Death, taxes and now health insurance? Having a medical plan or else paying a fine is about to become another certainty of American life, unless the Supreme Court says no.
People are split over the wisdom of President Barack Obama's health care overhaul, but they are nearly united against its requirement that everybody have insurance. The mandate is intensely unpopular even though more than 8 in 10 people in the United States already are covered by workplace plans or government programs such as Medicare. When the insurance obligation kicks in, not even two years from now, most people won't need to worry or buy anything new.
Nonetheless, Americans don't like being told how to spend their money, not even if it would help solve the problem of the nation's more than 50 million uninsured.
Can the government really tell us what to buy?
Federal judges have come down on both sides of the question, leaving it to the Supreme Court to sort out. The justices are allotting an unusually long period, six hours over three days, beginning March 26, to hear arguments challenging the law's constitutionality.
Their ruling, expected in June, is shaping up as a historic moment in the century-long quest by reformers to provide affordable health care for all.
Many critics and supporters alike see the insurance requirement as the linchpin of Obama's health care law: Take away the mandate and the wheels fall off.
Politically it was a wobbly construction from the start. It seems half of Washington has flip-flopped over mandating insurance.
One critic dismissed the idea this way: "If things were that easy, I could mandate everybody to buy a house and that would solve the problem of homelessness." That was Obama as a presidential candidate, who was against health insurance mandates before he was for them.
Once elected, Obama decided a mandate could work as part of a plan that helps keep premiums down and assists those who can't afford them.
To hear Republicans rail against this attack on personal freedom, you'd never know the idea came from them.
Its model was a Massachusetts law signed in 2006 by Mitt Romney, now the front-runner of the Republican presidential race, when he was governor. Another GOP hopeful, former House Speaker Newt Gingrich, supported a mandate on individuals as an alternative to President Bill Clinton's health care proposal, which put the burden on employers.
So much for compromise.
Obama and congressional Democrats pushed the mandate through in 2010, without Republican support, in hopes of creating a fair system that ensures everyone, rich or poor, young or old, can get the health care they need. Other economically advanced countries have done it.
Doing nothing is more expensive than most people realize.
Congress found that when the uninsured go to clinics and emergency rooms, the care they can't pay for costs nearly $75 billion a year. Much of that cost is passed along and ends up adding $1,000 a year to the average family's insurance premium.
The overhaul is neither the liberal dream of a single government program supported by taxes and covering everyone nor the conservative vision of stripping away federal rules and putting free enterprise in charge.
The Obama plan relies on private companies plus lots of regulation to make sure they provide basic benefits, keep premiums reasonable, and cover the sick as well as the healthy. That's where the mandate comes in. If insurers must cover everyone, even those with existing medical conditions, healthy people have little incentive to sign up before they get sick.
Insurance companies argue that if only the sick sign up, insurers will go broke. So the law says everybody must have insurance for themselves and their children, or pay a penalty.
Also, because everyone needs health care sometime, if everyone purchases insurance, the price per person can be lower, with the cost of care spread out over many people.
After all, the government requires workers to pay Social Security and Medicare taxes, whether they want the benefits or not.
One argument for the insurance mandate is that the fines are just federal taxes by another name. Another is that it falls under the government's constitutional power to regulate commerce that crosses state borders.
State governments, of course, tell people to buy lots of things, including auto insurance or motorcycle helmets.
"You can always move to another state," said Tom O'Connor, a consultant in Fairfax, Va., who thinks the health care law overreaches. "It's a little more difficult to move to another country."
In an Associated Press-GfK poll, 85 percent said the U.S. government should not have the power to require people to buy health insurance. When the question is worded without the specific reference to federal power, acceptance of the mandate grows a bit, but 6 in 10 are still against it.
Even among those who generally support the health care overhaul, one-third said they are against the insurance mandate.
There's also a significant minority who sees mandates as a cop-out and prefer a government program that covers everyone, Medicare for all.
It's clear that many people do not understand what the law would do or how it would affect them.
Jan Gonzales, an out-of-work bookkeeper in Pablo, Mont., calls fining people for going without insurance "the most ridiculous, asinine thing you ever heard of."
"If I can't put food on the table for my children, how can I pay for health care coverage?" asks Gonzales, who's been without insurance for seven years. "What moron came up with that idea?"
Of course, she might qualify for the law's exemptions for those too poor to pay and for assistance for low-income people, as well as many in the middle class.
There also are some religious exemptions. .
Estimates vary widely of how many uninsured people will get insurance once it's required in January 2014.
By 2016, the fine reaches $695 per uninsured adult or 2.5 percent of family income, up to $12,500 per year. The IRS is in charge of the penalties but can't prosecute violators or place liens against them. Its only enforcement option may be withholding money from refunds.
That leaves insurance companies, who stand to gain lots of new customers, worried that people instead will shrug off the weak mandate.
Meanwhile, the state-federal Medicaid program will expand to cover more low-income people, and that's another issue before the Supreme Court, because many states say they cannot afford the extra cost.