth in the late 1990s and early 2000s, housing problems for the poor
worsened. There was a shortage of affordable apartments, and four million families paid
more than half their income in rent. Those spending more than 30 percent of their income on
rent also increased between 2000 and 2005 due to stagnating wages for the unskilled, high
property values and the government’s failure to supply enough subsidized housing.
However, in 2008, President George W. Bush’s National Housing Trust Fund provided some
communities with funds to build, rehabilitate and preserve housing for people on the lowest
incomes.
It is estimated that some 15 million households qualify for federal housing assistance, but
only about 4.5 million receive it. About one-third of these live in public housing projects, while
the rest receive subsidies that allow them to live in private housing. The tenants often
contribute 30 percent of their income toward the rent while the government provides the rest.
The public housing sector also suffered because of the 2010 Great Recession.
As a result of various problems, many housing projects constructed in the 1950s and 1960s
have been demolished. In recent decades, public housing has increasingly taken on different
formats. Since the 1970s, subsidized housing was funded through rent vouchers rather than
the construction of subsidized units. From the 1990s, rather than constructing large,
subsidized complexes, the federal government has used funds under the HOPE VI Program
to tear down distressed public housing projects and replace them with mixed communities
constructed in cooperation with private partners.
1. The homeless
Homelessness in the US is of concern for social service providers, government officials and
society generally. Although this may be a temporary situation, homeless people are visible in
many American communities. However, it is difficult to define who the homeless are and
what can or should be done to help them. Action is restricted by a lack of reliable information
on the causes of homelessness and the actual number of people living on the streets or in
transitional housing or emergency shelters. Local, state, and federal governments in the US
have failed to provide sufficient low-cost rented accommodation for low-income groups, and
the federal government has reduced subsidies for such housing since the 1980s.
The number of poor Americans fluctuated in the 1980s and 1990s and resulted in homeless
people throughout the country, particularly African Americans, men, families with children
and armed services veterans. Estimates of their current numbers vary widely, with official
figures from the federal government generally being much lower than the numbers from
private welfare advocates.
Determining the number of homeless people is difficult, particularly of those under the age of
21. Many adolescents, teens and runaways are uncounted because young people living on
the streets do not want to be counted for various reasons. Texas, California, and Florida
have the highest numbers of unaccompanied homeless youth under the age of 18. The
turnover in the homeless population means that the number of people who experience
homelessness for a few nights during a year is thought to be higher than counts taken over a
period. Amnesty International USA suggests that vacant houses outnumber homeless
people by five-fold.
Voluntary organizations, funded by private donations, attempt to help the homeless by
providing shelter and food for limited periods. There are a large number of federal assistance
schemes for the homeless controlled by a range of departments. Despite this federal
funding, known as the McKinney program, states and cities finance most of the care for the
homeless. They have recently successfully developed an initiative (“housing first”) that
places homeless persons in apartments of their own and has cut chronic homelessness.
III. Attitudes to social services
Attitudes to social services are often rooted in people’s political views. Conservatives
generally believe in personal responsibility and are often opposed to expanded social
services. While most Americans support contributing to social services such as Medicare
and paying for medical insurance, they are ambivalent about the role that government
should play in helping the poor obtain non-contributory aid, such as Medicaid and insurance
subsidies under the ACA.
The Affordable Care Act has gradually become more popular since it was enacted in 2010.
Many people in 2010 thought the ACA was controversial, complex, and inadequately
explained by the government. According to a Pew Research Center poll in March 2010, 48
percent of respondents opposed the legislation, while 38 percent favored it. By contrast, in
2020, Morning Consult polling found that a record-high 62 percent of respondents supported
“Obamacare.” It is likely that the pandemic led to greater understanding of the need for
government involvement in healthcare. Nevertheless, the idea of private insurance is so
strong in the US that the goal of progressive Democrats to enact a Medicare for All plan to
replace “Obamacare” was at the time of the 2020 elections regarded as too radical by a
majority of Americans.
Social Security and Medicare are other aspects of social services that are also regarded as
problematic. Majorities of respondents in recent opinion polls have consistently supported
these programs and would not vote for politicians who want to cut their budgets. Former
president George W. Bush and former House speaker Paul Ryan advocated partial
privatization of Social Security but were unsuccessful in their attempts at change. Ryan also
proposed a Medicare reform but did not receive sufficient support.
A poll conducted by the University of New Hampshire Survey Center for the National
Committee to Preserve Social Security and Medicare (NCPSSM) in 2016 reported that 64
percent of respondents thought Social Security provides security and stability to the US
economy, 20 percent saw the program as a drain on the economy and 70 percent believed
the 2008–10 recession emphasized the crucial role Social Security plays for families in need.
The poll revealed that 98 percent believed Social Security funds belong to the contributors
and their beneficiaries, and 71 percent said that Social Security is a promise to all
generations that should not be broken. Only 2 percent of respondents believed Social
Security was a major cause of the federal deficit, and 77 percent did not think that
policymakers should change or cut Social Security in order to reduce the deficit. In fact, 70
percent of Americans expect to need Social Security in retirement. Substantial majorities of
all demographic groups, including two-thirds of younger Americans and Republicans,
thought that Social Security should be left alone.
There is concern about the Social Security system, and many people are worried about its
condition. A Gallup poll in July–August 2015 reported that 45 percent of respondents thought
Social Security would be able to pay them a benefit when they retired and 51 percent did not
think so. As of 2020, Gallup had not asked this question since. In the 2015 poll, 49 percent
of retired respondents thought they would continue to get full benefits, but 43 percent
believed there would be cuts in their amounts. Such responses led 21 percent to think that
Social Security was in crisis, while 45 percent think it has major problems and 28 percent
think it has minor problems. Suggestions for ensuring the long-term future of the system
were raising taxes (51 percent) or cutting benefits (37 percent). Other suggestions include
raising the retirement age or supporting privatization of the program by allowing investments
of Social Security taxes in the financial markets. Most people are opposed to raising the
retirement age to preserve Social Security.
Script
Good [morning/afternoon] everyone,
Today, I’m going to talk about four major social issues in the United States: healthcare,
housing, homelessness, and attitudes toward social services. These areas are closely
interconnected and reflect deeper concerns about equity, government policy, and quality of
life in America.
1. Healthcare
Let’s begin with healthcare. The U.S. spends more on healthcare than any other country—
around 17.7% of its GDP, or $3.6 trillion. While there are some strengths, such as high
survival rates for diagnosed diseases and relatively short wait times, the system also faces
serious problems.
One key issue is access. Many people are excluded from regular healthcare due to cost or
lack of insurance. In 2010, over 51 million Americans had no health coverage. Even today,
despite reforms, high costs remain a major barrier. Insurance and treatment can be
extremely expensive—so much so that 25% of senior citizens declare bankruptcy due to
medical expenses.
The Affordable Care Act, or ACA, signed into law in 2010, aimed to increase access and
affordability. It introduced mandatory coverage, subsidies, and insurance exchanges. By
2019, it had helped reduce the number of uninsured people. However, not all states
expanded Medicaid, and opposition—especially from conservatives—continues. Critics
argue that despite massive spending, the U.S. does not get good value from its healthcare
system compared to other wealthy nations.
2. Housing
Now let’s move to housing. For many Americans, owning a home is tied to success and
stability. But this ideal has been challenged over the years due to economic instability, high
divorce rates, and a rise in single-parent and single-occupier households.
Housing is sharply divided between private ownership and public assistance. While many
aspire to own homes, high prices and job insecurity make that difficult. The 2008 housing
crash, caused by reckless lending and borrowing, led to millions of foreclosures and long-
term economic damage. Even today, affordable housing is in short supply.
Public housing in the U.S. is often underfunded and stigmatized. Some housing projects
became concentrated areas of poverty with high crime rates. Although newer approaches
like mixed-income housing and rent vouchers have been introduced, millions of Americans
still spend over half their income on rent.
3. Homelessness
This brings us to the issue of homelessness. It’s a highly visible and persistent problem in
American cities. Causes include lack of affordable housing, job loss, poverty, and mental
health issues. The actual number of homeless people is hard to calculate, especially among
unaccompanied youth, but it’s clear that the problem is widespread.
Despite numerous local and federal programs, shelters are often temporary, and resources
are limited. A promising initiative has been the “housing first” approach, which prioritizes
giving people stable housing before addressing other needs. This method has been effective
in reducing chronic homelessness, but it requires ongoing investment.
4. Attitudes toward Social Services
Finally, let’s consider public attitudes. In the U.S., views on social services are deeply
influenced by political beliefs. Conservatives tend to favor personal responsibility, while
liberals support more government assistance.
Social programs like Medicare and Social Security are popular across the political spectrum.
Most Americans believe these are essential for retirement and support maintaining or even
expanding them. However, newer programs like the ACA were initially controversial. Over
time, support for Obamacare has grown—62% supported it by 2020—especially after the
COVID-19 pandemic highlighted the need for public health systems.
Interestingly, most Americans oppose cuts to Social Security or raising the retirement age,
even though there are concerns about the system’s long-term sustainability.
Conclusion
In summary, the U.S. faces significant challenges in healthcare, housing, and
homelessness. While efforts have been made—such as the ACA, rent subsidies, and the
Housing First model—systemic inequalities and political divisions continue to shape both
policy and public attitudes.
Understanding these issues is crucial if we want to work toward a fairer and more
sustainable society.
