Len Nichols of the New America Foundation (he's leaving soon for academia) has an impassioned plea for passage of health care reform in the current issue of the New England Journal of Medicine, which just hit my email inbox. He offers a persuasive answer to fiscal hawks who argue cost control must precede coverage expansion:

Fiscal hawks will still ask why we can't contain cost growth first and expand coverage later. This is a fair question - although the Congressional Budget Office has determined that both the House and Senate health care bills reduce the deficit, and a choice that forces the growing number of uninsured to wait another decade would, in my view, be immoral. Nevertheless, the simple answer to the hawks' question is that it is not feasible to tackle costs without tackling coverage. Our delivery system could not withstand the stress. Two thirds of hospitals lose money on Medicare now. Virtually all lose money because of Medicaid underpayment. To impose serious delivery reform and incentive realignment while leaving hospitals on the hook for the mounting billions of dollars in uncompensated care would bankrupt many and strain most to the breaking point. With expanded coverage, we'll get absolutely essential hospital cooperation. Without expanded coverage, hospitals will have to protect themselves from change, and their local communities will want them to.

I would add one caveat to his argument, however. A majority of the new insurance enrollees under the proposed health care reform bill comes from an expansion of Medicaid, which, Nichols claims, routinely underpays for 41 million poor and near-poor people those state programs serve. That means the massive cost-shifting to the insured sector to pay for the uncompensated parts of their care will only grow worse shortly after reform passes. And that means figuring out how to make providers deliver cost-effective care will become a frontburner within a very short time of the legislation being enacted -- as has already become the case in Massachusetts.