The health care bill will further privilege private insurance coverage by offering many individuals new subsidies for its purchase. That will create incentives for employers to game the system, dropping or discouraging coverage and sending their workers to buy health insurance on the more expensive federally subsidized exchanges. That will strain the federal health care budget. This problem is outlined by Amy Monahan and Daniel Schwarcz, law professors at the University of Minnesota, in their new paper “Will Employers Undermine Health Care Reform by Dumping Sick Employees?”

There is also the danger that a few governors with tight budgets will shirk their Medicaid responsibilities, with an eye toward sending potential recipients to the federally subsidized insurance exchanges. In both cases, the quest for a better deal will strain the federal budget.

The American system of federalism, with its checks and balances and slow policy evolution, has many strengths, but it has also helped create this crazy quilt of health care reimbursement rates. The more demand-side pressure is placed on medical supply, the more Medicaid and Medicare reimbursements rates will determine who and what is rationed.

One option is to simply allow budget pressures to dominate, forcing down even private insurance reimbursements. Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

An alternative is giving most people means-tested vouchers for a fixed amount of insurance coverage  which can run out or face up-front caps  making Medicaid and Medicare less of a blank check. The cost explosion would be checked by shifting more of the burden onto consumers. We would have better incentives for consumer-oriented care, and cost control, but we would be making an explicit public decision, at some point or another, to let some people do without medical care.

Recently the Arizona state government restricted transplant coverage for Medicaid patients, but it remains to be seen whether such measures can be applied to Medicare recipients. President Obama already has reversed some of the planned, budget-saving cuts to Medicare.

AN entirely different approach is suggested by the system in Singapore, where the government requires savings (say 10 percent to 12 percent of income), patients pay for medical care from those savings, and the government takes care of additional catastrophic expenses. That system has a good record for cost control and access, but would Americans accept so much required saving?

The default course is to maintain or extend Medicare reimbursement rates, raise taxes considerably and accept that Medicaid recipients will face worsening health care access. If you hear of a new solution to the health care puzzle, put aside the politics and instead think through the endgame. Ask not about the rhetoric, but rather about the reimbursement rates.