President Joe Biden’s nominee to lead the National Institutes of Health faced detailed policy questions about drug costs and biomedical research but few political fireworks during her Wednesday appearance in front of the Senate Health, Education, Labor and Pensions Committee.

The relatively bipartisan nature of nominee Monica Bertagnolli’s confirmation hearing came as somewhat of a surprise, considering the tumult that preceded her Senate appearance and how politicized the agency became during the COVID-19 pandemic.

Democrats on the committee quizzed the nominee on what she would do to lower drug costs, while Republicans focused on restoring public trust in the agency.

The committee plans to vote Oct. 25 on whether to send her nomination to the Senate floor.

Ranking member Bill Cassidy, R-La., told Bertagnolli, who currently heads the National Cancer Institute, that, if confirmed, much of her tenure would involve rebuilding the agency’s trust with the American public. 

“There are no questions regarding your scientific qualifications. But there are questions about your ability to lead NIH through this next phase,” he said, noting the many lightning rods surrounding the NIH, including gain-of-function research and care for transgender youth.

But the concerns didn’t seem to be that deep. Republican Sen. John Barrasso, a Wyoming Republican, introduced Bertagnolli in the hearing. Bertagnolli is also from Wyoming. 

“I do have serious concerns about the way the administration has handled the pandemic,” Barrasso said. “I think it’s important that the position be filled with someone with a critical and open mind ready to tackle the challenges ahead and for these reasons, Chairman, I am supporting her nomination to serve as the director of the National Institutes of Health.”

Bertagnolli, a longtime cancer surgeon, rose to the top ranks of the National Cancer Institute just last fall. She was diagnosed with breast cancer in December 2022.

The top job at the NIH has been vacant since December 2021, when long-time director Francis Collins retired. Biden announced plans to nominate Bertagnolli in May, but HELP Committee Chairman Bernie Sanders delayed a hearing because of concerns that the Biden administration was not doing enough to lower the cost of prescription drugs.

Sanders, I-Vt., reiterated those concerns during the hearing, noting the high cost of drugs in the U.S. compared to other western nations. Over the past 20 years, the average cost of new treatments co-developed by NIH scientists was $111,000, Sanders said, pointing to a committee report released in June. “We pay for the research, drug companies develop the drug, and they make millions,” Sanders said. “It doesn’t make sense to me.”

Bertagnolli told Sanders that she had sat in the clinic next to patients of her own who could not afford their cancer treatments, and told him she would work to lower drug costs.

But Sanders went further, asking her if she would commit to reinstating and expanding the reasonable pricing clause that guarantees Americans don’t pay more than patients in other countries for NIH-developed prescription drugs.

He was not pleased with her noncommittal answer. 

Cassidy argued that adding the reasonable pricing clause to NIH contracts would end up hurting patients because it could limit research. Former director Collins consistently said during his tenure that the NIH could not apply march-in rights, as they are called, to lower drug costs. Bertagnolli told him she would follow the law — an answer Cassidy liked.

Multiple Republicans raised the issue of NIH research on gender-affirming care for transgender youth, a topic that has become increasingly politicized in the GOP.

Sen. Tommy Tuberville, R-Ala., asked about an NIH study looking at psychosocial function of transgender youth on hormones, during which two people participating in the study died by suicide. He called the study a tragedy, and Bertagnolli pledged to ensure NIH research does no harm and serves all people from all walks of life. 

Sen. Roger Marshall, R-Kan., called surgery on transgender youth a “horror of medicine” and asked her to commit to preventing NIH funding from going to these surgeries. Again, Bertagnolli responded by saying NIH research aims to reach the best health outcomes for vulnerable groups. 

Appropriations

Many members of the HELP Committee are also on the Senate Appropriations Committee. One, Sen. Tammy Baldwin, D-Wis., asked the nominee about the House’s proposed cuts to the NIH’s research budget. 

The fiscal 2024 Senate Labor-HHS-Education funding bill would provide $47.8 billion for the NIH, or $943 million more than enacted levels. The House bill would fund NIH at $43 billion. The Senate version would increase funding for Alzheimer’s by $100 million and for cancer research by $60 million. The House bill has been approved by subcommittee, while the Senate version has advanced through the full Senate Appropriations Committee.

“There is a chance that the budget will force us to leave opportunities on the table — because the opportunities are enormous,” Bertagnolli said of the House bill.