The eternal triangle of a sound health system

The ongoing drama of Bill Kissick’s life involves a triangle, not of romance, but of health policy. The three sides of Kissick’s triangle are access, quality and cost containment. “I can deliver any one of these three by compromising one or both of the other two,” said Kissick.

William L. Kissick, M.D. ’57, M.P.H. ’59, Dr.Ph. ’61, has been puzzling over his triangle’s three sides since he began his professional life in Washington, in 1961. He was planning to start his dream job at the National Institutes of Health (NIH), assisting in the lab of future Nobel laureate Baruch S. Blumberg, M.D. Thanks to a misfiled application, the young physician ended up not at the NIH, but at the office of the Surgeon General, where he was assigned to work on a health insurance plan for elderly Americans. With a further nudge from what he calls “The Princes of Serendip,” Kissick became one of the authors of Medicare. In the 18 months that he worked on the program, Kissick got a crash course in the art of the possible from Wilbur J. Cohen, then assistant secretary of health, education and welfare.

By the time Kissick arrived in Washington, Cohen had survived almost three decades in government in administrations of various political persuasions, beginning with President Franklin Delano Roosevelt. Cohen, one of the architects of the New Deal, had proposed that it include national pensions and health insurance. The pensions came to pass when Roosevelt signed Social Security into law in 1935. “FDR dropped the health care idea, but Wilbur didn’t,” Kissick said. Thirty years later, after President Lyndon Johnson signed Medicare legislation, Cohen told the young physician, “If you choose to continue working in health policy, you must learn to appreciate delayed gratification.”

His old mentor, were he alive, would be angered by the recent changes in Medicare, particularly the privatization of the program, said Kissick. He brands the new legislation entirely “political” and attributes it to the lobbying strength of the pharmaceutical and insurance industries. For example, under the new legislation, Medicare will no longer use its enormous purchasing power to negotiate prescription drug prices. The lost savings further compromise Medicare’s financial stability, Kissick said.

Not that Kissick—who is the George Seckel Pepper Professor Emeritus of Public Health and Preventive Medicine at the University of Pennsylvania School of Medicine, professor emeritus at the Wharton School and Penn’s School of Nursing and visiting professor emeritus of health policy and management at the Yale School of Public Health—considers the original legislation he helped write to be perfect. As Kissick sees it, the drafters made three serious mistakes. They dramatically underestimated the growth of the elderly population and the sophistication of medical technologies that would become available in ensuing years. Perhaps most importantly, they did not count on rising patient expectations.

Those expectations are discussed at length in Kissick’s Medicine’s Dilemmas: Infinite Needs Versus Finite Resources (Yale University Press, 1994), currently in revision. “No society has sufficient resources to provide all the health services its population could utilize,” Kissick explained. “We all expect the ultimate in health care.”

In the 1970s Kissick took a sabbatical in the United Kingdom, where he had an eye-opening conversation with a man who was wearing a bilateral truss. Kissick advised him to have surgery for his hernia.

“I intend to,” the Englishman answered. “I’m waiting.”

“How long have you been waiting?” Kissick asked.

“Five years.”

“That’s appalling!”

“My neighbor has been waiting for six,” the man replied.

The British system relies on citizens’ willingness to wait. “Ignore the queue and the system collapses,” said Kissick. He finds it unlikely that Americans would patiently wait years for surgery.

“Health care transcends the biomedical sciences. It’s a cultural affair,” Kissick said. In a vast and populous country like the United States, where it is difficult to define a single culture, he suggests that health care plans organized by states are more viable than a single-payer federal system.

But state-by-state health care is by no means a panacea, Kissick cautions. “The more I read, the more confused I get,” he said. But he is not giving up on the idea of a health policy that serves America well, despite his perplexing triangle. “By the time I finish the revision of my book, hopefully, I’ll have some idea,” he said. (He’s also counting on more than 150 physicians who have graduated from an M.B.A. program in health care management he and a Wharton colleague established there in 1968. “They are now challenged to address the issues,” Kissick said.)

Kissick’s model of perseverance is his wife, Priscilla, who in 1982 founded and directed the first Medicare-approved hospice program, which became part of the University of Pennsylvania Health System in 1998. The Kissicks met at a Yale tea when he was a medical student and she was at the School of Nursing. Kissick committed the social error of turning up at the refined white-glove affair run by faculty wives with several friends, all dressed in khakis and laughing and joking as if they were on their way to The Game. Spotting her future husband, Priscilla Dillingham remarked to a friend, “Somebody needs to straighten that guy out.”

The Kissicks, who have three sons and a daughter, recently celebrated their 48th wedding anniversary. According to Kissick, “She still hasn’t given up trying to straighten me out.”