“What if” scenario reveals the impact of a drastically smaller NIH
American Association for the Advancement of Science (AAAS)Reports and Proceedings
Roughly half of all FDA-approved drugs from 2000 onward rely on publications funded by grants that would have been cut assuming a 40% reduction in U.S. National Institutes of Health (NIH) funding in past decades, say authors of a new Policy Forum. In this piece, Pierre Azoulay and colleagues present an analysis of a hypothetical alternative history. “Assuming that the near term resembles the recent past,” they say, “our analysis indicates that substantial NIH budget cuts – including those implemented at the funding margin – could curtail research linked to a large share of potential drug approvals.” The NIH, historically one of the world’s most consistently supported biomedical research funders, faces unprecedented uncertainty. In 2025, the agency began canceling existing grants and delaying new ones, with funding for competitive grants falling more than 40% below the previous year’s levels. What’s more, the Trump administration’s proposed FY2026 budget calls for a nearly 40% cut in spending.
To explore potential impacts of such cuts, Azoulay and colleagues performed a “what-if” scenario analysis to determine how these cuts would impact downstream drug development. Azoulay et al. focused on “at-risk” grants – those that would have likely been cut in a 40% smaller budget from the years 1980 to 2007 – for small-molecule drugs. The authors found that among 557 drugs approved between 2000 and 2023, 40 had at least one patent directly acknowledging NIH extramural funding, and 14 of these were supported by at-risk grants. And, when considering research citations, 331 cite at least one NIH-supported publication, and 286 reference research funded by grants that would have been cut under a hypothetical 40% budget reduction. These findings suggest that a large portion of modern pharmaceuticals rely on publicly funded science, often through indirect pathways that provide critical background knowledge, methods, or foundational research. Moreover, the authors show that the drugs linked to at-risk research are often highly valuable, demonstrating that NIH funding not only underpins a substantial share of medical innovation but also supports drugs that are clinically and economically important.
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