The federal government should expand public medicare to pay for services beyond those offered by hospitals and doctors, says the man charged with recommending ways to repair Canada's health-care system.

Failure to expand the public system will force Canadians to bear a greater burden of their own health costs, federal health-care commissioner Roy Romanow told a Harvard University audience yesterday in a speech signalling some of the broad outlines of his long-awaited report.

He also issued warnings about the creeping use of private diagnostic equipment, such as MRIs, and laid out ideas for how to reorganize doctors' offices.

Mr. Romanow would not say what new areas Ottawa should enter. But services not covered by medicare include drugs and home care, which make up an increasingly large amount of the health-care bill.

"I think the universal, single-payer system should actually be expanded beyond the basket of services offered in hospitals or by doctors," Mr. Romanow said in the speech, a text of which was made available to The Globe and Mail.

"True, expanding the scope of medicare coverage would demand some additional public investment in the near term. But in the long term, it would ensure a more rational, cost-effective and sustainable use of all health-care services."

The speech is the clearest indication yet of the direction Mr. Romanow will take on medicare when he reports at the end of next month. Prime Minister Jean Chrétien appointed him to look at the entire health-care system, and his comments yesterday suggest his ideas will require a sizeable injection of new public money.

Speculation is rife that Mr. Romanow will recommend that Ottawa provide money for home care and, perhaps, a limited prescription drug program -- moves that could add billions in costs.
"I can't say now which ones ought to be included; that is grist for more public discussion," Mr. Romanow told about 50 academics, medical students and others. "But I can say that if we don't lay the groundwork now, the private costs for these services will continue to grow with little restraint."

If the government doesn't expand the system, more Canadians will turn to hospitals and doctors, "which they perceive as free."

In Canada's system, the government covers the cost of drugs provided in hospital, but not, by and large, those purchased at a dispensary.

Mr. Romanow also suggested a fundamental change in the way doctors services are delivered.

He said provincial governments must break down barriers among health-care providers, a signal that he will recommend lumping professionals like nurse practitioners, doctors, nurses, dieticians and others under one clinical umbrella, rather than having them practise separately.

Many provinces are experimenting with such forms of primary care, arguing that they are more efficient and may cost less.

But many doctors are wary because it could change how they are compensated.

He also said he has become increasingly concerned about the proliferation of private clinics and the fact that those who can afford it can get tests done faster.

"This is a growing phenomenon and, in my view, potentially threatening," Mr. Romanow said.

"It is a serious violation of a core value shared by Canadians -- the notion that people should have equal access to care, and that medical need should be the only criterion governing who should be tended to first."

Mr. Romanow was referring to private MRI (magnetic resonance imaging) clinics where individuals can pay for what are considered medically necessary services.

He also warned that there will be pressure for private services if Canadians don't believe their governments will adequately provide them with high-quality care.