On September 30, a Senate committee voted 12–11 to advance President Donald Trump’s nomination of Dr. Nicole Saphier to be the next Surgeon General of the United States. Her nomination now moves to the full Senate.
By the time the Senate gets around to voting on her nomination, the U.S. will have gone nearly two years without a confirmed Surgeon General.
Somehow, we survived. Americans continued seeing their doctors, hospitals treated patients, and state and local health departments carried on. The CDC tracked infectious diseases. The FDA regulated drugs and medical devices. HHS oversaw federal health programs. Business continued as usual.
Which raises an obvious question: If the country can go this long without a confirmed Surgeon General while its health agencies continue operating, why do we need one? And why do we still maintain the roughly 6,000-member uniformed service the Surgeon General oversees?
Last year, I joined Akiva Malamet, Bautista Vivanco, and Michael Cannon to examine that question in a Cato Institute policy analysis titled “Unnecessary Relics: The Surgeon General and the Public Health Service Commissioned Corps.” We concluded that both institutions have outlived their original purposes. Congress should abolish them and transfer their necessary functions to existing civilian agencies.
The larger reform concerns the 6,000-person Public Health Service Commissioned Corps. Its officers work throughout the federal government, often performing the same duties as civilian employees while receiving compensation and benefits modeled after the military. Abolishing the Surgeon General’s Office would eliminate a largely symbolic position. Civilianizing the Corps would tackle a more consequential problem: a costly, separate personnel system for work the federal government already employs civilians to do.
The institutions share a history. In 1798, Congress created hospitals to care for sick and disabled merchant seamen. Congress consolidated them into the Marine Hospital Service in 1871. John Maynard Woodworth organized its physicians into a mobile, uniformed workforce, which Congress formalized as a Commissioned Corps in 1889. As federal responsibilities expanded, the service became the Public Health Service, and its officers eventually provided care in federal prisons and on Native American reservations.
The Surgeon General once oversaw much of the federal government’s health apparatus. The Public Health Service Act of 1944 placed the office in charge of the Public Health Service and its constituent agencies. But reorganizations in the 1960s transferred that authority to other officials. The Johnson Administration abolished the Office of the Surgeon General in 1968, but it was reestablished in 1979 — without its former authority over federal health agencies — when Congress split the Department of Health, Education, and Welfare into the Departments of Health and Human Services and Education."
Today, the CDC, FDA, National Institutes of Health, and other agencies have their own leadership and responsibilities. The Surgeon General largely serves as an adviser and spokesperson. The Commissioned Corps survived these reorganizations, retaining its separate personnel system long after the government developed civilian alternatives.
The Surgeon General’s Uniformed Corps
In the 19th century, the federal government needed physicians it could deploy to Marine Hospitals across the country. Today, Corps officers work throughout the federal government as physicians, nurses, pharmacists, dentists, therapists, veterinarians, scientists, engineers, administrators, social workers, and other professionals. Many perform roles virtually indistinguishable from those of civilian federal employees.
The federal government doesn’t need a separate uniformed service to employ these individuals. Agencies that need physicians, nurses, pharmacists, scientists, engineers, or other health professionals can hire them directly. They can also contract with private-sector professionals when that is more practical. Federal agencies already use civilian employees and contractors to perform many of the same functions that Corps officers perform.
Supporters argue that the Corps can mobilize health professionals rapidly during emergencies. Emergency readiness matters, but a uniform does not guarantee a faster response. An HHS analysis cited in our paper found that Commissioned Corps officers took 24 hours or more to deploy during emergencies, compared to less than 12 hours for personnel from the civilian National Disaster Medical System.
Those figures do not prove that civilian responders will outperform Corps officers in every emergency. Missions and deployment requirements may differ. They do, however, challenge the assumption that a separate uniformed service is essential to an effective disaster response.
The historical cost comparisons also favor civilian staffing. A 2010 HHS analysis estimated that the average Commissioned Corps officer cost 15 percent more than a civilian employee performing equivalent work and estimated savings of approximately $217 million from using civilians instead. A 1996 Government Accountability Office analysis estimated that converting Corps positions to civilian roles could reduce spending on those positions by 22 percent.
In our Cato paper, we estimated the Corps’ annual costs at approximately $1.3 billion in inflation-adjusted dollars, based on 2009 data. Not all of that represents potential savings: civilian replacements, transition costs, and retirement obligations would remain. Still, historical HHS and GAO analyses suggest meaningful savings are possible. Congress should commission an updated estimate of the net savings from civilianizing the Corps.
Part of the problem is that the Corps has a compensation system modeled after the military. Its officers receive benefits that include tax-free housing and subsistence allowances, TRICARE coverage, military shopping and recreation privileges, and eligibility for certain veterans’ benefits. Host agencies pay officers’ salaries and administrative expenses, while HHS covers health and retirement costs. That arrangement can make a Corps officer appear cheaper to the employing agency, even when the officer costs taxpayers more overall.
It also obscures accountability. A Corps officer belongs to the Commissioned Corps but works for another federal agency. In an emergency, that officer may be expected to deploy elsewhere unless the employing agency deems the officer essential to its mission.
There’s a simpler way: Congress could abolish the Commissioned Corps and let federal agencies determine which functions they need. The Bureau of Prisons could directly hire or contract with medical professionals to care for federal prisoners; the Indian Health Service could do the same. Agencies needing scientists, pharmacists, engineers, or other specialists could employ them directly. Emergency medical personnel could work through existing civilian disaster-response programs.
Current Corps officers whose services federal agencies need could continue working as civilian employees or contractors. Congress would need to protect accrued benefits, address retirement obligations, and maintain recruitment, emergency readiness, and continuity of care during the transition. These are practical problems to solve, not reasons to preserve a separate personnel system indefinitely.
We don’t need a 19th-century uniformed service to staff a 21st-century federal government. The office that oversees it deserves scrutiny as well.
From Administrator to “The Nation’s Doctor”
Today, HHS calls the Surgeon General “the nation’s doctor.” But the U.S. is home to more than 340 million people and hundreds of thousands of physicians. We don’t need — and shouldn’t want — a government-appointed doctor to tell all of us how to live.
As the Surgeon General’s administrative authority declined, the office increasingly became a bully pulpit. Surgeon Generals have weighed in on topics ranging from smoking, diet, exercise, and drug use to violent video games, pornography, guns, social media, loneliness, working conditions, housing, and parental stress.
Public health intervention has a strong justification when people impose risks on others without their consent, as with contagious diseases or pollution. Sanitation, vaccination, and infectious-disease control have saved countless lives. But not every personal health risk is a public health emergency, and medical expertise alone does not settle questions of individual liberty or public policy.
Autonomous adults should be free to decide how to live, even when their choices pose health risks. Physicians can advise them, and government agencies can provide reliable information. Neither role requires a national doctor whose prestige lends medical authority to political judgments.
Physicians and public health officials can explain the health consequences of different choices. But policies on guns, housing, labor, education, or social media also entail costs, competing interests, and individual liberty. Medical expertise can inform those judgments, but it does not settle them. A presidential appointee’s title does not confer special expertise across all of these fields.
The prestige of “the nation’s doctor” can blur the line between scientific evidence and an administration’s policy preferences. When government health officials enter contentious political debates, Americans who disagree may become less willing to trust their advice. That can make it harder for those officials to convey credible information during a public health emergency.
The government already employs specialists in infectious disease, toxicology, epidemiology, and other fields. These experts can communicate with the public about matters within their expertise. We do not need a separate, presidentially appointed office to speak on their behalf.
Retire the Institution, Preserve the Work
The next Surgeon General nomination offers Congress an opportunity to examine the institutions behind the title. Why do federal agencies need a separate uniformed service to employ medical and scientific professionals they can already hire as civilians?
The prolonged vacancy has not prevented federal health agencies from doing their work. The more consequential question is whether the Corps’ separate personnel system improves their performance enough to justify its complexity and expense.
Congress should commission an updated assessment of the Corps’ costs, deployment capabilities, and recruitment needs, then establish a planned transition to civilian staffing where those functions can be performed as effectively. The goal should be to preserve essential services while eliminating unnecessary institutional overhead. That means protecting accrued benefits, maintaining emergency readiness, and ensuring continuity of care.
The United States needs physicians to care for federal prisoners, medical professionals to serve Native American communities, and skilled responders to handle public health emergencies. The federal government needs public health professionals, not a separate uniformed bureaucracy to employ them.
Jeffrey A. Singer, MD, practices general surgery in Phoenix and is a senior fellow at the Reason Foundation. His latest book is Your Body, Your Health Care (Cato Institute, 2025)