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The Obama administration and its supporters say it is obvious that the point of Obamacare was to provide subsidies to everyone. Solicitor General Donald Verrilli told the court in a written submission that eliminating subsidies to people who used Healthcare.gov would make the law "unrecognizable to the Congress that passed it." The court, which was split 5-4 on Obamacare in 2012, could uphold the law again even if it deems the four words unclear. A lower court found the wording "ambiguous and subject to multiple interpretations," so it decided, under a test established in another case, to defer to the government's "permissible" stance.

The four words took a circuitous route to the Supreme Court. Nobody spotted the issue during the seemingly exhaustive debate over the law prior to its passage. A lawyer in Greenville, S.C., discovered the possible flaw months later, then brought it to the attention of Washington conservatives and libertarians who were scouring the text to find the basis for a possible challenge. "This bastard has to be killed as a matter of political hygiene," said Michael Greve, chairman of the Competitive Enterprise Institute, which went on to fund the lawsuit.

"I do not care how this is done, whether it's dismembered, whether we drive a stake through its heart, whether we tar and feather it and drive it out of town, whether we strangle it." Oral arguments will be heard March 4. The court's decision is expected in June. The South Carolina lawyer, Thomas Christina, told the Greenville News he doesn't expect Obamacare to disappear.

"Personally, I have a difficult time foreseeing that Congress would allow a statute to just vanish into a puff of smoke," he said. "Really, when you look back in American history, things like that just don't happen."

Meantime, other important measurements of debt are also in retreat, including debt to revenue, direct operating debt and overall growth of debt. When you talk to people in the Clark administration, there is near-unanimous agreement that one of the key factors in the government's ability to begin getting its fiscal house in order was its single-minded focus on health care. "Addressing health-care costs is one essential prerequisite [to balancing budgets]," Finance Minister Mike de Jong said. "And I think the other is addressing costs around your overall labour costs. They both accumulate and aggregate and continue to build year over year."

From 2001-02 to 2011-12, Health Ministry costs grew at an average of just over 5 per cent annually. But the last three years of that period - from 2009 to 2012 - department accounts grew at rates of 5.7, 4.9 and 6.3 per cent respectively. When Ms. Clark became Premier in 2011 and made balanced budgets a priority, pressure built inside government to find ways to start containing those costs. Government bargained tough new agreements with nurses and doctors and also drove better deals with medical laboratories throughout the province. It urged greater collaboration among health authorities in an effort to find efficiencies that would save cash. It introduced patientfocused health care, a change from the block-funding model in which hospitals were given a set amount of money each year. Under the new formula, the funding moved with patients; consequently, the more patients a hospital handled, the more money it received. This set up a competition among hospitals for customers, which helped drive further cost savings. The other major price escalator was Pharmacare - drugs are expensive.

Again, B.C. began driving harder bargains with drug manufacturers. It joined with other Western provinces to make bulk buys, which also helped lower costs. It looked more often at generics. Between 2007-08 and 2010-11, Pharmacare costs increased an average of 5.6 per cent annually. From 2011-12 to 2013-14, that number fell to an average of just 1 per cent, according to the Ministry of Finance. Mr. de Jong believes that containing health-care costs is getting harder, with the province set to receive less in health transfer payments from Ottawa in 201718, under a new funding model linked to nominal GDP and population. "To the extent there was ever low-hanging fruit - generic drugs, laboratory costs, etc. - I think we've dealt with most of those," Mr. de Jong said. "But with a [Health Ministry] budget of $18billion, I'd like to think there are other efficiencies that can be found." He believes rate increases that hover near or slightly above the rate of inflation could become the new normal. "I believe it is sustainable," he said, "and when you look around the country, more and more jurisdictions are coming to the same conclusion, mostly out of necessity."

But Germany's current legal situation offers far too few possibilities to apply penalties. Last year, the European Commission gave the Federal Republic a good score on its evaluation of anti-corruption efforts in the country. Still, the first report on combating corruption criticised the lack of criminal provisions for practicing doctors (see background).

In Sweden, the pharmacy sector was a government monopoly from 1971 to 2009. Consequently, it was among the countries with the lowest number of pharmacies by population, with barely one outlet per 10,000 inhabitants, about a third as many as in most Canadian provinces. State pharmacies offered very limited opening hours: from 10 a.m. to 6 p.m. Monday through Friday, and from 10 a.m. to 2 p.m. on Saturday. Not a single pharmacy was open on Sunday, and many closed down completely for the summer. Sweden has since profoundly liberalized this sector and the number of pharmacies has skyrocketed as a result, increasing more in the following four years than in the previous 30. In addition to the hundreds that were privatized, 374 new private pharmacies entered the market, thereby improving access for the inhabitants of all regions. The effectiveness and accessibility of the health services provided by the private sector result primarily from the market mechanisms that govern them, namely entrepreneurship, competition and patients' freedom of choice. We should not be surprised to find that these mechanisms are largely absent in the public healthcare system. Yet it is these mechanisms that ensure that patients remain at the centre of care-providers' concerns. We should keep that in mind when thinking of how to reform our ailing public system. Yanick Labrie is an economist at the Montreal Economic Institute (Iedm.org) and author of The Other Health Care System: Four Areas Where the Private Sector Answers Patients' Needs.

Hundreds of thousands of patients on B.C. waiting lists know that role is not being fulfilled. The health minister and premier recently admitted that patients were waiting inappropriately long times, and a health region spokesperson reported some "life-saving" procedures were being delayed. Provincial health commissions were the brainchild of Tommy Douglas, who believed they should be chaired by doctors and never subject to political influence. But the MSC is always chaired by a politicallyappointed civil servant. Douglas supported premiums and felt they made the public cost-conscious, creating a sense of individual responsibility. He would never have condoned the practices of raising premiums to compensate for fiscal failures, nor reporting low-income earners, delinquent with their payments, to collection agencies. The commission is wasting health care funds as it displays contempt, in terms of its fiscal and social accountability, toward taxpayers.. In one example of carelessness and incompetence, I received cheques from them totalling hundreds of thousands of dollars, for services on patients that I had never seen. I also received confidential personal information on hundreds of patients unrelated to me or our clinic. When informed of their error, they responded: "Just mail them back." They were not inclined to investigate.

In Canada, health providers are compelled by law to share confidential patient files with government employees armed with the right to inspect and copy patients' files. Your health record is considered public property; you cannot block government access. Consent is not needed, and you are not notified when Big Brother is looking. Privacy rights have been legislated away. I witnessed a defeated provincial cabinet minister's medical file being reviewed by a newly elected government. In the 1989 tainted blood inquiry, Justice Horace Krever was "shocked by the inadequate laws, the abuses of confidentiality, and the fact that so many people - except the patient - had access to medical records." Little has changed.

The MSC is also charged with defining what services are "medically necessary" - and therefore publicly insured. They have never created a definition, but have arbitrarily designated clearly essential services such as ambulance, drugs, physiotherapy, artificial limbs, and dentistry as unnecessary, creating a true two-tier structure of care. The government's last action in delaying our constitutional challenge on patient rights resulted from a "last minute" discovery of 300,000 documents they were legally bound to provide. After a delay of more than seven years, the plaintiffs in the coming June trial will confirm that the Supreme Court of Canada's 2005 finding - that patients are suffering and dying on waiting lists - applies in B.C. Supporters of a system that limits timely access are complicit in such outcomes.

Our public sector health system (MSC included), is grossly overstaffed with non-clinical workers. A 2011 study revealed that Canada has 11 times as many public health bureaucrats per capita as Germany, where there are no waiting lists. Canada has 14 ministries of health, each with bloated bureaucracies and commissions scavenging dollars that should go to patient care. The mentality that cost inefficiencies can be balanced by increased taxes or "premiums" is responsible for our escalating charges. Independent health groups in Europe rated Canada as last in value for money compared to hybrid public-private systems that have accessible public systems. The Commonwealth Fund, a non-profit foundation focused on issues affecting lowincome groups, ranked Canada 10th of 11 health systems in developed nations.

What specific changes would I incorporate if I were minister of health? Apart from incorporating the best practices of other hybrid systems (including private-sector competition), I would dismantle the ministry and its committees and commissions. Then I would resign. The finance ministry could fund patients directly (thus empowering them), and also assign budgets to the newly emancipated, self-regulated health organizations, allowing them to cater directly to patient needs. Maybe our June constitutional court challenge will point us in that direction. Dr. Brian Day is an orthopedic surgeon, medical director of the Cambie Surgery Centre, and a former president of the Canadian Medical Association.

Dr. Brian Day says bureaucrats at the Medical Services Commission sent him cheques totalling hundreds of thousands of dollars for services on patients he had never seen.

The New Brunswick branch of the Canadian Union of Public Employees accused the government of fear-mongering by releasing the wish list, while the president of the New Brunswick Union said generating revenue should be at the top of the list for the provincial government. "We are always open to looking at ways to improve the quality of public services, so long as there are no job losses among public sector workers who are already stretched to the max," Susie Proulx-Daigle said in a statement. "We also believe public services need to stay public." Education

In schools, the government may cut additional teachers on top of the 249 teaching positions slashed in the 2015-16 budget. Enrolment has declined by 30 per cent over the past 23 years, but the number of teachers hasn't seen a significant decline. Cutting one teacher for every 20 students who leave New Brunswick's school system could save $10 million to $12 million, the government estimated. "What was done in the first budget was done," said Health Minister Victor Boudreau, who is responsible for overseeing the program review. "What we're saying is we could continue doing the same on an annual basis." Other options include increasing the maximum class size by four students per class, which could save $50 million to $70 million, and reducing the number of educational assistants to meet enrolment, a move that could save $3 million to $6 million. They may also privatize all custodial services within the education system, estimating savings of $5 million to $7 million, and convert pensions for school bus drivers, nursing home workers and custodians to the shared risk model ($7.5 million to $9 million in estimated savings).

The New Brunswick Teachers' Association was not available to comment on the possible cuts on Friday afternoon. Bennett believes the government could find savings and have little impact on classrooms by cutting the number of teachers and increasing class sizes.

He said research shows that class size reductions only have an impact on student performance up to Grade 3. After that, he said they don't have much impact and can be expensive. The New Brunswick government decreased class sizes about a decade ago and officials say that has cost taxpayers $50 million per year. But he is "extremely nervous" about basing cuts of educational assistants on financial considerations alone, arguing it could add tremendous pressure to teachers.

I think they need to re-think that." He's also disappointed the government isn't considering suggestions from a paper he co-wrote in January, which suggests the New Brunswick government could find savings by contracting out bus services in some of its school districts, which would produce competition. Health care

The provincial government is considering closing rural hospitals, trimming the number of full-service emergency rooms or centralizing specialized services in one location, like the New Brunswick heart centre in Saint John. The government estimates that could save between $50 million to $80 million. Gilles Lanteigne, president and CEO of Vitalité Health Network, said there isn't enough detail in the report to give him a sense yet of how it might affect service delivery in the francophone health authority. The health network is rolling out a plan to reduce 99 acute care beds in order to save $10 million.

The president of CUPE Local 1252, the union representing hospital workers, is concerned about "significant job losses" that could come from closing rural hospitals. But Norma Robinson is also concerned about the impact on people who live in rural New Brunswick and will have to drive up to an hour to get to an emergency room or to a major urban centre for specialized services. The government estimates 90 per cent of New Brunswickers live within an hour's drive of an emergency room. Universities

The province is also considering changing the funding model for universities, moving toward a performance-based formula that focuses on criteria like graduation rates and limiting duplication. The possible changes could save between $15 million and $45 million, the government says.

It all started with Opposition critic Trent Wotherspoon, who questioned the logic of government-employed snowplow operators plowing the Trans-Canada Highway having to lift their blades as they approach the 20-kilometre stretch of bypass from Balgonie to Regina.

This is what will happen once the bypass opens in 2018, because all maintenance matters (plowing, grass cutting, pothole and structural repairs, etc.) for 30 years will be the responsibility of the successful bidder - a Paris-based conglomerate. It will hire Saskatchewan crews to do the work. Highways Minister Nancy Heppner was especially indignant, scolding Wotherspoon for not asking enough questions at his technical briefing and thus again bringing information to the assembly "that is not always correct."

The problem, however, is Wotherspoon does appear to be correct. And the Highways Ministry explanation as to why this would be the case was something-lessthan gracious. "So what?" ministry spokesman Doug Wakabayashi told the Leader-Post's Emma Graney, adding he failed to see why this was even an issue because it wasn't like "nobody's plowing" the bypass.

Of course the bypass will get plowed. No one is being so disrespectful as to assume the minister or her departmental officials don't understand their rudimentary maintenance responsibilities ... even if the politicians and their officials seem to have little interest in exchanging the same courtesies.

The question is how much more this approach might cost Saskatchewan taxpayers. It seems it will be substantially more expensive than using government crews ... although no one seems to know how much more. Notwithstanding the government spin-session briefings, that's one of the many things about the P3 bypass project ministers are not telling us. The maintenance costs are a portion of an extra $680 million (essentially, the difference between the previous bypass construction estimate of $1.2 billion and the current $1.8-billion-plus price tag) that is called "risk transfer."

But how much of that extra $680 million taxpayers will shell out during the next 30 years for maintenance of the measly 20-kilometre stretch of highway remains an unknown. What we do know is that the snowplowing budget for the whole province is only $29 million a year. Under the rules of the P3 bidding process, such a detailed breakdown in the bypass contract can't be released for competitive reasons, said SaskBuilds president Rupen Pandya.

But why, then, is the global cost of "risk transfer" so high? Well, risk transfer in P3 contracts is what the government considers to be the cost of replacing or restoring something to brand-new condition. Some in the know don't much like the concept.

Ontario provincial auditor Bonnie Lysak (who used to be Saskatchewan's auditor) criticized the use of risk management in her assessment of Ontario P3s. She concluded risk transfer didn't apply to any accounting reality. After all, it's not likely a school or hospital will have to be replaced because it was swept away by a tornado. It's even less likely this will happen to a bypass.

But it is a good way for a government to hide cost overruns and thus prove its philosophical case that P3s are less expensive than the traditional method of private companies bidding and then building an infrastructure project without taking any long-term ownership of it. By the same token it would also be a very good way of government claiming that a P3 project came in under budget if there were no cost overruns, or only modest ones.

"Risk transfer" may not have ever been a real cost in the P3 process - something the government might not be eager to tell you in a technical briefing. Maybe one day we will get answers. But one guesses the Sask. Party government won't be offering them before the April election.