The good news for the National Institutes of Health and its university researchers is that after some 14 years of flat budgets, Congress may be about to loosen the purse strings.
The bad news is that the scientists might not like the terms.
Evidence of a possible break in the budgetary logjam is headed by legislation, expected to reach a floor vote this month in the House of Representatives, that would give the NIH an extra $2 billion a year in each of the next five years.
The other encouraging signs include enthusiastic pledges of support for the NIH from various presidential candidates, from some fiscal conservatives, and from the 23 members of a new congressional caucus formed specifically to help the agency.
At the same time, NIH officials and some of its advocates have warned, there’s a troubling trend among lawmakers to get more deeply involved in deciding what the NIH should and should not study, down to specific disease categories.
A common theme among such lawmakers, the NIH’s director, Francis S. Collins, told his advisory committee on Thursday, is the concept of “burden of disease” — trying to weight NIH spending on various diseases by their estimated economic cost to society.
Examples include the growing calls by advocacy groups for the NIH to spend more money on Alzheimer’s disease, estimated to cost the U.S. economy more than $200 billion a year. Such calls are often accompanied by comparisons to diseases, such as AIDS, that affect far fewer people. The NIH spends about $600 million a year on Alzheimer’s research, compared with about $5 billion for cancer, $3 billion for AIDS, and $2 billion for heart disease.
Dr. Collins told the semiannual meeting of the NIH’s Advisory Committee to the Director that he appreciated lawmakers’ desire to better understand the nation’s $30-billion annual investment in his agency. But, he said, “simply adding up burden-of-disease calculations and saying that’s how NIH should be spending its money is shortsighted.”
The NIH’s Priorities
Pressure on the NIH — the largest single source of research money for universities — to be more specific comes in several forms. One chief element, contained in legislation enacted last year to set the overall federal budget, asked the NIH to draft an agencywide strategic plan.
That request is being reiterated in the legislation now moving through the House, known as 21st Century Cures (HR 6), that would give the NIH an additional $10 billion from 2016 to 2020. The measure passed a House committee last month on a 51-to-0 vote, and is expected to face floor votes this month. The Senate is working on a similar bill.
Dr. Collins told his advisory panel that lawmakers have made clear they want to see an NIH strategic plan in return for improving the budgetary prospects of the agency, which is getting the same amount of federal support it received more than a decade ago, as measured on an inflation-adjusted basis.
“They want to know what are our priorities,” he said. “That’s a fair question, that’s a question we should have an answer to.”
At the same time, the question has potentially worrisome implications, Dr. Collins and several advisory-panel members said. In drafting the strategic plan, the NIH should be wary of suggesting too many statistical measures, said one member, Christopher B. Wilson, director of the Global Health Discovery Program at the Bill & Melinda Gates Foundation. “Be very careful about what you measure,” Dr. Wilson said.
Another panel member, Helen Haskell Hobbs, a professor of molecular genetics at the University of Texas Southwestern Medical Center, reiterated the point. “That’s how you can change behavior overnight — and not in good ways,” Dr. Hobbs said of a strategic plan that rested too heavily on statistics-based arguments.
In the case of AIDS research, Dr. Collins said, the relative financial burden of the disease may not be the best measure of whether it’s worth maintaining a strong push toward a cure, given how close scientists may now be to defeating it altogether. “This is a disease we could eradicate, and that ought to count for a lot,” he said.
It’s an example, he said, of why lawmakers should stick to their longstanding tradition of largely leaving medical experts to set priorities within medicine. He endorsed the assessment of the NIH’s associate director for legislative policy and analysis, Adrienne A. Hallett, who told the panel that there’s been “a little bit of fraying” in the “unwritten gentlemen’s agreement” that the NIH’s peer-review system for judging grant applications should be the primary driver of spending allocations.
“The word ‘frayed’ describes a little bit that the bargain right now is not quite as robust as it has been in the past,” Dr. Collins said.
‘High-Risk, High-Reward Research’
Similarly, the prospects for actual increases in NIH spending are tough to read, Ms. Hallett told the advisory panel. The 21st Century Cures bill and influential lawmakers’ public advocacy of more NIH spending are encouraging, she said. Yet it’s “a bit of a paradox” in that nobody is actually crafting a “grand bargain” that would end the fundamental constraints caused by the budget-sequestration vote of 2013.
“We have wide-scale support,” Ms. Hallett said. “But the appetite for some sort of breakthrough on a deal is fairly weak.” There’s also the risk, she said, that Republicans might try to finance NIH increases through cuts that Democrats would find unacceptable, such as reductions in support for carrying out the Affordable Care Act, otherwise known as Obamacare.
In addition to its demand for an NIH strategic plan, the 21st Century Cures bill would direct the agency to spend the additional $10 billion in specific areas. The House version calls for 35 percent of the increase to be dedicated to younger researchers, and 20 percent to “high-risk, high-reward research.”
The NIH has already identified those areas as priorities, and as such they don’t appear especially troublesome, said Howard H. Garrison, deputy executive director for policy at the Federation of American Societies for Experimental Biology.
But the precedent of taking money with restrictions is worth at least some caution, Mr. Garrison said. And the specific source of the $10-billion increase could raise some concerns for universities, said David B. Moore, senior director of government relations at the Association of American Medical Colleges. About half of the money would come from selling oil from the Strategic Petroleum Reserve, the federal government’s emergency stockpile of crude. The next-biggest source, however, would involve cuts in Medicare reimbursements, and that could hurt some academic medical centers, Mr. Moore said.
Over all, though, both Mr. Moore and Mr. Garrison said congressional drafting of the 21st Century Cures bill appeared to be moving in a positive direction. “But it’s a long way,” Mr. Moore said, “to anybody cashing checks.”
Paul Basken covers university research and its intersection with government policy. He can be found on Twitter @pbasken, or reached by email at paul.basken@chronicle.com.
