Kei Koizumi

1. Historical Trends in Health-Related Research
2. Federal Support for Research in the Life Sciences
3. Life Sciences Research within the Federal Research Portfolio
4. Outlook

All Figures are in PDF format.

Medical and other health-related research has long been a priority for the federal government, but in recent years the level of federal support for medical research has expanded dramatically to become the largest part of the federal civilian research and development (R&D) portfolio. This paper examines historical trends in federal support of medical research and places the federal investment in a variety of contexts, including the relationship of medical research to research in other fields and the overall budgetary context of federal R&D.

Historical Trends in Health-Related Research
In the post-World War II era, the U.S. government has supported a diverse and growing U.S. science and technology enterprise through a decentralized, mission-oriented system that stands in sharp contrast to the more centralized R&D allocation systems of most other industrial countries. Almost two dozen cabinet departments and agencies support R&D, and except for the National Science Foundation (NSF) no agency supports R&D solely to advance science, in contrast to the more centralized R&D allocation systems of most other industrial nations. Rather, agencies support R&D to advance their missions as part of a diverse portfolio of programs, and ideally each agency's R&D should be tightly coupled to its mission and other ways of achieving the mission.

As a result, the primary supporter of health-related R&D in the United States is the Department of Health and Human Services (HHS), which funds Medicare, Medicaid, disease control activities, health training, as well as research to advance its mission of improving Americans' health. R&D accounts for only 5 percent of the department's total budget. Budget decisions for health-related R&D are made in the context of all HHS programs, and seldom systematically in the context of other federal sponsors of R&D.

In such a decentralized system, combined with a decentralized congressional budget process in which R&D budget decisions are made by 9 different appropriations subcommittees acting nearly independently, it may appear impossible to set priorities or to allocate resources among different R&D interests. Yet the beauty of the U.S. system is that despite its decentralization, priorities do get set, and in the post-World War II era one priority that has grown in importance is health-related R&D.

Figure 1 shows federal support of nondefense R&D over the past four decades by mission. The importance of various national missions has changed over time, and these changes can be seen clearly in the ups and downs of R&D funding. In the 60s, for example, funding for space R&D increased dramatically because of the high priority assigned to landing on the moon before the Soviet Union. Energy R&D has closely tracked the nation's concern over dependence on imported oil, with increased funding in the mid-70s and the early 80s and a decline in recent years.

Federal support for health-related R&D, however, has grown consistently over the past four decades. Although it was a relatively small part of the R&D portfolio in late '50s and early '60s, federal support has grown steadily since then and now accounts for the largest part of the nondefense R&D portfolio. Even in the decentralized, loosely coordinated U.S. system in which appropriations decisions are made annually, health R&D has shown steady growth, reflecting the increasing concern among the American people and their elected representatives for finding new ways to prevent and cure disease.

The primary supporter of health-related R&D within HHS is the National Institutes of Health (NIH). Nearly 95 percent of HHS R&D is funded by NIH.(1) The steady growth in health-related research over the past decades has been fueled by an aggressive expansion in the size of the NIH budget.

NIH has enjoyed consistent popular, congressional, and presidential support during the post-World War II era. Figure 2 shows that over the past fifteen years the NIH budget has doubled in inflation-adjusted terms, with real increases nearly every year.

NIH has especially benefited from strong congressional support. Figure 2 also shows that nearly every year, Congress has added to the amount NIH asked for in the budget request. The FY 1999 budget of $15.6 billion for NIH (including non-R&D programs), for example, is nearly $2 billion or 15 percent more than the FY 1998 budget, and $815 million more than the agency's FY 1999 budget proposal. For the last few years, the pattern has been the same: because of the support of Republican champions of medical research as key appropriators, each year NIH has won larger increases than most other R&D funding agencies, and has won larger increases than the agency itself requested. Despite the relatively tight budgets of recent years, congressional support for NIH has if anything become stronger, and last year several influential lawmakers publicly called for doubling the NIH budget in five years, with the FY 1999 increase as the first installment. So it is likely that the just-announced FY 2000 request for NIH of $15.9 billion (an increase of 2 percent) will be a starting point for congressional appropriators, and the final FY 2000 NIH budget will likely be higher than that, perhaps as high as another 15 percent increase, which would bring the NIH budget near $18 billion.

Federal Support for Research in the Life Sciences
The steady growth in the NIH budget has had a dramatic effect on federal support for medical research. Although figures for medical research per se are not well defined, the closest approximation is the category of 'life sciences research' in R&D funding statistics compiled by the National Science Foundation.(2) Figure 3 shows that in FY 1998, federal support for life sciences research totaled $13.0 billion, of which the overwhelming majority of support came from NIH, even though a dozen other agencies provide support for life sciences research as part of their missions. (DOE, for example, funds nearly a third of the Human Genome Project; NASA funds life sciences in microgravity environments; DOD funds cancer research). Many of these efforts have potential impacts on human health. Apart from NIH, no other agency accounts for even a tenth of the total life sciences portfolio.

In addition to the above research in the life sciences (which, as the chart notes, excludes development and R&D facilities), federal support of R&D funds development and R&D facilities in health-related areas. NIH, for example, funds development work on vaccines and medical technology devices and also maintains state-of-the-art in-house laboratory facilities. NSF provides some R&D facilities support to universities and colleges to build life sciences laboratories.

Not surprisingly, trends in life sciences research mirror trends in the NIH budget. Figure 4 shows that support for the life sciences has more than doubled over the past three decades.

Life Sciences Research within the Federal Research Portfolio
The trend in life sciences research is remarkable when contrasted with how other disciplines have fared during this time period. Federal support for engineering research, which was greater than life sciences support in FY 1970, has stagnated for three decades. Support for the physical sciences (physics, chemistry, astronomy, etc.) showed slow but steady increases until the early 1990s, but has declined steeply since then as a result of post Cold War restructuring in the Departments of Defense and Energy. Among other disciplines, only computer sciences and environmental sciences have shown any growth in the 90s, although these increases come from far smaller bases than in the case of the life sciences.

As a result, the federal research portfolio is dramatically different in FY 1999 than it was in FY 1970. Of the total federal research portfolio of $33.0 billion in FY 1999, $14.4 billion (or nearly 44 percent) goes to life sciences research, compared with less than 30 percent in FY 1970. This dramatic growth for the life sciences combined with flat funding or even cuts in the other sciences has resulted in increasing concern within the scientific community that the federal portfolio may be becoming unbalanced, with consequences even for the advancement of human health. Harold Varmus(3) , director of NIH, has warned:

Most of the revolutionary changes that have occurred in biology and medicine are rooted in new methods. Those, in turn, are usually rooted in fundamental discoveries in many different fields. Some of these are so obvious that we lose sight of them-like the role of nuclear physics in producing the radioisotopes essential for most of modern medical science. Physics also supplied the ingredients fundamental to many common clinical practices-X rays, CAT scans, fiber optic viewing, laser surgery, ECHO cardiography and fetal sonograms. Materials science is helping with new joints, heart valves, and other tissue mimetics. Likewise, an understanding of nuclear magnetic resonance and positron emissions was required for the imaging experiments that allow us to follow the location and timing of brain activities that accompany thought, motion, sensation, speech, or drug use. Similarly, X-ray crystallography, chemistry, and computer modeling are now being used to improve the design of drugs, based on three-dimensional protein structures. . . These are but few of many examples of the dependence of biomedical sciences on a wide range of disciplines-physics, chemistry, engineering and many allied fields.

The growing disparity between the life sciences and other sciences is even more apparent in the nation's colleges and universities, which perform nearly half of the total federal research portfolio, and a majority of the basic research within that portfolio. Table A shows that of the $24.3 billion in R&D performed by the nation's colleges and universities in FY 1997, $13.6 billion or nearly 56 percent was research in the life sciences. The federal government funds more than half (57.9 percent) of the life sciences research in universities, with the remainder coming from a mixture of institutional funds, industry, nonprofits and foundations, and state and local governments. Burgeoning federal support for life sciences research has resulted in the dramatic expansion of medical research in academia and the growth of large research complexes centered around universities' medical schools.

In the past few years, there have been more and more statements on the need to achieve a more balanced federal research portfolio. The President's FY 2000 budget proposal, as an example, calls for a modest increase to NIH and larger increases to R&D programs in agencies such as NSF and DOE, whose support is key to most non-life sciences fields. The text of the proposal states, "This budget reflects an effort to establish an optimum balance between health care research and other scientific disciplines - a concern voiced in recent years throughout the scientific community."

Even in the medical research community, there have been recent statements on the need to broaden federal funding beyond NIH and life sciences research. The Federation of American Societies for Experimental Biology (FASEB), a key lobbying group for medical research, recently called for another 15 percent increase in the NIH budget for FY 2000, but also advocated a 15 percent increase in the NSF budget and large increases for key DOE programs.(4) Other organizations, such as the Association of American Universities(5), have also increasingly articulated the theme that medical research depends on advances in many disciplines, supported by agencies other than NIH.

It is unclear what, if any, effect these calls for balance will have on future federal support for research. Because of the fragmented nature of the federal budget process, it is difficult to make tradeoffs in funding between NIH and other federal research agencies, so a zero-sum game of cutting NIH to move funds to other R&D programs is unlikely. The calls for balance mainly imply giving other agencies the same or greater increases as NIH. This implied scenario pictures robust federal support of life sciences research fed by an increasing stream of enabling breakthroughs from other disciplines as a result of increased research funding from non-NIH agencies.

Outlook
Past trends are of course not predictors of future trends, even considering the smooth, uninterrupted trend lines for medical research in the past. Although NIH enjoyed the largest budget increase in history in the final FY 1999 budget, there is no guarantee that such success will be repeated in FY 2000 and future years.

First, all federal R&D is funded out of the discretionary third of the federal budget, which is subject to tight caps by the Balanced Budget Act of 1997 until FY 2002. The cap for FY 2000 is well below actual FY 1999 discretionary spending, partially because the Congress and the President circumvented the tight FY 1999 cap through a variety of accounting maneuvers. One reason the NIH budget request for FY 2000 calls for a relatively small increase compared to recent years is that the overall FY 2000 budget has to give at least the appearance of complying with the FY 2000 cap. Although Congress may seek to give a larger increase to NIH, lawmakers will have to fit any increases within a constrained total discretionary budget or find, as in FY 1999, mechanisms for circumventing or repealing the discretionary cap.

Although the federal unified budget surplus is projected to grow substantially over the next several years, including a projected $117 billion surplus in FY 2000, neither the President nor Congress appears inclined at the moment to use the surplus to finance additional discretionary spending. Instead, the President and Congress favor using the bulk of the projected surpluses to extend the solvency of the Social Security and Medicare trust funds, while congressional Republicans would also like to use them to finance tax cuts.

Second, as noted earlier, there is no consensus on how to address the question of a balanced portfolio for federal R&D. While the Clinton Administration has made its statement on the subject with the release of the FY 2000 budget, it is unknown yet whether there will be public and congressional support for boosting other agencies' R&D programs and slowing down the growth rate in the NIH budget in the interest of achieving a multidisciplinary R&D portfolio that may ultimately have a greater positive impact on human health.

Whatever the outcome of the FY 2000 budget, historical trends and current indications of public and congressional support suggest that health-related research will continue to have the strong support of government policymakers. The big problems in the next few years, however, will be translating popular support into dollars in a time of tightly constrained discretionary spending, and figuring out what mix of R&D programs and research areas will best advance the cause of improving public health.

(1) The remaining 5 percent comes from the Centers for Disease Control (CDC), Health Resources and Services Administration (HRSA), Health Care Financing Administration (HCFA), the Food and Drug Administration, and others.

(2)Life sciences research (excludes development and R&D facilities support) includes research in biological sciences, environmental biology, agricultural sciences, medical sciences, and other life sciences. For more complete definitions, please see the publication Federal Funds for Research and Development: Fiscal Years 1996, 1997, and 1998 (National Science Foundation, Dvision of Science Resources Studies, NSF 98-332, 1998). See http://www.nsf.gov/sbe/srs.stats.htm.

(3) Varmus, H. "New Directions in Biology and Medicine," AAAS plenary lecture, Philadelphia, February 13, 1998.

(4) Federal Funding for Biomedical and Related Life Sciences Research: FY 2000 Recommendations, Federation of American Societies for Experimental Biology, January 1999. See http://www.faseb.org.

(5) "Biomedical Research Depends on Advances in Many Disciplines," Association of American Universities, January 1999.

© 1999 American Association for the Advancement of Science