The welfare regime in the United States, in comparison to England, is described as representing individualism, laissez-faire, residualism and a punitive view of poverty. These issues often seem to dominate US debates on welfare: examples are the introduction of ‘workfare’, the exclusion of long-term benefit dependents, and the criticism of the ‘underclass’ (Spicker, 2003). According to Keigher and Stone (1994), this unwillingness to fill the gap in the welfare system originates in the larger context of American democratic customs and interest-based capitalism. Cultural traditions emphasising individual freedom, trust in family, and fear of big government remain embedded in public policy. Some US commentators have even argued that guaranteeing health care should neither be a right nor a responsibility of government:

This has been a dominant and long-held debate in US health care policy. The principle of universality in terms of welfare is absent in the United States. Only Social Security begins to approach universality of coverage, however its benefits are limited to subsets of the disability population.