By Robert Cook-Deegan, research professor at the Sanford School of Public Policy
After decades of strong budget growth, the National Institutes of Health now faces an increasingly constrained funding environment and questions about the value of its research.
For six decades after World War II, the National Institutes of Health (NIH) was the darling of Congress, a jewel in the crown of the federal government that basked in bipartisan splendor. Each year brought concrete accomplishments, examples of how federal dollars had advanced the conquest of disease, such as cancer, heart disease and childhood leukemia. The stories were simple and easy to understand, and there was truly a line from NIH research to clinical advances.
Today, NIH politics have changed. NIH’s purchasing power dropped by double digits after the 2003 peak, and even fear of disease does not seem to overcome the partisan gridlock that besets Congress. Is this inattention specific to NIH or is NIH merely suffering collateral damage from the larger and deeper paralysis of national government? Are political undercurrents permanently changing how federal support for all research will carry into the future? And what might the answers to such questions mean for scientists and decision makers?
When the NIH budget was $700,000 going into World War II, it was easy to quadruple the budget to $3.4 million by the war’s end, and to boost it another tenfold by the early 1950s. Until the 1970s, the U.S. economy was generally healthy, discretionary budgets floated on rising waters, and NIH got disproportionate increases. From 1970 through 2003, NIH’s research funding consistently and significantly outgrew other federal research accounts.
The rise of molecular biology and the continued efforts of disease-research advocates help explain this growth. NIH grew, but so did health expenditures. As a fraction of U.S. health expenditures, the federal health research budget has hovered around 2 percent since 1980.
As NIH’s budget has grown to $30 billion annually, it has become harder to increase it without pinching other agencies. Appropriations to the Departments of Labor and of Education come out of the same appropriation subcommittee allocation, so NIH also competes directly with other, non-health programs. It is hard to argue that the agency is more deserving of increases than other key agencies.
Health activist Mary Lasker discovered a political strategy for using private philanthropic capital to leverage biomedical research funding from Congress in the years after World War II. She was married to Albert Lasker, a pioneer of the nascent advertising business whose accounts included Lucky Strike, and they started the Lasker Foundation and ran the American Cancer Society. By the time of the AIDS crisis, hundreds of disease groups following the same script that Lasker used to boost cancer research, lobbying to create institutes for their own conditions.
As NIH grew, so did the institutions it funded to do research. NIH-funded research is an industry that sustains academic health centers throughout the nation. That industry sometimes behaves as political scientists predict, as an interest group, building national organizations and crafting political strategies to influence elected and executive branch officials in Washington. Academic health centers have expanded remarkably over the decades, and entire careers are devoted to biomedical research lobbying.
When NIH’s budget was up for discussion soon after its doubling, in March 2004, Sen. Pete Domenici (R-NM), a long-time supporter of NIH and passionate advocate for mental health, exclaimed in frustration: “I hate to say it, the NIH is one of the best agencies in the world. But they’ve turned into pigs. You know, pigs! They can’t keep their oinks closed. They send a Senator down there [to] argue as if they’re broke.”” as he spoke in opposition to an amendment by Sen. Arlen Specter (R-PA) to boost NIH funding by $1.5 billion.
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The NIH Campus
The NIH hospital campus in Bethesda, Md. (c) NIH
Despite its name, NIH’s mission has not generally been current health per se, but rather research for tomorrow’s health and progress against intractable diseases. And that is surely an appropriate government mission, since it is inherently long-term, the main output is information and knowledge, and the financial benefits are hard for private firms to appropriate. These are all features of public goods that only collective action and patient, public capital can supply.
The truth is that there is no overarching theory of biomedical innovation sufficient to specify a “right” balance with any precision. At the macro level, Congress appropriates to institutes and centers that focus on particular diseases, health missions or health constituencies—factors that weigh in the political assessment of social value. At the micro level, most project funding decisions are made by merit review—usually peer review—as a fair way to assess scientific opportunity. This is a political process solution to a wicked problem with no reliable predictive theory. It is probably not optimal; but the question of what would work better has no agreed-upon answer.
Time for rethinking
NIH is an effective agency, and it was no small feat to establish and sustain its excellence. But there are very large imbalances in the health research portfolio, with health services research and prevention the perennial stepchildren, and biomedical research the favored biological child.
If we turn explicit attention to fostering economic growth and to more tightly connecting research to its intended goal of improving health, then there is the possibility of more fully integrating it into the national economy as a matter of national policy.
The prospect is exciting but daunting. Current policies of regulating and paying for health goods and services reward introduction and overuse of expensive technologies that add incremental improvements in health, but with scant attention to cost or relative effectiveness. The Medicare statute, for example, explicitly denies authority to consider cost-effectiveness in medical practice, which sets up perverse incentives which favor expensive new drugs and devices that command high profit, and discourage low-cost innovation. To call this a “system” or a “market” is to stretch those words beyond coherence.
The importance of research as a component of economic growth commands bipartisan consensus. Although research universities have had strong and productive ties with industry since the late 19th century, only recently have they explicitly taken on the mantle of fostering economic growth as key components in a national system of innovation. Recent reports such as Restoring the Foundation from the American Academy of Arts and Sciences and the National Research Council’s Rising Above the Gathering Storm and its sequels build on this theme. Universities and research clearly are important sources of ideas, information, and technologies that matter immensely in the innovation ecosystem.
One difficulty with the framework, however, is that it relies on open-ended arguments that support increased funding but offer less guidance about how to make investments in economic growth more effective. No coherent theories predict how best to spend public dollars—or tell us how many dollars are enough. The reports are persuasive in documenting stagnation, and about the danger of under-investment and trends pointing to the emergence of R&D-driven economic policies in Asia that could overtake U.S. pre-eminence in research and knowledge-based economic growth. But “more money for research” is an incomplete response, as it fails to address the imbalances and inefficiencies that have accumulated over six decades.
The open question for NIH is whether these arguments about economic growth, when combined with the attractive logic of boosting support for research to address the burden of diseases for which current public health and medical care are inadequate, will build political momentum to reverse a decade of neglect. Has NIH lost its halo, or will it begin to shine again?
Robert Cook-Deegan is a research professor at the Sanford School of Public Policy. This is an excerpt from a longer article published in Issues in Science and Technology, Winter, 2015, and is reprinted by permission.