The blueprint for GOP Medicaid work requirements was laid down 175 years ago

North Carolina Republican lawmakers are advancing legislation that would impose work requirements on people enrolled in the Medicaid health insurance program.

It’s not a new idea.

As NC Newsline’s Lynn Bonner reported last week, North Carolina’s hard won 2023 Medicaid expansion law already includes a provision requiring the state Department of Health and Human Services to pursue work requirements — that is, to condition eligibility for benefits on enrollees having a job — if it can secure federal approval for such a plan. The Biden administration rejected this idea, but it’s expected that a federal HHS department under Trump would approve it (if, that is, there’s anyone left at the department after recent mass firings to review such a proposal).

But, of course, the idea of conditioning public assistance programs on a demonstration of “worthiness” by those in need goes back a lot further than 2023. Affluent people in positions of power – many of whom inherited their wealth and almost all of whom benefit greatly from tax breaks and subsidies designed to protect it — have long employed such a strategy to restrict aid programs.

Indeed, as author Padraic X. Scanlan documents in a powerful new book, one of the seminal examples in western history took place way back in the mid-19th Century. Scanlan’s book is entitled “Rot: An Imperial History of the Irish Famine,” and in it he details a series of terrible events and policy decisions that led to one of the great human disasters of recent centuries.

The Potato Famine – a calamity also often referred to as “The Great Hunger” – is an event of which many Americans (nearly 10% of whom claim some Irish ancestry) still have a general awareness. The massive blight affecting the main crop that sustained Irish peasants caused as many as two million people to die of starvation and disease or flee the tiny country – many of whom ended up migrating to the U.S. The carnage was so massive that the Irish population today has still yet to recover to the level it was at prior to the famine.

What most people have much less familiarity with, however, are the circumstances that turned a series of crop failures into a massive human catastrophe.

As Scanlan details (and journalist Fintan O’Toole neatly summarizes in a recent essay in The New Yorker entitled, “What made the Irish famine so deadly”), one of the chief contributors to the famine was the refusal of the British politicians and landowners who ruled Ireland to distribute relief because they thought it would violate rules of the free market and indulge the peasants.

Convinced that dispensing free food to starving people would make them slothful, British leaders instead established a kind of “workfare” program in which hungry people were forced to work – at below market wages – in hopes of staying alive.

O’Toole’s essay summarizes the situation this way:

If this sounds familiar, it should, because the premise for Medicaid work requirements – that providing access to health care to people not gainfully employed enriches the undeserving and encourages harmful sloth and dependence — is precisely the same.

Interestingly, one of the ironies of the recent action in Raleigh is that the sponsors of Medicaid work requirements are, among Republicans anyway, the liberals in this discussion.

GOP state Rep. Donny Lambeth, a Forsyth County Republican who long championed Medicaid expansion and helped convince his GOP colleagues to accept it a decade after it became an option, has rightfully stated that plans under consideration among congressional Republicans to gut Medicaid with hundreds of billions of dollars in cuts would be “a disaster.” He’s actually pitching the enactment of work requirements as, in effect, a kind of human sacrifice to hard right politicians bent on vastly more devastating cuts to the program.

It’s a remarkable state of affairs. Like their pompous predecessors in the bygone British Empire, Republican leaders who control the federal government and the North Carolina legislature are callously and offensively debating two options for how best to deal with low-income people at risk of dying if they lose their health insurance: a) making them work or do community service to keep getting it, or b) simply cutting them loose altogether.

Talk about history repeating itself.

As O’Toole notes, “Above all, ‘Rot’ reminds us that the Great Hunger was a very modern event, and one shaped by a mind-set that is now again in the ascendant,” even if, as he adds ruefully, the chance of other countries taking in millions of starving migrants probably can’t happen today.

As he and Scanlan might have also added, Medicaid work requirements won’t kill as many people as the 19th Century pro-starvation policies of the British in Ireland, but many undoubtedly will die prematurely and the maddening arrogance of the policy makers in the two situations is essentially indistinguishable.