Medicare must be changed to be saved. The question is how.

Next week, Senator Michael Kirby's committee will publish a report outlining options for changing the system. Some of them will be far-reaching ones challenging the status quo as defined by the Canada Health Act.

Shortly thereafter, Mr. Kirby's committee will release two background reports -- one on health-care delivery systems in other countries, the other on what's driving the costs of medical care in Canada.

These reports will not recommend changes -- the specifics will come in the committee's final report next February -- but the analyses will challenge many of the conventional wisdoms about medicare. Put metaphorically, they will reflect "outside the box" thinking about Canada's health-care system.

By contrast, it is likely that the health commission under former Saskatchewan premier Roy Romanow will recommend "inside the box" changes when it delivers a final report in about a year. Mr. Romanow has already ruled out some radical changes such as user fees.

When the Kirby and Romanow reports are completed, Canadians can finally launch a serious debate over health care. They will essentially have two versions of the future: the Romanow one of changing the system without challenging most of its principles, and the Kirby one outlining why the better administration won't suffice. The Kirby report will be the more interesting, the Romanow one the more politically palatable. Mr. Romanow is a former politician -- and a pragmatic social democrat to boot -- and he'll know the limits of the possible.

Everything we know about Mr. Romanow and his staff suggests they believe that medicare can only be saved with a huge administrative overhaul. Mr. Kirby will argue that administrative reforms are necessary but insufficient. His first report correctly underlined how the Canada Health Act has become an icon that is widely misunderstood and, as such, is an obstacle to better health care.

The act, for example, requires that public administration deliver health care, but this has wrongly been interpreted as meaning that all medically essential services must be provided publicly. But public administration can mean many other things, such as public regulation of private industry or mixed public-private delivery.

Similarly, the act leads Canadians to believe they have universal, public health insurance, whereas what they really have is public payment for hospitals and doctors. More and more health care, however, is being delivered through drugs, long-term care and at-home care where public coverage is sporadic or non-existent.

Think of health care as a continuum from prevention to treatment. Public health delivery covers only part of that continuum, whereas more of that continuum is covered in other countries with a public health system. Even hospitals don't provide full public coverage. Fracture a leg and need a cast? You pay. Suffer a heart attack and go to the hospital in an ambulance? You pay.

So the Canada Health Act doesn't always say what its most ardent defenders insist that it does. And yet it has achieved mythical status that renders politically dangerous any serious debate about it. The act has become what Americans would call the "third rail" of politics: Touch it, you die.

Mr. Kirby will do a great service by questioning the act, and asking how its objectives might be achieved by other means. Mr. Romanow is likely to stay within the act's conventional approach.

The two reports probably will differ in another fundamental way. Both will underline that the existing system is financially unsustainable, unless Canadians want either higher taxes or reduced spending on other services, or both.

The Romanow report will be long on the planners' dream that better information, improved management, a rearrangement of functions, new lines of responsibility and different divisions of responsibility can extract sufficient savings that the essence of the current system can be financed. After all, some of the experts working with Mr. Romanow were among those who argued in the mid-1990s that what Canada was then spending on health should suffice. That was billions of additional dollars ago.

Mr. Kirby doesn't believe better administration can save the system and make it financially supportable. Something more dramatic will be required, and he'll reveal some of those options next week.