Rejuvenate the Public Health Service Commissioned Corps
Build a corps that acts as the doctors and nurses of the federal government
On Tuesday, I talked about the problems that any reform to the United States’ public health agencies needs to tackle. In it, I alluded to my low opinion of the Public Health Service Commissioned Corps. I want to explore why it is and how the corps can be reimagined into the federal government’s doctors to be a stronger uniformed service.
The United States has eight federal Uniformed Services. Six of them are the Armed Services: Army, Navy, Air Force, Marine Corps, and Space Force. They are what you probably think of when the term “Uniformed Services” comes up. The other two are lesser-known.
The Department of Commerce has the National Oceanic and Atmospheric Administration Commissioned Officer Corps or the NOAA Corps. While most Americans have probably have never heard of the NOAA Corps, they know the work that the corps does. The NOAA Corps is one of two groups — along with the Air Force’s 53rd Weather Reconnaissance Squadron — that flies into hurricanes to monitor their intensity. The NOAA Corps also sails oceanography research ships.
The Final Unformed service is part of the Department of Health and Human Services. The Public Health Service Commissioned Corps (PHSCC) is larger than the NOAA Corps but their work touches the lives of most Americans less. They staff the Indian Health Service, respond to natural disasters, work in federal prisons, and are assigned to the CDC and FDA.
Objections to the current PHSCC
I have a few main objections to the current way the PHSCC is used and thought about. The first has to do with senior flag officers. The right was aghast when Rachel Levine became the first trans Flag Officer last year but in their transphobia, they missed the forest from the trees. In no other uniformed service are people with no time spent in uniform made high ranking officers as a political appointment. But, with the PHSCC this routinely happens.
The Assistant Secretary for Health can be appointed as an O-9 or Four-Star Admiral as a virtue of their position. Since they can it often happens. Since 1993, only three Assistant Secretaries for Health served in the position as a civilian: Philip R. Lee (1993-1998), Eve Slater (2002-2003), and Howard K. Koh (2009-2014). The rest were political appointees who were given a commission as an ego boost.1 There is no evidence that Philip Lee was worse at his job because he did not have a commission. There is also no evidence that the Secretary of the Army would be better equipped to lead the Army if he received a commission as General of the Army (O-10; Five-Star General) as part of the gig.
Another objection that I have is that the PHSCC fills in the gaps in the federal government instead of providing a coherent role. They work as a part of the Indian Health Service because it has a hard time filling roles in extremely rural areas. Inside of the Department of Health and Human Services, I am not sure why their roles at the FDA and the CDC could not be done by civilians. Unlike with the military, PHSCC members can decline deployments to places where doctors are urgently are needed.
The PHSCC is entirely made up of commissioned officers. This creates a major downside. Unlike the military which has support personnel and public affairs staff drawn from the enlisted ranks, the PHSCC has none of that. It leads to highly-trained doctors doing support work and the work of the corps being unnoticed by most Americans.
The doctors and nurses of the federal government
A way to rejuvenate the PHSCC and to make it the medical professionals of the federal government. This would involve moving the health providers from other parts of the government into the corps and then funding it in the way that it deserves.
The federal government needs a lot of doctors, nurses, veterinarians, etc. to fulfill its mission. These professionals are spread across almost every agency. Under this idea, they would all be members of the PHSCC, including medical professionals in the military. Then PHSCC would be assigned where they are needed. The lion’s share would be assigned to the military, but people would also be assigned to embassies around the world, the Indian Health Service, Hospital Ships Comfort and Mercy, and anywhere else that the federal government needs a doctor or nurse. The doctor to the president and vice president would be PHSCC members.
Part of doing this would clear up the current mismatch of reporting lines that the PHSCC has. Corps members would be assigned to a place for 3-5 years, but their long-term reporting line would be to their unit commander within the corps.
With a much larger PHSCC, it would put pressure on presidents to stop using it as a way of stroking the egos of political appointees. It would be the military’s doctors after all and might be able to generate the respect that it deserves.
With this, maybe they could take over the much better name Public Health Service which is a vestigial designation inside of the Department of Health and Human Services. With a larger number of members, the PHSCC will hopefully develop their own uniforms and ranks instead of borrowing from the Navy. All of these would help the PHSCC be more visible and known.
Expand v. Abolish
Skeptics might look over my list of criticisms of the PHSCC and wonder if it is best to just abolish the uniformed service. In 2018, the Trump administration proposed cutting the Corps by 40% and made overtures to abolishing it. While I agree that it would solve some of the problems, abolishing the PHSCC ignores many of the upsides of keeping the corps.
An integrated command structure would help balance the various medical needs of the country. Our current medical system does not allocate doctors and nurses effectively. The shortage of doctors in the Indian Health Service mirrors the shortages of doctors in all rural areas of the United States. It might be less severe in rural Arkansas, but the problem is still there. An expanded PHSCC that can deploy doctors and nurses to where there are shortages could help ease the burden in rural areas and start to solve urban-rural health inequities in the US.
Part of the rural shortage has to do with recruitment. Uniformed service has a number of perks that come with it. Becoming a medical professional is expensive. Time serving the country can ease that burden. Rural areas do not pay very well. To make this an attractive option for doctors leaving med school, the federal government could pay members of the expanded PHSCC more than if they were in rural Nebraska privately.
This is a bold idea, but it is an idea that has the possibility of improving the lives of Americans and an idea that could be more efficient than our current system.
I have similar ire for the Surgeon General. The position is a Three-Star Admiral (O-8) as a part of the job and, of the recent appointees, only Antonia Novello (1990-1993) and Regina Benjamin (2009-2013) were previously members of the PHSCC.