The National Institutes of Health sent shockwaves through academic research circles late Friday, saying it will dramatically cut the rate it pays for universities' administration and overhead costs to save the government more than $4 billion.

Why it matters: The reductions will particularly hit elite institutions including Harvard, Yale and Johns Hopkins and fulfill a long-sought conservative goal that was included in the Project 2025 blueprint.

• Trump proposed a similar change during his first term, but Congress didn't act. Project 2025 says the reimbursements "cross-subsidize leftist agendas" and that universities use the funds to pay for diversity, equity and inclusion efforts.

Driving the news: NIH, as of Monday, will cap the indirect cost rate on all new and current grants at 15% of the total cost. Reimbursements vary by institution and have averaged between 27% and 28%, with some receiving more than 50%.

• It noted Harvard, Yale and Johns Hopkins each received more than 60%.
• The agency said in a post on X that $9 billion of the $35 billion that it granted for research in fiscal 2023 was used for administrative overhead, as opposed to direct research.
• The reimbursements can be used to cover the cost of lab space, data processing, safety measures for human subjects and to pay support staff, per the Association of American Universities.

What they're saying: "The United States should have the best medical research in the world. It is accordingly vital to ensure that as many funds as possible go towards direct scientific research costs rather than administrative overhead," the agency said in announcing the change.

• But academic research interests predicted the cuts will slow medical breakthroughs, including treatments for cancer and chronic diseases like diabetes and heart disease.
• The reductions "represent the federal government stepping back from commitments it has made to world-leading researchers," said Mark Becker, president of the Association of Public and Land-Grant Universities. 
• "This action will slow advances for millions of patients who desperately need critical breakthroughs and imperil the U.S.'s position as the world leader in biomedical innovation," he said.

A senior Democrat in Congress, Sen. Patty Murray (D-Wash.), said the move was illegal because annual spending bills prohibit modifications to NIH's indirect costs.

• She said the move would shift costs to states that can't afford to pay the difference.

Context: President Trump's early actions on federal health agencies included temporarily freezing NIH grant reviews and rescinding job offers.

• NIH has become a frequent target of conservatives, with lawmakers proposing a major overhaul that would include new oversight of research and additional reviews of the process for awarding grants to universities.

Dozens of newly confirmed cases of avian influenza in wild birds and the first verified U.S. case of a new strain of the virus are raising concern the bird flu crisis may be entering a troubling new phase.

Why it matters: While the developments don't necessarily raise the risk of a pandemic, they could create more havoc for farmers, exacerbate egg shortages and expose more gaps in government disease surveillance.

• The outbreak is intensifying as the Trump administration maintains a pause on most external federal health agency communications, including publication of CDC's Morbidity and Mortality Weekly Report (MMWR), a venerable source of scientific reports on public health.

Driving the news: The Department of Agriculture last week confirmed 81 detections of highly pathogenic avian flu in wild birds collected across 24 states between Dec. 29 and Jan. 17.

• Wild birds can be infected and show no signs of illness, allowing them to spread the virus to new areas and potentially expose domestic poultry.
• Officials in Pennsylvania and New York have culled thousands of wild geese, as well as commercial poultry flocks, after detecting cases of flu.

What they're saying: "If you look at what's happened the last eight weeks, the number of poultry operations that have gone down — and more recently, the duck operations — is absolutely stunning," Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota told Axios.

• The virus is being spread as wild birds comingle with birds in commercial poultry operations.
• Changes in migratory patterns may be worsening the issue in northern states, which now see certain wild birds stay for the winter because water sources aren't freezing, Osterholm said.

"There is a lot of H5N1 out there. And we're going to see more cases in humans," he said.

• But "they're going to be single, isolated cases," he said.

The intrigue: A new strain of avian flu called H5N9 was recently identified on a duck farm in California that had an outbreak of the more common H5N1 flu last fall.

• The new type is a sign that two or more viruses could be infecting the same animal and swapping genetic material. Ducks make good hosts for what scientists call "reassortment" because they aren't badly sickened by many types of avian flu.
• About 119,000 birds on the farm were euthanized following the discovery.

Such mutations, in and of themselves, may not pose a greater threat to human health.

• The H5N9 strain originated in China and is itself a mix of several other strains. It isn't thought to be more of a threat to humans than the H5N1 strain that's widely circulating in U.S. poultry, cattle and wild birds.
• But its presence could become a major problem if there was a reassortment between avian flu and a seasonal human flu, Richard Webby, director of the World Health Organization's Collaborating Center for Studies on the Ecology of Influenza, told the Los Angeles Times.
• That combination could result in a virus that is more easily transmitted between people.

Catch up quick: The bird flu crisis has struck 113 flocks in the past 30 days, affecting more than 19 million birds, per USDA. It's also been confirmed in 943 dairy herds, the vast majority in California.

• The Trump administration hasn't publicly outlined steps it's taken yet to address the spread. HHS didn't respond to a request for comment.
• HHS Secretary-designate Robert F Kennedy Jr. said he intended to "devote the appropriate resources to preventing pandemics" during confirmation hearings this week, leading some Democratic senators to point to past statements he made about giving infectious disease research "a break."

Between the lines: The partial blackout on health communications has effectively blocked publication of a pair of studies on bird flu, including one on whether veterinarians who treat cattle have been unknowingly infected by the virus, KFF Health News reported.

• The other report looked at whether people carrying the virus might have infected domestic cats.
• The reports were due to appear in the MMWR, which hasn't published since January 16 and is subject to the pause ordered by acting HHS Secretary Dorothy Fink to allow the new administration to set up a process for review and prioritization.

The communications freeze has been met with outrage in some medical and science circles. "This idea that science cannot continue until there's a political lens over it is unprecedented," Anne Schuchat, a former principal deputy director at the CDC, told KFF Health News.

• There's a lot of uncertainty around whether the administration is merely pausing communication or making a wholesale change in how the agency functions, Patrick Jackson, a UVA Health infectious diseases expert, said on a call with reporters Friday.
• "Frankly, getting CDC up and running at full speed is going to be essential to keep track of avian influenza," he said.

The Supreme Court on Friday agreed to review a challenge to the Affordable Care Act's requirement that insurers cover certain recommended preventive services at no cost.

Why it matters: Eliminating the requirement could limit access to services like cancer screenings, preventive medications for heart disease, behavioral health counseling and HIV drugs known as PrEP.

• The timing of the high court review puts the legal defense of the ACA mandate in the hands of the incoming Trump administration.

Zoom in: The case takes up whether the coverage requirement, based on the recommendations of the U.S. Preventive Services Task Force, is invalid because the panel lacked authority since its members weren't Senate-confirmed.

• Two Christian-owned companies and several individuals sued the federal government on religious freedom grounds in 2020 over the requirement that their employer-sponsored insurance cover no-cost preventive medicines for HIV.
• A federal judge in Texas in 2022 ruled in favor of the plaintiffs and blocked the government from requiring insurers to provide free coverage of recommended services.
• The 5th U.S. Circuit Court of Appeals last year agreed with some of the arguments but overturned the nationwide injunction, only blocking the requirement for the companies and individuals who brought the case.

The Biden administration and the challengers each asked the Supreme Court to review that mixed ruling. The administration argued it called into question insurers' legal duty to cover task force recommendations without cost-sharing.

• Allowing employers to exclude PrEP over religious objections could open the door to objections over other covered services, including vaccines, KFF has noted.

President-elect Trump told Time magazine he will ensure the FDA will not block access to abortion pills on his watch, the first time he has made such a commitment.

Why it matters: Medication abortions account for nearly two-thirds of all abortions nationwide. Anti-abortion groups and some Trump allies see limiting access to abortion pill mifepristone as a top priority in the new term — but, for now at least, Trump does not.

What he's saying: In the interview accompanying his Person of the Year designation, Trump said he had been "against stopping" the abortion pill during his campaign and that it was "very unlikely" he would do anything to restrict access.

• However, Trump initially declined to take a firm stand, saying that while it was "100% unlikely" he would do anything to limit access, he knew people felt "really strongly both ways" and would look into the issue at a later date.
• However, pressed on whether he would ensure the FDA does not strip access, Trump finally said: "That would be my commitment."

Context: The Supreme Court in June turned away a challenge to the FDA's guidelines for accessing the commonly used abortion pill mifepristone, saying a group of doctors who oppose abortion and brought the case couldn't show they were directly injured.

• While that ruling preserved access to the pills, several conservative-led states are continuing to challenge FDA rules that expanded access to the pill.
• Anti-abortion advocates have urged the next administration to broadly interpret the 1873 Comstock Act, which banned the interstate mailing of "obscene" material like pornography, as well as abortion drugs and contraception.
• The Biden Justice Department issued a legal memo saying Comstock didn't prohibit the lawful mailing of abortion drugs, but the memo could be rescinded.

More from the interview:

• Trump open to detaining immigrants in camps
• Trump insists Elon Musk will put country before his companies
• Trump says his daughter-in-law and children could carry on political dynasty

The public trusts Anthony Fauci more than President-elect Trump and his incoming health team as a source of medical information, according to the latest Axios-Ipsos American Health Index.

• But Robert F. Kennedy Jr.'s focus on safe food and nutrition clearly resonates with many Americans, who see chemicals and unsafe additives as a bigger health risk than climate change or infectious diseases.

The big picture: Our first polling since the election shows most Americans are happy with their ability to get quality health care or foods, but there's continued dissatisfaction with out-of-pocket costs for health care.

• 84% of the public report their own emotional well-being is very or somewhat good.
• Only about a third think the government puts the public's health and well-being first, or that America is adequately prepared to deal with another pandemic.

There's lingering dissatisfaction with health industries: 59% support banning TV pharma ads and 64% want insurers to cover prescription weight-loss drugs like Ozempic and Wegovy — up 3 percentage points from when we asked the question in August.

Between the lines: Members of the incoming Trump administration won't be entering office with widespread public trust.

• 60% or more of respondents say the have at least a fair amount of trust in information from the Food and Drug Administration, Centers for Disease Control and Prevention or National Institutes of Health. And 45% report trusting information from Fauci.
• Fewer say they have the same amount of trust in information on health topics from Trump (32%), Kennedy (30%), Elon Musk (25%), Mehmet Oz (23%) or others Trump has nominated to lead federal health agencies.

"A lot of Trump's health picks aren't well-known, so they're not trusted, but even Donald Trump hasn't seen a resurgence in public views of his credibility on public health since COVID," said Ipsos pollster and senior vice president Chris Jackson.

• There are significant partisan splits, with nearly 7 in 10 Republicans saying they trust Trump, while just 7% of Democrats do.
• And as we saw during the pandemic, independents tend to side with Democrats on the trust issue: Even now, 45% of independents say they trust Fauci, though his rating has fallen since the height of COVID.

Friction point: Kennedy, Trump's pick for Health and Human Services secretary, has struck a chord with his focus on food and nutrition. Some of that is linked to concern with obesity, which continues to rank as the top overall health threat, ahead of poor mental health and opioids and fentanyl.

• But support for his other positions is low. Just over a quarter of the public (29%) supports removing fluoride from water supplies. About 1 in 5 (18%) back ending vaccine requirements for attending public schools. One quarter (24%) support firing science staff at the FDA and NIH. And 1 in 5 (19%) would reduce testing requirements before allowing new drugs or therapies to be sold to the public.
• "RFK Jr.'s focus on safe foods goes over well with the public. He's also in the majority with his hostility to the health care industry," Jackson said.
• "But as you get to some of his other views on public health — removing fluoride, ending vaccine requirements for kids, firing research and science staff at health agencies — only a small minority support any of the non-nutrition health things he's calling for," Jackson said.

The survey shows the public still sees a significant role for government in health care.

• Presented with a choice between Musk's and Kennedy's positions, 60% support increasing food safety inspections to 37% cutting federal spending by $2 trillion.
• Majorities want to see public health programs strengthened, including 72% for food safety inspections, 71% for the Veterans Health Administration, 64% for Medicare, 57% for the CDC and 54% for Medicaid.
• 73% say the Affordable Care Act should be strengthened or left as it is.

Methodology: This Axios/Ipsos Poll was conducted Dec. 6-9 by Ipsos' KnowledgePanel®. This poll is based on a nationally representative probability sample of 1,002 general population adults age 18 or older.

• The margin of sampling error is ±3.3 percentage points at the 95% confidence level, for results based on the entire sample of adults.

Robert F. Kennedy Jr. could use Health and Human Services' vast bureaucracy to put a distinct stamp on vaccine policy, drug approvals and food regulation if he's confirmed. But with so many legal requirements and bureaucratic layers baked into the process, it's hardly a foregone conclusion he will.

Why it matters: Experts say RFK Jr.'s public calls for more transparency and vows to shore up the trustworthiness of federal health agencies may translate into more requests for vaccine safety data and into appointing like-minded individuals to advisory panels that could influence coverage of drugs, services and devices.

• They also say it could result in shifting public health funding to chronic disease or environmental health and away from infectious disease, or a diversion of federal investment to study unproven health issues instead of known risks.
• And they're expecting attempts to remove job protections from career federal employees who work in policymaking roles and reduce the ranks of officials who don't align with RFK Jr.'s goals.

Between the lines: In the near term, he's likely to focus on how much influence he might exert on negotiations between the Food and Drug Administration and the health industries it regulates over user fees for companies, which fund a significant portion of the FDA's operations.

• Talks to reauthorize programs for prescription drugs, medical devices and generics are due to start next year and could provide a crucible for Trump appointees to take aim at what they describe as regulators' coziness with industries they police.
• The spotlight could fall especially hard on vaccines, based on Kennedy's criticisms of the federal pandemic response, his calls to revoke emergency use authorizations for COVID shots and his advocacy of hydroxychloroquine and ivermectin, both of which were found ineffective for treating the virus.

The general thinking is RFK Jr. could have more openings to exert his influence through the Centers for Disease Control and Prevention than the FDA, which is tightly bound by the Food, Drug and Cosmetic Act.

• He also stack outside advisory panels like the CDC's Advisory Committee on Immunization Practices, or ACIP, with fellow vaccine skeptics.
• ACIP recommendations influence whether Medicare covers a vaccine at no cost to patients. State Medicaid programs have to cover recommended adult vaccines.
• "They have the ability to change the bylaws or the charters under which those committees run, and essentially have the ability to ignore the committees or disband it entirely if they felt like they needed to," Joshua Michaud, associate director of global health and HIV policy at KFF.

Zoom in: RFK Jr., with the help of Congress, could also seek to make changes to the National Vaccine Injury Compensation Program, which dates to the 1980s and gives vaccine makers legal immunity for any injuries caused by their products, in exchange for a 75-cent tax on each dose sold.

• The program drew criticism from the right during the pandemic, when makers of COVID-19 vaccines were not required to pay the tax because the shots were designated as "countermeasures."
• "We've never had an HHS secretary who wants to blow up the nation's immunization system. So there are questions here that haven't come up before," said Sara Rosenbaum, who served on ACIP between 2009 and 2013.

Zoom out: The HHS secretary still has a great deal of authority at the FDA.

• "The Secretary's role doesn't have to be just routinely sign off on things," said Richard Besser, former acting director for the CDC from January to June 2009 and current CEO of the Robert Wood Johnson Foundation.

Flashback: In the Obama administration, HHS Secretary Kathleen Sebelius made an unprecedented decision to override an FDA decision that would have made emergency contraceptives available over the counter, Besser pointed out. (The decision was later reversed in 2013.)

• "And Mr. Kennedy as the secretary has some strong feelings about what drugs are effective and which ones are not, and what things should be used to promote health," Besser said.

Reality check: HHS's budget and legal mandates are determined by Congress and have limits. Any major regulatory changes must go through public comment periods and comprehensive legal review.

• They would also certainly be subject to lawsuits, particularly after the fall of the Chevron doctrine.

What to watch: There's a question about whether HHS could usurp school vaccine requirements using section 361 of the Public Health Service Act of 1944, which gives it the authority to "control communicable diseases."

• "The answer is not entirely straightforward and would set off legal challenges," Richard Hughes of Epstein Becker Green wrote.

Regardless, experts say some of the most significant effects of an RFK-led HHS may be how health guidance and evidence-based information, including about vaccines, are communicated.

• "If the CDC and the HHS secretary are out there saying we have doubts about the safety of this vaccine ... that might have some downstream effects at the state and local level, which is where those vaccine requirement decisions are actually made," Michaud said.