There has been more hypocrisy and posturing over medicare in the past month than in the previous 30 years combined. The Prime Minister's was as usual the most barefaced. Jean Chretien pranced into Alberta last week to lecture the Premier on the evils of delisting services and private care. This from the man who, in a post-budget interview, defined universality as not having to sell your home to pay for treatment.

Nonetheless, Mr. Chretien won himself the usual raft of admiring headlines. In this he was aided no end by public ignorance of how medicare actually works. For all the clamour over national standards and comprehensive coverage, there is tremendous variation in the services different provinces will pay for now. For all the frantic disavowal of private care, the system is largely private now: while about one-third of the cost of health care is privately financed, the bulk of it is provided by private entrepreneurs, namely doctors.

Indeed, Mr. Chretien didn't actually draw the line against delisting services: he just wants all the provinces to delist together. "We will not give more flexibility to one province," he said on Edmonton TV. "Why more to Alberta than to the others? . . . I want everyone to be served in a system with the same national standards, so if you move from Alberta to B.C. or Ontario or Quebec, you know what to expect." National standards, note, not current standards.

Of course, Mr. Chretien is not about to say which services should be delisted. He wants the provinces to take the lead, leaving him free to pick which cuts to disallow, based on the public reaction they arouse. "It is up to the provinces to advance a proposition," he said in Alberta last week, "and if it is acceptable or not acceptable, we will tell them." The provinces, for their part, want Ottawa to go first. Provincial health ministers emerged from their recent meeting demanding a clear definition of what services must be covered under the Canada Health Act.

In other words, none of these very public defenders of medicare is actually against chopping it up into little bits. They just want the other guy to take the blame. The Canadian Medical Association, for example, worried after the budget that the federal government had lost the means to enforce the five principles in the Canada Health Act. Yet the CMA has itself been actively working to undermine those principles, most notably in the matter of "additional funding measures," i.e. user fees. Which brings us to the point. Far from the sort of tough but realistic reforms their proponents pretend, user fees and delisting of services, whatever their failings in terms of fairness, are also a false economy. Consumer sovereignty is a wonderful thing, but consumers in the market for health care simply do not have the information needed to make the right choices.

Genuine reform, rather, would focus market disciplines on the real decision- makers in the system: the doctors. Doctors working within institutional structures that emphasize costs as well as care, such as the health maintenance organizations that are now sweeping the United States, must follow strict rules in treating patients, based on the relative cost- effectiveness of different treatments. Doctors hate that, of course, grousing about beancounters practicing "cookbook medicine." But that's what any serious reform entails.

This is not an easy issue to break down into left versus right, or public versus private terms. Indeed, one of the best ways of preserving health care within an affordable publicly financed envelope, avoiding either user fees or higher taxes, would be to let private companies compete to manage public funds. But that means taking on the doctors. And since governments don't like to take on entrenched interest groups, they'd rather take the path of least resistance: you. Which is why medicare's "defenders" are beating their shields so loudly.