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NIH missing top leadership at start of a divided Congress

Read the article on Roll Call.

The departure of two key public health leaders at the National Institutes of Health has created vacancies some worry could present a hurdle to NIH’s agenda in the new Congress.

The Biden administration has yet to nominate a permanent replacement for former NIH Director Francis Collins, who stepped down from the post in December 2021. And efforts to replace the longtime director of the National Institute of Allergy and Infectious Diseases, Anthony Fauci, who left in December of last year, are underway.

While Fauci in particular was a lightning rod for conservatives who were angry about the federal government’s handling of the COVID-19 pandemic, the vacancies nonetheless come at a time when the administration has big plans for advancing medical research.

The administration has set the lofty goal of “ending cancer as we know it” through its Cancer Moonshot effort, and scientists and Congress are also working to create a new medical research agency that would work closely with NIH scientists to find cures for high-impact diseases. Both efforts require federal funding.

But House Republicans have a lot they want to get done too and have promised to put the NIH on the stand as they probe medical research, especially as it relates to the COVID-19 response.

Collins began his leadership of NIH in 2009 under President Barack Obama. Even after stepping down as director, he continues to run his lab at the NIH’s Center for Precision Health Research — a less public role than before. He was known for cultivating longtime, bipartisan relationships on Capitol Hill, which helped elevate the agency’s reputation throughout the COVID-19 response as he repeatedly testified on the Hill about the NIH’s work.

And while Fauci, who led NIH’s infectious disease wing for 38 years, was frequently the subject of GOP criticism in his final years at the agency, he was also a familiar face to lawmakers and had ingrained relationships on the Hill. Industry experts say both men’s deep, bipartisan relationships helped galvanize interest in, and funding for, public health.

Lawrence Tabak has served as acting NIH director since Collins departed, while Fauci’s deputy, Hugh Auchincloss — the father of Rep. Jake Auchincloss, D-Mass. — stepped in after Fauci retired. Both scientists have years of experience at the NIH, but Congress watchers and industry stakeholders say a permanent NIH head could smooth agency relations with Congress.

“Just by the nature of someone being in an acting position, they’re only going to go so far in terms of implementing a vision,” said Erik Fatemi, a former staff director of the Senate Labor-HHS-Education Appropriations Subcommittee who handled NIH appropriations. He is currently a principal at Cornerstone Government Affairs.

“Their job must be, by definition, largely a caretaker role,” Fatemi added.

A time of scrutiny

It’s been more than a year since Collins stepped down as NIH director, but the White House has not yet nominated a permanent successor.

Collins’ long-standing relationships on both sides of the aisle helped him secure a roughly 50 percent increase for the NIH budget during his tenure, going from $30.5 billion for fiscal 2009 to $46.18 billion for fiscal 2022. Multiple health industry lobbyists called the former NIH leader “the best lobbyist in D.C.”

Republicans in the House and Senate have generally supported the NIH’s mission. But this year, House Republicans plan to put the agency under the microscope, conducting a slew of oversight hearings about the agency’s handling of the COVID-19 pandemic and the pandemic’s origins.

Both Fauci and Collins served as the faces of the NIH’s COVID-19 response and gained a quasi-celebrity status both inside and outside the Beltway. Both men are likely to be called to testify in GOP oversight investigations. But their new status could also help current agency leaders avoid scrutiny or retaliation from lawmakers.

“In a way, he’ll take some of the pressure off of NIH,” Fatemi said of Fauci.

Ellie Dehoney, who is vice president of policy and advocacy for Research!America and a former Capitol Hill staffer, said having nonpermanent leaders at the helm of the NIH and NIAID could help the Republican oversight agenda land softer in a climate of investigations and finger-pointing.

“Keeping a little bit of a lower profile is not a bad thing when controversy is swirling,” she said.

Asked about its oversight agenda, a House Energy and Commerce Committee spokesperson pointed to Republicans’ requests for information on the pandemic’s origins. The committee’s Republican leaders sent a letter to Tabak in November, soon after they clinched the House majority, demanding documents and information related to the origins of COVID-19.

Republicans on the committee sent the NIH 12 information requests about the pandemic’s origins and the agency’s role between March 2021 and October 2022, but none of the requests received a response.

New committee Chair Cathy McMorris Rodgers, R-Wash., Subcommittee on Health Chair Brett Guthrie, R-Ky., and Subcommittee on Oversight and Investigations Chair Morgan Griffith, R-Va., accused the agency of purposefully avoiding congressional requests and said the agency’s lack of transparency was “troubling.”

Despite concerns over handling of the pandemic, Republicans have generally helped the NIH increase its budget every year. While Collins has been a great lobbyist for the agency, Dehoney said, she is optimistic the agency’s budget will grow even without him.

“NIH is something that both parties can be for, and the Republicans really have embraced that they can be for this even though it’s a federal agency,” Dehoney said.

Big goals

The White House has set a goal of “ending cancer as we know it” through its Cancer Moonshot. But it needs Congress to provide funding this year if it wants to get that done. The moonshot is currently authorized through the 21st Century Cures Act, but that runs out at the end of 2023, and Congress will also need to appropriate more money to keep the effort going.

For fiscal 2024, the NIH’s National Cancer Institute is requesting $9.98 billion to help expand on the research conducted during the first five years of the moonshot effort.

Cancer advocates are optimistic that they won’t face the same level of scrutiny as the agency’s infectious diseases wing because of bipartisan buy-in. And the center’s newly sworn-in director, Monica Bertagnolli, who was herself diagnosed with breast cancer in December, has yet to ruffle any feathers on Capitol Hill.

“Cancer is uniquely nonpartisan, and it impacts every single person. So we’re going to have a lot of people telling that story to members of Congress and holding feet to the fire to keep this nonpartisan and above the fray,” said Julie Nickson, American Cancer Society Cancer Action Network’s director of federal relations.

Advanced Research Projects Agency for Health, Biden’s new research agency, falls under the NIH budget but won’t be physically located at the agency. Much of ARPA-H’s stated goals of finding cures for novel and prominent diseases falls under the purview of the NIH and overlaps with what the Bethesda, Md.-based agency already does. The Biden administration has still not explained how the new agency will carry out its mandate, or how much the two will work together if at all.

Congress’ recently passed fiscal 2023 funding law includes $1.5 billion for the research agency — an increase of $500 million above the fiscal 2022 enacted level but still far less than the $5 billion the White House had requested.

Tough confirmation process

The White House would not comment on why it has not yet nominated a new NIH director. Over at NIAID, meanwhile, a search committee has already begun searching for a new director. The NIAID director is not a Senate-confirmed position.

But any White House pick to head the NIH will likely face a tough confirmation process. Biden’s nominee to lead the NIH will have to clear the Senate Health, Education, Labor and Pensions Committee and then a majority in the Senate.

Given the increased scrutiny on public health and COVID-19, health agency heads often face headwinds. Food and Drug Administration Director Robert Califf sailed through his Senate confirmation in 2016, but in 2022 he was narrowly confirmed 50-46.

At this point, any NIH director whom Biden nominates could potentially serve less than a two-year term. Collins was the rare political appointee who stayed on through different presidencies.

“Everything’s a bit more challenging right now,” Nickson said of appointing an NIH director in the new Congress. “The farther we get into the Congress, the more difficult this becomes.”