The most thoughtful comment, amid all the blustering on both sides, about the single-payer healthcare bill passed by the Legislature last week that Gov. Arnold Schwarzenegger now says he'll veto, comes from the Legislature's resident physician, Assemblyman Keith Richman.

Richman voted against the bill last week, but not for any of the knee-jerk reasons many of the opponents raised. Yes, he thinks a single-payer system would reduce administrative costs in the system and produce a one-time savings. Yes, he believes single-payer systems work in other countries. But, he argues, it's a not a system that can work in the American culture.

European countries with government-run health insurance systems, Richman said, tend to have a "we're all in it together" approach. People can openly discuss cost-benefit issues and debate whether to either raise taxes to cover the costs of expanded services or to engage in the sort of rationing of care that would ultimately be necessary to contain costs. In the end, people can collectively agree on what approach would provide the most good to the greatest number of people.

In the United States, that's not the culture. What would inevitably happen if a single-payer system was established in California, Richman argues, is that politicians would respond to the public's desire to have access to every imaginable treatment for anyone who desired it. At the same time, politicians would be unwilling to increase the taxes that would be needed fund the higher level of care. The end result, he insists, would be that the system would become underfunded. And that would mean the state would have to start reducing reimbursement rates paid to doctors, hospitals and other healthcare providers.

Richman noted that Medicare, which has been repeatedly cited as a model by the proponents of a single-payer system, is not as rosy as the supporters suggest. Yes, it's administrative costs are low and, yes, it is an efficient system that delivers care to every American 65 and older. But the long-term financial health of Medicare is not good, he said. But, politics and the American culture being what they are, no one in Congress is even talking about the problem, Richman says.

It's a toughtful critique — and one that Sen. Sheila Kuehl and other advocates need to consider as they continue to press their case. A system that insures everyone, allows everyone a free choice of doctors and hospitals, covers just about every imaginable medical and dental care, and doesn't charge copays or require deductibles is a ultimately a recipe for a system that will cost more than voters will be willing to pay.