By lambert strether of Corrente.

And we go to Happyville, instead of to Pain City. –Thomas Pynchon, Gravity’s Rainbow

One of the things I hate most about ObamaCare is the vicious and relentless way that it creates first- and second-class citizens. ObamaCare does this by construction, of course: ObamaCare’s central concept of eligibility — the outright denial that health care is a human right, but is instead just another pigfest of rental extraction — necessarily implies that those who are “eligible” and those who are not eligible are granted different levels of access to care. Here, however, I want to focus on three whimsical and arbitrary distinctions that ObamaCare draws between the worthy and the unworthy, the saved and the drowned, the lucky winners and the losers.

To begin, if you’re from Libby, MT, you’re a first-class citizen. If you’re from anywhere else, you’re a loser. I’m so sorry. Dr. Philip Caper in the Bangor Daily News:

After his own constituents in Libby, Mont., became uninsurable by private insurance due to industrial pollution with carcinogens and were unable to get the courts to hold the polluters responsible, [Senator Max] Baucus came to the rescue. He simply tucked a little provision into the massive health reform bill making affected Montanans eligible for — you guessed it — Medicare. No health insurance exchanges for these hardworking folks. Nothing but the best for Libby. By taking the simple, direct and most efficient route to expanding health-care coverage, Mr. Baucus did the right thing by his constituents. But Baucus made sure that everybody else had to settle for Obamacare.

So whenever an Obot waxes lyrical on the glories of the Orwellianly named Affordable Care Act, just ask them how come the citizens of Libby, MT get to board the train to Happyville with a first-class health care system — single payer Medicare for All — and the rest of us losers have to settle for Pain City and ObamaCare.

Next, if you’re banked, you’re a first class citizen. But if you’re unbanked (or debanked), you could be out of luck. From Jackson-Hewitt:*

• More than one in four uninsured Americans eligible for the new premium assistance tax credits under the ACA does not have a checking account. Among the uninsured, non-elderly population with household incomes in the tax credit eligible range, 27 percent are effectively “unbanked.” • Many insurance companies plan to require customers to pay premiums automatically through a checking account. While such restrictions may help insurers reduce administrative costs, unbanked customers will not be able to pay their required share of insurance premiums. Though contrary to the spirit and intent of the ACA, such restrictions are permissible under current federal guidance absent a policy clarification • These restrictions will undermine efforts to expand health coverage under the ACA. Requiring enrollees to pay their premiums using a checking account would effectively deny coverage to the more than eight million unbanked Americans who are otherwise eligible for the new tax credits under the ACA. Unless addressed, such restrictions may hollow out the ACA’s expansion of coverage. • The impact will be especially large among African Americans and Hispanic Americans, who are over 40 percent more likely to be unbanked relative to white residents in the same income category. This is particularly concerning given the existing disparities in access to health coverage and health status for minority groups. Further, as many as five million veterans and other Americans who receive federal benefits on prepaid debit cards may not be able use those same cards to pay their premiums for federally- subsidized insurance. • The impact on the unbanked will be disproportionately large in states where the federal government operates a health insurance marketplace. Federal marketplaces will operate in 11 of the 12 states with the highest proportion of unbanked among those eligible for tax credits.

Sure, a wise and beneficent administration could fix this with a rule. But ObamaCare’s been around since 2009, and we’re only now getting around to this? Especially when the staggering genius minds behind the Obama campaign juggernaut now ensconced at Enroll America want to appeal to Hispanics? (Granted, they don’t have to appeal to blacks; “they have no place to go.”) Honestly, who the heck designed this thing? It’s like ObamaCare was written by some health insurance executive and then implemented by a gaggle of creative class technocrats, neither of whom have any understanding (if indeed they cared to have understanding) of ordinary people’s lives. Oh, wait….

Finally (for now), if you’re forced into Medicaid — and that means really being a loser, w-a-a-a-y more than buying a Bronze plan makes you a loser — you’re a second-class citizen because you might not be able to pass anything on to your kids, unlike the first-class citizens who are richer and whose kids are, therefore, more deserving of inherited wealth than your kids are. Counterpunch explains:

[I]f an Exchange determines you are eligible for Medicaid, you have no other choice . Code for Exchanges specifies, “an applicant is not eligible for advance payment of the premium tax credit (a subsidized plan) or cost-sharing reductions to the extent that he or she is eligible for other minimum essential coverage, including coverage under Medicaid and CHIP.” Therefore, you will be tossed into Medicaid unless there are specific rules as to why you would not be eligible. If you are enrolled in a private plan through an Exchange and have been receiving a tax credit, and your income decreases making you eligible for Medicaid, in you go. If you are allowed to opt out because you don’t want Medicaid, you will have to pay a penalty for being uninsured unless you can afford to purchase insurance in the open market. … Furthermore, to increase enrollment in health coverage without requiring people to complete an application on their own, states are advised to automate enrollment whenever possible by using existing databases for social services programs such as SNAP (food stamps) to enroll people who appear eligible for Medicaid but are not currently enrolled. Therefore, you could find yourself auto-enrolled in Medicaid against your will if your state acts on this advice. …. You won’t find the following info in the ACA. It’s in the Omnibus Reconciliation Act of 1993 (OBRA 1993) – a federal statute which applies to Medicaid, and, if you are enrolled in Medicaid, it will apply to you depending on your age. a) OBRA 1993 requires all states that receive Medicaid funding to seek recovery from the estates of deceased individuals who used Medicaid benefits at age 55 or older. It allows recovery for any items or services under the state Medicaid plan going beyond nursing homes and other long-term care institutions. In fact, The Centers for Medicare & Medicaid Services (CMS) site says that states have the option of recovering payments for all Medicaid services provided. The Department of Health and Human Services (HHS) site says at state option, recovery can be pursued for any items covered by the Medicaid state plan. … Your estate is what you own when you die – your home and what’s in it, other real estate you may own, your bank account, annuities and so on. And even if you have a will, your heirs are chopped liver. Low-income people often have only one major asset – the home in which they live and, in some cases, this has been the family home through several generations. So what this boils down to is: If you are put into Medicaid – congratulations – you just got a mandated collateral loan if you use Medicaid benefits at age 55 or older! States keep a running tally.

So, Medicaid: Pain City (if not for you, then for your kids). Not Medicaid: Happyville! Your kids get the house! (Even accepting ObamaCare’s eligibility framework, which I do not, you would think that citizens would be given the choice between opting for Medicaid, and sacrificing their children, and opting for a really crappy plan that wouldn’t sacrifice their children. But n-o-o-o-o-o-o!!!!! They’re forced into Medicaid; that’s the issue here.)

So, if the rigged game chances and vicissitudes of life have left you a non-resident of Libby, MT, without a bank account, or simply poor, congratulations! You’re a second class citizen!

Lebensunwertes Leben, donchya know…

NOTE * Jackson-Hewitt is a tax preparer. It couldn’t have been more clear to me from my H&R Block experience this year that the tax preparers want a piece of the action from ObamaCare’s stream of rents. I mean, here’s the screaming headline on Jackson-Hewitt’s corporate site: “April 15 is Now the Most Important Day in Healthcare.” And it is! It is!) That said, this report seems to make some good points. And mainstream ObamaCare coverage, on all sides, is just as reliable as the talking points for Campaign 2014 and Campaign 2016 — which is, in fact what the ObamaCare rollout is. So what can you do?