Is There A Better Way To Secure Stable Funding For Medical Research?

For Medical Research? The 5.7 percent increase in the National Institutes of Health's appropriation for fiscal 1996 represents startling bipartisan support by the House, the Senate, and President Clinton. The $11.94 billion total appropriation, greater than the president's original request, is $640 million over the 1995 funding level. The increase was made possible largely by a Republican Congress otherwise zealous about controlling the debt and the deficit. But let's look this gift horse in the mouth. The NIH budget success is not without ambiguity, irony, and uncertainty. Is there a better way to secure funding? Adequate funding for investigator-initiated proposals judged "outstanding" and "excellent" by scientific peers requires a stable, vigorous research enterprise, which cannot thrive with an uncertain, annual appropriation. The ideal, however, may be realizable-sans new taxes-through voluntary contribution. The Internal Revenue Service code could cast the net to secure the catch. The FY 1996 NIH appropriation was hard to believe. After planning sharp cuts to the NIH budget, Congress increased it instead. Two influential Republicans, Sen. Mark O. Hatfield of Oregon and Rep. John E. Porter of Illinois-who, respectively, head the Senate and House subcommittees of the appropriations committees responsible for NIH-miraculously reshuffled monies. In recognition of their leadership and advocacy in Congress for biomedical research, the Federation of American Societies for Experimental Biology (FASEB) honored the pair with its 1996 Public Service Award. Others in the Congress need to be aware that the American public cares about medical research. People are astonished to learn that of public and private expenditures for health, only three cents of each dollar is spent on research. According to focus groups and a June 1995 national public-opinion poll by Louis Harris and Associates of New York, commissioned by Alexandria, Va.-based Research!America, the public opposes cuts in medical research dollars. Moreover, 73 percent of those surveyed would pay higher taxes to support more medical research-unchanged from 1993. These results were not biased by age: The younger those surveyed, the stronger the support. For medical research, 85 percent of the 18- to 24-year-olds surveyed are willing to be taxed a dollar per week more. Elected leaders, however, appear unaware of this public support. The same Americans who support biomedical research do not associate that research with NIH. Perhaps this is because reporting in the popular news media ignores funding sources, thus contributing to a lack of awareness. For example, the New York Times Tuesday "Science Times" section, which contains more than a half-dozen articles on research advances, does not mention a single research sponsor, although the articles do cite institutions, investigators, and journals. In a Research!America-commissioned poll of metropolitan New Yorkers conducted by the Greenwich, Conn.-based Taylor Research Group in October 1993, only 7 percent of those surveyed could name NIH as the government agency that funds most of the medical research in the United States. Another 16 percent named other agencies, and 77 percent didn't have a clue. Polls commissioned by Research!America and conducted in different states indicate that as few as 1 percent of those surveyed can identify NIH. Did this contribute to the inclusion of NIH in the initial budget-cutting frenzy? Lack of NIH recognition must not be equated with lack of support for federal medical research funding. The public mandate is for more medical research and for more stable funding. Apart from the health mandate, the perception that biomedical research is an "engine of economic growth" may have saved the day. House Speaker Newt Gingrich supports the NIH increase, as he has mentioned in recent television interviews. The impetus comes primarily from contemporary Republican values: Support for biomedical research is fiscally responsible. Basic biomedical research results not only in better health, but also in increased agricultural productivity. Probably half the biotech industry products being developed spring from governmental funding of university laboratories, according to a New York Times article (R. Pear, Jan. 16, 1996, page A13), and industry is not about to replace government basic research spending. Executives from small biotechnology firms, such as Biogen Inc. of Cambridge, Mass., and large pharmaceutical firms, such as New York-based Bristol-Myers Squibb Co., helped garner the speaker's support in a personal meeting. FASEB's scientists echoed the fiscal responsibility drum beat: Cure disease and save money. On Capitol Hill, miracles are man-made. The NIH targeted appropriation needed to be attached to a bill scheduled for a floor vote. The appropriation was attached to the Marine Fisheries Service Rule-a totally unrelated bill-and sailed through, 344-24. William Safire, in a New York Times op-ed (Jan. 29, 1996, page A17), intoned respect for Porter's biomedical R&D mobilization, saying that the appropriation is "spending to save lives as well as money." Despite his background as the former speech writer for Richard Nixon, the president who attempted the largest NIH rescission, Safire labeled the inclusion of NIH in federal spending cuts as "pound-foolish." He wrote, "If Medicare growth is to be curtailed, oldsters ought to be given real hope for scientific breakthroughs." Real advocacy was inspired, and came from many sources. FASEB recommended a 10 percent funding increase and deplored a 15 percent success rate for investigator-initiated research proposals, urging that opportunities be seized in neuroscience as well as cardiovascular, cancer, and molecular genetics research. The Association of American Medical Colleges (AAMC) endorsed the recommendation of its Ad Hoc Group, which, in turn, endorsed the level proposed in NIH Director Harold Varmus's professional judgment budget, an estimate of the minimum funding needed to carry out the agency's goals of the coming fiscal year. Varmus concluded that NIH needed a 15 percent increase for FY '96. Meanwhile, "slash and freeze" prevailed: The House voted a 5 percent cut and a six-year freeze; the Senate Budget Committee cut 10 percent; and the conference agreement cut 1 percent in 1996, 3 percent from the 1995 level after that. As events intensified in late spring, Varmus noted that no real increase could be expected before the end of this century; federal employees, even Nobel laureates, are constrained. Even professional scientific organizations took faint-hearted positions; too passionate a stance might backfire in these strange times. They recommended extending the 1995 funding level, without mentioning biomedical inflation. What energized the turnaround? In Congress, several heroes emerged to champion the cause. Rep. Constance Morella (R-Md.) was persuasive with Republican colleagues. She represents the Mary- land district that includes NIH and its 16,000 employees. Remember Tip O'Neill's observation that all politics are local! Nineteen House members sent a letter to Porter, organized by Joseph P. Kennedy II (D-Mass.), Carolyn Maloney (R-N.Y.), and Morella. Calling NIH one of the great federal success stories, they held firm that "at the very minimum . . . NIH funding should be maintained to keep pace with inflation." Given the "Contract With America's" mid-March 1995 tax cut plan, the NIH increase voted, however merited, takes on the luster of a gift. Herein lies the rub: Can we count on future gifts, and hope each year for future heroes, risking again and again sacrifice of biomedical research advances on the balanced-budget altar? Advances are important and ongoing. For 1994, AAMC's Ad Hoc Group cites several NIH achievements. These include a reduction of the HIV transmission rate from mother to infant by two-thirds; 95 percent effectiveness of laser treatment in preventing diabetic retinopathy blindness; development of revolutionary new treatment for peptic ulcers caused by bacteria; and improved effectiveness of bone-marrow transplantation in breast cancer. The Harvard Health Letter (21[5]:1, March 1996) annually ranks the top 10 new discoveries that Harvard faculty advisers predict will have far-reaching impact on human health. In 1995, those breakthroughs included results of long-term cholesterol-lowering simvastatin treatment, which offered the first convincing evidence for life extension; determination of the risk of short-acting calcium channel blockers, which are used by 2 million people; and the development of influenza vaccines offering multiyear protection. Today's research holds many promises for the future. For example, molecular genetics will allow the development of gene therapy. New stroke preventative approaches will come from epidemiology. Health services research will result in reduction of low-birth-weight deliveries through low-cost, community-based nursing, and behavioral research will help stop tobacco and alcohol abuse and promote healthy diets. Will we bemoan but tolerate delays and funding gaps? Or can we find a better way to stabilize and to increase funding to match opportunities for advances in scientific knowledge? We need to create an instrument to capture our best intentions. A fund for medical research that will provide significant increases is overdue. A national fund for health research, S. 1251-sponsored by Sens. Hatfield, Tom Harkin (D-Iowa), and Barbara Boxer (D-Calif.)-languishes in the Senate Finance Committee. The thrust of the bill's best section amends the IRS code to allow individuals to designate a portion of any tax refund to be paid over to the fund. Four additional Democrats have signed on, but no other Republicans. As yet, there is no House version. The sections of the bill imposing expanded tobacco product taxes likely are problematic. Next year's budget is in the making, and President Clinton is calling for increased NIH funding in 1997. The budget hearings have begun. With the administration prodded toward a seven-year balanced budget, the cycle recurs. Do we chant for another annual medical miracle, or do we focus resolutely on a secured and enduring national fund for health research? Voluntary rebate of a tax refund portion through a simple checkoff would avoid the "no new taxes" shibboleth, and trigger automatic collection. (Donations, gifts, and grants would be additional.) Fund assets would expand and not replace ordinary NIH appropriations. The fund would support the mission of the NIH extramural program. It would be established as a nonprofit corporation, not a government agency, with the ability to invest reserves. The mechanics to secure biomedical research's future through a fund that provides significant enhanced funding would require expert crafting. Considerations include: widely acceptable revenue mechanisms to encourage bipartisan support; a mechanism to secure reserved funds so that they cannot be tapped for other purposes; a check valve so that trust fund monies are not activated until regular NIH funding is appropriated, a level that would be determined, for example, by indexing to an independent economic measure; and a system for allocating released trust dollars to ensure that the majority of monies are applied to investigator-initiated research in areas of significant scientific opportunity. A working panel could develop a manifesto for this legislation. The panel would be composed of representatives from the executive branch of government (such as the Office of Management and Budget and NIH), the legislative branch, professional and scientific societies, as well as scientists and research administrators and the public. Let's catch our breath, but not hold it. It's time to speak out again, not to rest on one success, but to be buoyed by it, to rise up together to create a healthier future for all America's people. What a glorious cause, by the people, for the people. In John Porter's words, "There is no more vital endeavor." Lorraine Lasker is associate dean and director of the Office of Research Administration at New York Medical College and past president of the Society of Research Administrators. She serves on the board of directors of Research!America, an Alexandria, Va.-based national advocacy alliance to increase public awareness about medical research.

Is There A Better Way To Secure Stable Funding For Medical Research?

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