John F. Early and Terence Kealey
In our Cato working paper “Mission Lost: How NIH Leaders Stole Its Promise to America,” Terence Kealey and I highlighted some strategic failures by the National Institutes of Health, supported by a detailed analysis of budgets and projects funded by NIH. Since the completion of that analysis, which largely relied on data through 2024, a new leadership team has been installed, so some reflection on its impact seems in order.
In this update, we identify some good news about improvements that the new team is making. There is also some not-so-good news, and at least one piece of really bad news.
At a recent MAHA Institute roundtable, “Reclaiming Science: The People’s NIH,” Dr. Raj Bhattacharya and his team summarized the changes they have made and are planning at NIH. Dr. Bhattacharya’s published work and especially his dissent from the COVID-19 policies in the Great Barrington Declaration would lead one to expect two themes in his management of NIH: an insistence on data to prove health claims and a reluctance for the government to use claims about health as a basis to force individuals to act in prescribed ways.
The NIH presentations at the roundtable reflected those initial expectations. But managing a government agency that spends $50 billion annually, employs 18,500 individuals, and makes 50,000 grants to 300,000 people and 2,500 institutions also requires some additional considerations. NIH submissions for the fiscal year 2026 budget provide additional insight.
Research Model
The most effective and successful model for research is the “mission” model by which a program of work is undertaken with a specific, measurable, time-bound goal for the result. A large project may be composed of multiple smaller projects, each with its own mission to create some component or enabler of the larger mission that is specific, measurable, and time-bound. The alternative pipeline model believes that by exploring interesting questions, valuable information will eventually lead to useful results.
In our working paper, we demonstrated how the mission model has been more effective. Beginning in the 18th century, England dominated scientific research by adopting a mission model with minimal government involvement, except in national defense. In the late 19th century, England’s leadership gave way to the United States, which pursued the mission model aggressively with minimal government activity as well. Government funding of science rose only during World War II with defense initiatives such as the Manhattan Project. After the war, there was an effort to continue and expand government funding of research. But President Truman resisted, and government spending on research returned to its limited mission-focused scope.
Sputnik inspired an explosion in government research spending that included acceleration of NIH spending by a factor of five. The NIH model for research was transformed from mission-directed to the pipeline model, in which government funding supported whatever research appealed to academic scientists, rather than research directly focused on those elements of improved health that could only be done by the government.
NIH now funds more than half of biomedical discovery research in the United States. NIH, the National Science Foundation, and other government agencies combined account for three-quarters of the total. This compares with government spending of less than 5 percent of the total before Sputnik. This government domination has reduced the effectiveness of biomedical research by crowding out new and innovative research with orthodoxy preferred by the presiding NIH and academic overseers.
This is not just theory. The adverse consequences have been real. While NIH spending grew five times faster post-Sputnik, the rate of improvement in longevity fell by more than half. (See Figure 1.) The current leaders cannot be responsible for that disaster, but what are they doing to reverse it?
Figure 1: Trends in funding for National Institutes of Health and life expectancy, 1900–2024
Strategy
Unlike the unfocused chatter of its predecessor, the FY2026 budget lays out five goals that are at least a start toward strategic thinking:
Focus on Improving Population Health
Reproducibility and Rigor
Innovation and Collaboration
Research Safety and Transparency
Academic Freedom
At the roundtable, Dr. Bhattacharya offered three goals:
Make America Healthy
Deliver the second scientific revolution – reproducibility
Encourage scientists to take big intellectual risks
While one might prefer a more precise concordance between the two sets of goals, the first two track well with the budget goals, and the third is at least in the spirit of budget goals 3 and 5. The fourth budget goal is not really a strategic outcome and is best left off the list. These nascent goals must be developed into proper strategic goals that justify the spending and drive the results.
Within the 2026 budget, justification is the start of a proper strategic goal: “reducing cancer deaths by half in the next 25 years.” There are a number of ways one might measure that, but none are specified. Nor is it clarified that this goal was actually set in 2022, so 2026 would already be 4 years into the effort. The strategy and budget offer no evidence of the progress made. Clarity about timing and progress is critical because the original goal required improvement at twice the rate of the previous 31 years, and we now have only 21 years left to make twice as much progress.
So, what will NIH do differently from the immediate past to double performance? The budget justification lists only: [1]
Substantially increasing the number of people who participate in clinical trials
Improving access to current and new standards of cancer care
Enhancing the cancer research workforce
Increasing the pipeline of new cancer drugs
The first item may be important, but it is only supportive of some other initiatives that require clinical trials. What new clinical trials are proposed, and how will NIH complete the needed research to justify more clinical trials that will then require the expansion of participants?
The second item is totally wasteful. This is not NIH’s responsibility. Access to care is purchased in the marketplace from insurers and caregivers; it is not a research activity.
The third item may be necessary, but what is missing from the research workforce? No need has been shown. First, show the work that needs to be done by NIH (and only by NIH), then, as a derivative of that, show the need for enhancing the workforce.
Finally, the fourth item is promising, but it needs specific treatment classes and timelines. It also needs to be tied explicitly to treatment outcomes.
But as limited as the top-side line is, it is better than the banal list from the National Cancer Institute within NIH, which is nothing but a generic description that could be applied to any disease at any time:[2]
Understanding How Cancer Develops
Understanding the Causes of Cancer
Detecting and Diagnosing Cancer
Treating Cancer and Improving Survivorship
Improving Cancer Prevention and Control
Budget
NIH has a lot of work to do, identifying and targeting the health improvements it will make, while showing that government, and only government, is the proper place to do the work. Before Sputnik, 95 percent of medical research was in the private sector, and it was twice as effective.
One of the institutional barriers to progress is the Research, Condition, and Disease Categorization (RCDC) reporting that NIH uses to show how its money is spent on research. It consists of 315 categories, but the categories are not mutually exclusive, with some spending counted twice, thrice, some ten times, and some not at all. There is no hierarchical structure that shows how the categories relate to each other and to the whole research enterprise.
The RCDC structure was developed to meet a Congressional request for what diseases were being researched and how much was being spent on each. NIH emphasizes that RCDC reports are created by a computer text-processing algorithm that scans the project definitions and budgets after the grants have been made and cannot be used for budgeting. Congress has accepted this lame excuse. The new leadership has an opportunity to fix it.
Of the 315 categories of spending that NIH reports, our working paper identified 28 that should be eliminated, or sharply curtailed. The funded projects in these categories are harmful or wasteful in one or more of the following dimensions:
Projects that reject the scientific method and make claims that their own data show are false. These projects result in the promotion of medical care that is either ineffective or harmful. One example is the recommendation to stop hormone replacement therapy because the NIH leadership said it increased the risk of breast cancer, despite the statistical tests that explicitly showed that was not true.
Projects that endanger liberty by seeking to prescribe government compulsion of behavior. These include “shaken baby syndrome” projects that falsely promote the theory that only abuse of a child can cause a particular constellation of symptoms, when research shows that other causes are possible, resulting in parents losing custody and, in one case, being convicted of a capital crime.
Projects that are irrelevant to health. For example, a $2 million project claimed to study the effects on 450 minority elders from singing in a community choir, with only one published paper that discussed the effects of a community choir in Finland. Another looked for a relationship between mortgage foreclosures and visits to the emergency room. This project failed on multiple grounds. It began with assumptions about the economics of mortgage foreclosures that were simply false. And it only compared the number of foreclosures and the number of emergency room visits at the community level, not whether the individuals undergoing foreclosure were the ones going to the emergency room.
Projects that are pure and simple waste. There has been no case of smallpox on the entire planet in the last 48 years. What is the research need? CDC and the Department of Defense have programs related to biological warfare, but this is not a current threat to the health of the population
These 28 categories account for 43% NIH spending. But they include only 3.9% of mortality and 18.8% of disease incidence. The president’s budget for 2026 proposed a 38% reduction for NIH, which was consistent with our findings. However, Congress and the president finally approved a 9% increase in the NIH budget, losing an opportunity to begin rationalizing health research by opening more opportunities for private initiatives for better health.
The Really Bad News
Missing an opportunity to moderate spending and increase market-driven research is not good news, but the really bad news is that NIH wants to “spread the wealth to more universities,” with a vague hope for diversification of inquiries.
The justification is that research grants tend to be concentrated in a few universities because they have better facilities that attract better faculty, who get more grants. NIH is proposing to give grants to some universities to build better facilities so they can attract better researchers, and thus more research grants. Somehow, NIH characterizes this as “letting the market decide.” Just how government grants to build facilities are letting the market decide completely eludes me.
Available data show that research in the private sector already uses more diversified sources than the government. For all contracted scientific research, the government gives 80% to the top 200 entities. In the private sector, only 33% goes to the top 200. That is the market. The proposed facility grants will increase the government’s control of the whole enterprise and reduce its effectiveness.
New leadership at NIH offers hope for progress. Unfortunately, the habitual behavior of government, the associated entrenched interests, and the implicit belief system that promotes government doing something new rather than stopping harm will make it difficult. But we must keep trying.
[1] Congressional Justification for the fiscal year 2026 budget, Director’s Letter, p. 27
[2] Congressional Justification for the fiscal year 2026 budget, National Cancer Institute, p. NCI‑9.
