The Canada Health Act (CHA) was adopted in 1984, to shore up a health-care system conceptualized in the 1960s. Under the CHA, universal coverage is limited to “medically necessary” hospital and physician services, to the exclusion of vital goods and services such as outpatient pharmaceuticals, dental care, long-term care, and many mental health services. Inequities resulting from these gaps in public coverage are partly to blame for pushing Canada’s health system to the bottom of recent international rankings. But there is more to modernizing Canada’s health care system, we argue, than filling these gaps in universal coverage. Every major health system review undertaken in Canada over the past decade has ended with a call for greater accountability, and rightly so: accountability is arguably the sine qua non of high-performing health systems. Whereas many countries have established open and rigorous processes for evaluating health goods and services, targeting public spending on those that deliver the biggest bang for buck, Canada’s governance mechanism for defining the medicare basket is passive, opaque and only tenuously evidence-driven. A move to expand medicare’s scope of coverage must be accompanied by improvements in this type of accountability.