Romanow said doctors and patients can adapt relatively easily to piecemeal change "that conforms to our habits and prejudices," but it is far more difficult to accept never-ending change. His key message was that change of every type, from user fees to privatization, is on the table as he prepares his recommendations. "I'm prepared to listen to evidence . . . but I will be challenging everyone. And if someone is making an argument it has to be evidence based and factually based." He also added: "My mandate is to make the public system work."

Change was 1 of the 4 commission themes outlined by Romanow, who must submit his recommendations to the prime minister by November 2002. The others are:

• The need for collaborative relationships: Romanow said the current system "is peppered" with mistrust, uncertainty, fear and built-in adversarial relations. "We need to shore up the partnership that went into achieving medicare and restore the trust that different levels of government must have if they are to work together successfully. Canadians are fed up with political bickering."
• The system's sustainability: He said Canadians have to ask 2 questions when deciding this: To what extent are they prepared to make changes within the system in order to reduce costs? To what extent are they prepared to pay more?
• The need for public input: Romanow said Canada is probably the only country in the world in which the health care system is "our core symbolic program" and he wants to understand how and why. This means Canadians must have "meaningful input" into the future direction of public health care.

Romanow said his 1-man commission is a chance to forge a new consensus on medicare, but he acknowledged that it faces some difficult questions. "Can we really tell the public that $95 billion a year is an ungenerous amount to be spending on [health care], for what by world standards is a very healthy population? And when Canadians report very high levels of satisfaction with services received [CMAJ 2001;165(5):621], can it be simultaneously true that the system is on the brink of collapse?"

When asked if his report might not end up gathering dust like so many others, Romanow said he is determined to produce a report that Canadians and their politicians have to deal with. "This is my last go at public policy. If the recommendations resonate with the public, no government will be able to ignore them.