Federal Funding of Rehabilitation Research: Delayed and Disrupted

Science does not occur in a vacuum. Historically, scientific processes and the subsequent results have been (and, I believe, will continue to be) influenced by social, cultural, political, and ideological factors. Interestingly and somewhat contrary to the previous sentence, scientists have been encouraged to “stay in their lane” when discussing those outside influences. Sometimes, however, there is a good reason for scientists to contribute their knowledge and experience to ensure that decisions are made with a full understanding of their potential implications. As Editors of Physical Therapy & Rehabilitation Journal (PTJ), we outline below the impact that recent policy changes may have on the United States (US) scientific landscape, with an emphasis on professional communities served by PTJ.

The US government has long supported research through various venues like the National Institutes of Health, National Science Foundation, Department of Defense, and Centers for Disease Control and Prevention (to name a few). The US Congress supports these agencies with a budget and provides directives for scope and mission. Scientific review and funding decisions are made at the individual agency level with awards going to institutions to support the research teams that developed and submitted the proposal. Historically, after the budget and directives were set by Congress, there was very little governmental interference after a proposal was funded.

While not perfect, this investment at the federal level helped the US become a global leader in biomedical research while providing economic benefit to our country.¹ Despite this track record of leadership, recent activity by the new administration has drastically altered the federal government’s position on funding research. In the US there has always been political influence on the scientific process, but it did not have the destructive nature reflected in the initiatives currently being put in place.

EXACTLY WHAT IS BEING DELAYED AND DISRUPTED?

Global Positioning of the United States in Biomedical Research

Overall, the recent NIH directive² to reduce indirect costs to 15% will make it extremely challenging for the US to maintain its position as a global leader in biomedical research. Federal funding has always consisted of direct and indirect costs, both supporting research in different ways. Direct costs are related to the project itself, while indirect costs are negotiated with the US government and are related to the institution’s infrastructure to support a scientific enterprise. Judging by the surge of interest in this topic, there is confusion around these terms and how they are used to support research. One editorial referred to indirect costs as a “misnomer,”³ so we offer the highway system as an analogy in our attempt to provide some clarity on this model for funding research. In this scenario, direct costs are the costs borne by drivers (eg, a car, its fuel, and/or tolls), whereas indirect costs are borne by state and federal government (eg, signage, road and bridge upkeep, and/or creating new routes). The NIH’s decision to reduce indirect costs to 15% is not correcting “a rip off” scheme led by academic institutions (as per 1 notable claim⁴). Rather, this directive will limit the infrastructure that these institutions can make available to its researchers. In the US we already know what happens when transportation infrastructure is neglected over a long period of time—poorly maintained roads and bridges that do not help the driver. Implementation of this NIH directive, which is being challenged on legal grounds, will result in a steady decline in the world-class research infrastructure developed at US universities and organizations. This will be a detriment to all those that would want to use these roads for future discoveries and advances in physical therapy and rehabilitation science.

Positioning of Physical Therapy and Rehabilitation in the Scientific Community

Physical therapy and rehabilitation scientists have worked hard over the past 20 to 30 years to establish a presence in the broader scientific community. Indeed, when our researchers made it to “the big leagues” by successfully competing for federal funding, this was seen as important indicator of progress. The indirect cost reduction will impact the ongoing work of these researchers, who will have to stop enrollment of an ongoing clinical trial, limit purchase of equipment and supplies vital to the current work as well as the “next experiment,” and put off hiring personnel to move a project forward. The long-term impact is predictable and includes lost opportunities for new discoveries and new therapies and a weakening of the evidentiary base of physical therapy and rehabilitation science. These losses will have real impacts on the lives of individuals who need rehabilitation due to trauma, disease, and impairment.

Advancement of Population Health

Good science is generalizable to the “real world.” This is a key issue for biomedical research as its aim is to improve population health broadly, not just in select groups. This is 1 area where the US has performed poorly, with many studies under-enrolling individuals who are representative of the overall population. This tendency is well documented in randomized clinical trials, an important trial design that is the preferred form of evidence to inform clinical practice guidelines. The literature is quite clear on this topic with women, historically underrepresented minority groups, and older adults all enrolled in clinical trials at lower rates (and in some instances much lower) than population rates.^5,6 This lack of representation in clinical trials limits our ability to generate high-quality evidence on how best to treat these same groups. Accordingly, many existing practice guidelines have very low relevance for these groups. Limiting the study of the motivations of underrepresented populations in pursuing research careers or in enrolling in clinical studies⁷ is a surefire way to ensure that biomedical research will continue to fail to broadly improve population health.

Creation of High-Quality Scientists

Physical therapy and rehabilitation scientists have struggled to attract new potential researchers into the field. The need for additional training, continued economic sacrifice, and high competition for federal funding are all notable reasons for this struggle. These new governmental policy changes introduce a notable and unneeded barrier to a career in research, adding a disincentive that could be particularly devastating to our community for 3 primary reasons:

• First, we have had success in federal funding but, due to the relatively small percentage of those active in this area, we are extremely vulnerable to attrition. Loss of established research programs for even a few of our rehabilitation science investigators could have long-standing ramifications and erase the progress made in competing for federal funds.

• Second, these changes will disproportionately affect early career researchers as they may not have accumulated the resources necessary to weather this storm. Furthermore, the additional barriers in place may prevent people from taking that first step to explore research as a career or complete training experiences already started. These are not speculative examples; we have heard these concerns expressed by trainees and junior faculty we mentor when discussing future career options.

• Third, the inability to use federal funding to support training of underrepresented groups will limit our ability to create trainees who will build upon the range of experiences and perspectives of current physical therapy and rehabilitation researchers. There is already 1 training program specific to rehabilitation science with this goal that has been disrupted and is expected to receive no additional federal funding. As already mentioned, the implication of this policy change will be a continued struggle to ensure our evidence base represents broader swaths of the population.

DAMAGE TO THE HEALTH OF SOCIETY

The administration’s proposed slash and burn approach to manage federal funding threatens ongoing and future biomedical and rehabilitation research that will result in untold damage to the health of our population and the US economy.¹ This executive directive is being challenged on legal grounds. As this editorial was being finalized, a federal judge extended a temporary restraining order to block the reduction in NIH’s indirect cost rate.⁸ The lawsuit in question, which was filed in Massachusetts on behalf of 22 different states, argued that the change in NIH indirect cost rate alone would “mean the abrupt loss of hundreds of millions of dollars that are already committed to employing tens of thousands of researchers and other workers, putting a halt to countless life-saving health research and cutting-edge technology initiatives.”⁹ Furthermore, as the lawsuit indicated, the perception that this is an isolated attack on academia is faulty: “the sudden cut of funding will have ripple effects into the private sector as it disrupts numerous partnerships with private institutions.”⁹ The temporary restraining order decision offers a “short reprieve” but does not remove the uncertainty surrounding how the US federal government will support its biomedical research enterprise moving forward.¹⁰ There are additional legal challenges and decisions forthcoming on the indirect cost rate issue. While these challenges play out in the courts, the administration has already moved to reduce the NIH workforce and block processes that allow for grant review meetings to occur.¹⁰

There is certainly room to discuss whether the amounts that NIH pays to research institutions is warranted, but that evaluation should be done through a thought-out process that gives institutions and researchers time to plan and avoid unnecessary delay and disruption to the advancement of physical therapy and rehabilitation science. This seems especially true considering the potential damage caused by these changes would be far-reaching and long-lasting. Indeed, what is being proposed so far seems more like a last-minute going-out-of-business sale than a calculated move towards establishing efficiency in research funding.

ACKNOWLEDGMENTS

Dr George thanks Jan Reynolds and Steven Glaros for their review and suggestions to improve this editorial. Dr George is currently receiving NIH funding to his institution that supports ongoing clinical research and Dr Jette has been awarded NIH funding to his institution in the past. The views expressed in this Editorial are those of Drs George and Jette.