This blog is the second in a two-part series on the president’s fiscal year 2018 budget proposal. Read the first post here.

There is much speculation about the future of health services research given the president's proposal to transform the Agency for Healthcare Research and Quality (AHRQ) into a new institute at the National Institutes of Health (NIH) – the National Institute for Research on Safety and Quality (NIRSQ). While our members have reached out to us with both pros and cons for such a move, at this point in time, we thought it would be helpful to take a step back and explain what can and cannot happen under the law, as well as what we can (realistically) expect for this year. 

First, it is important to remember that the president's proposal is just that – a proposal. We have confirmed with congressional staff and with staff from the U.S. Department of Health and Human Services (HHS) that dismantling an agency and moving it elsewhere requires legislation. Therefore, moving AHRQ into NIH is not something the administration can do unilaterally. 

With respect to legislation, AHRQ could become an NIH institute through two possible paths: authorizing legislation or appropriations legislation. 

Authorizing legislation would authorize the establishment of a new institute, followed by appropriations legislation that would provide funding to the new institute. Just last December, Congress nearly unanimously reauthorized NIH, including the statutory cap on the number of institutes and centers. Given all that authorizers will need to tackle in the remaining months of this year (health reform, CHIP reauthorization, the primary care funding cliff, etc.), our sense is that there is little – if any – appetite to take on the AHRQ/NIH merger at this time.

The appropriate time to authorize a new NIH institute would be during the next NIH reauthorization cycle, which is at the end of fiscal year 2019. 

Concerning the appropriations route, appropriators could implement the president's proposal on a spending bill in one of two ways: 

  • Appropriators could eliminate a current NIH center/institute to create a new one, and in so doing remain under the statutory cap on the number of NIH institutes and centers. There is a historical precedent for this. Appropriators created the National Center for Advancing Translational Sciences (NCATS) by terminating the National Center for Research Resources (NCRR) in 2012. You may recall that the president's budget suggested eliminating the Fogarty Center. According to appropriations staff, this proposal is a "nonstarter." 
     
  • Alternatively, appropriators could create a new institute/center on a spending bill and increase the cap on NIH institutes/centers. 

Under either of these scenarios, when the bill came to the Rules Committee before going to the floor for debate, lawmakers could waive the rule that prohibits authorizing on an appropriations bill. Such a move would require the blessing of authorizers, who would essentially be ceding their authority to appropriators (something they don't often do). 

In this regard, neither course is easy. As mentioned, staff tell us there is no interest in eliminating and/or consolidating institutes/centers to create a new institute for health services research. Staff also tell us there is little interest in using up the political capital needed to waive the rules to make this proposed transition happen. There also seems to be some skepticism among some appropriations and authorizing committee staff on both sides of the aisle that NIH is the right home for AHRQ's work.

Of course, even if the political will were there to make such a change this year, there's the bigger question as to whether or not lawmakers will be able to move any appropriations bills. At all. We are hearing increased chatter that given the political gridlock in Washington it is most likely that we will be on a continuing resolution (CR) for fiscal year 2018 and potentially even fiscal year 2019 as well (spending bills don't fare well in election years). As a reminder, CRs keep the government funded at the same levels as the previous fiscal year or with minor modifications, such as the sequester's across-the-board cuts. 

In sum, we do not expect any movement on this proposal in the immediate future, but should staff and members of Congress wish for this transition to happen at some point, there is time to inform those discussions and ensure health services research has stable and secure funding and a reliable, robust home.