Six years ago, during the buildup to the Persian Gulf War, the deployment of military medical personnel threatened to create shortages of medical professionals in some parts of the country. No problem: the U.S. Government was, at least in theory, ready. This was precisely the sort of situation for which the Commissioned Corps of the Public Health Service -- a federally funded corps of medical shock troops -- was created.
In fact, the agency had signed a memorandum of understanding with the Department of Defense in 1988 for just such a contingency. It explicitly stated that Corps members could be called upon to relieve shortages caused by military deployments in wartime.
|
|
Our uniformed corps of medical personnel is costly, unnecessary -- and reluctant to serve its country. |
|
|
So when duty and country called, what did these highly paid, generously pensioned medical personnel do while other doctors and nurses mobilized for the front lines? They marched before Congress to demand that the Corps not be deployed. The Department of Defense, the Corps contended, should exhaust all possible options -- including recruiting civilian volunteers -- before asking the Corps to serve. And so the call-up never came.
Mission Implausible
Like the Army, Navy, Air Force, and Marines, the Commissioned Corps is a uniformed service of the United States. But unlike the armed services, the members of the PHSCC are not soldiers but doctors, nurses, even dietitians and veterinarians. Originally designed to provide the nation with a mobile, readily deployable cadre of medical personnel, over the years the PHSCC has drifted far from its mission. Today, no one is sure what it's supposed to do, but there is growing agreement on this: What it does, it does too expensively, and probably shouldn't be doing at all.
Remember James Felsen, the Styrofoam cup bureaucrat? A Commissioned Corps officer, Felsen was made infamous last summer by the Washington Post as a bureaucrat paid $117,000 a year to pass the time reading newspapers, telephoning friends, and constructing an arch of used Styrofoam coffee cups in his office at the National Institutes of Health (NIH). By his own reckoning, he did "virtually nothing" -- and got an annual $15,000 "valuable employee" retention bonus in return.
If the glare of the media spotlight has been unwelcome for Felsen, it has been doubly so for his boss -- the Surgeon General of the United States. The Surgeon General is the highest-ranking and most prominent member of the Corps. Although the office has remained vacant for more than a year and a half, little attention has been paid to the 200-year-old, $600-million-a-year program over which he presides.
The Commissioned Corps traces its roots to 1789 and the federal government's first entry into the field of health care under President John Adams. Adams created a series of government-funded hospitals to care for merchant seaman who showed up, broke and sick with scurvy, in strange ports. The Marine Hospital Service later broadened its mission and became the Public Health Service (PHS). In 1889, Congress created the Commissioned Corps as a mobile cadre of medical professionals within the PHS with military rank, pay, allowances, and benefits.
The Corps justified its quasi-military status -- and benefits -- on the grounds that it would go anywhere and do anything to respond to medical emergencies. And through the end of World War II, the Corps fulfilled its mission. It battled smallpox, typhus, and yellow fever outbreaks at the turn of the century and served alongside the armed services in both world wars.
But the history of the Corps since the New Deal is considerably less heroic, recorded in the rapidly proliferating acronyms of an expanding health-care bureaucracy. Today its 6,276 members are significantly less mobile, "seeded" throughout the federal government -- at NIH, the Indian Health Service, the Centers for Disease Control, even the Environmental Protection Agency -- and are virtually indistinguishable from the 40,000 civilian Public Health Service employees with whom they work.
Dollars for Doctors
Virtually indistinguishable, that is, but for one thing: they are more expensive. The General Accounting Office (GAO) has found that the taxpayers could save as much as $130 million a year -- or 22 percent of the program's cost -- by replacing it with civilians. Although the wage disparity between Corps members and PHS civilians has varied over the years, the difference in salary can be as high as $10,000 to $30,000. Corps members also qualify for a host of military and veterans' benefits, and they and their dependents receive free health care. After 30 years, they can retire at 75 percent of their base pay.
|
|
The Commissioned Corps has burrowed deep into the federal bureaucracy, keeping its profile low and its costs hidden. |
|
|
All of which might be justified if the Corps were providing a unique and valuable service. In fact, the GAO has found that civilians could easily replace Corps members without causing a ripple in the flow of public health services. The PHS already has more than 19,000 civilians performing the same duties as Corps officers. Officials at three government agencies that together employ more than 1,000 Corps members told the GAO that civilians could replace Corps members in every case.
The story of why they have not is a case study in bureaucratic survival techniques. The Corps has burrowed deep into the federal bureaucracy, keeping its profile low and its costs hidden in the federal budget. In short, it owes its existence to the same combination of public ignorance and bureaucratic self-interest that allowed James Felsen to spend three years building a polystyrene bridge to nowhere in his office in the suburbs of Washington.
Like other programs that have outlived their missions, the PHSCC benefits from its anonymity. Unlike most federal programs, there is no line in the budget that shows how much is appropriated each year for the Commissioned Corps. Each agency that hosts Corps members finds money in its own budget to pay their salaries. But they are still a bargain, because the individual agencies do not pick up the retirement costs of Corps members -- resulting in an unfunded pension liability of almost $4 billion in 1994.
No Accountability
The real secret to the longevity of the PHSCC, however, is its refusal to establish standards by which taxpayers can judge its performance. Despite its origins in the pomp and circumstance of the military -- with uniforms and insignia all its own -- the contemporary Corps has refused to allow itself to be defined by anything more than the basket of benefits that its member "officers" enjoy.
C. Everett Koop, the Surgeon General under President Reagan, came into office determined to restore some of the faded military luster of the Commissioned Corps. But when Koop suggested in 1987 that Corps members wear their uniforms more often, howls of protest went up at the federal health agencies, particularly the NIH. Some PHSCC physicians, it turns out, had joined the Corps during the Vietnam War as an alternative to military service. By the 1980s, they occupied senior research positions at the NIH and made it clear to Koop that they regarded their Corps uniforms as a "routinized expression of loyalty" that would stifle their creativity. "I regard this as an academic institution," an NIH laboratory chief told Science magazine. "Uniforms create a distinction that is detrimental and divisive." Sniffed another NIH physician, "I am not here because of the Corps, but in spite of it." Dissent was so great that Koop eventually backed down.
And so it has fallen to James Felsen to push this elusive federal program back into the sunshine of public review. What happens next is anybody's guess, but the omens are not good. After the Post blew the whistle on Felsen, the government convened a retirement board to see if he could be forced out of public service. It determined he couldn't, and so he was given a new job at the CDC. He expects to receive his old salary and carry the title "senior program management officer consultant."
