Is there an insidious ‘iron triangle’ in American health care?

Associated Press/Jacquelyn Martin
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, holds his face mask at a House Committee on Appropriations subcommittee on Labor, Health and Human Services, Education, and Related Agencies hearing about the budget request for the National Institutes of Health, on May 11, 2022, on Capitol Hill.

The recent stories about government scientists at the National Institutes of Health (NIH) earning royalties from COVID-19 drug patents highlight the dangerous “iron triangle” among Big Pharma, Big Health Care, and government research and policymaking agencies. Iron triangles emerge from reinforcing financial and political ties among government offices, private organizations, and government aid recipients. Once in place, they can create enormous leverage over public policy, self-finance their own political power (lobbying, campaign contributions), and generate tremendous growth and cash flow — and they are nearly impossible to shut down. They are found throughout the public sector, from national defense to public welfare to health care.

The payment of royalties to NIH scientists involved in the development of drugs (and their patents) sold by private companies gives the appearance of potential conflicts of interest, especially when the leaders of those agencies push public policies on the use of those drugs. COVID certainly comes to mind because $50 billion in federal funds were made available for research and development and manufacturing and distribution of vaccines, netting drug companies $100 billion in revenue and $40 billion in profits. The mRNA technologies and patents, used to develop COVID vaccines, have led to a stream of royalty payments to government scientists for these and other drug breakthroughs.  

There have been intense legal fights over patents and the allocation of royalties between private companies and NIH scientists. This is not new; it happened with the HIV drug AZT and other major, highly profitable breakthroughs. Both Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and former NIH Director Francis Collins were recipients of such royalties, a 2005 Associated Press investigation found. The doctors said they donated the payments to charity, but no one seems to know how much was paid, to whom, and where the money went.

Big Health Care — hospitals, doctors, health care delivery systems — profits substantially from administering vaccinations and other drugs, and depends on Fauci’s annual budgeted distribution of nearly $5 billion in external research money, so no one is likely to raise obvious questions about propriety, nor about the Fauci/NIH pressure to use the vaccines. Most recipient universities and other private medical research centers, of course, celebrate Fauci’s leadership. Any questions about NIH or Fauci’s decisions are termed “disinformation” and, as we saw with COVID, “not following the science.” But “following the money” continues to raise some important questions.

The secrecy of NIH is reflected in the next leg of the triangle, Big Pharma, which has grown dramatically and may represent as much as 15 percent of all spending on health care. It is projected to be the fastest growing segment of health care costs in the future. Studies over the past 20 years have suggested that Big Pharma contributed around 9 percent of the operating budget of leading medical schools such as Stanford and the University of Pennsylvania , nearly 30 percent of the costs of continuing medical education for doctors, and made large payments to deans of leading medical schools. Medical associations and schools claim this has been curbed but, as with NIH, there is little to no available data to investigate that. The iron triangle seems to have donned an invisibility cloak.

Unfortunately, all that may partially explain why medical education increasingly has been reduced to vertical specialty silos following algorithms that teach students to “name it,” “drug it or cut it (and then drug it),” and “bill it.”  Four-year medical students must memorize a vast array of drugs and drug applications, literally doubling their vocabulary. And, of course, the Centers for Medicare & Medicaid Services (CMS) and insurance companies pay according to these diagnostic/treatment/billing frameworks, further supporting modern, robotic, drug-based medical treatment. 

Is it any wonder that policymakers, NIH scientists and university research and medical teaching institutions would want to be closely connected to that money machine? And, of course, both Republicans and Democrats are on board

The question then becomes: Does this give Americans longer, healthier lives? Apparently not.

Throughout the COVID pandemic, there was evidence that many Americans who had poor metabolic health and were overweight were at very high risk of serious illness and death. Similarly, Americans with poor metabolic health and high levels of inflammation are at greatest risk for nine of the top 10 killer diseases. U.S. life expectancy has been declining for years, pre-COVID, despite ballooning health care spending. Excess sugar intake is a primary culprit. Yet the NIH inexplicably joined with the U.S. Department of Agriculture (USDA) in 2021 to approve high sugar-content standards for American foods and government-financed food. If you think of sugar as a dangerous, addictive drug, you might say that NIH/USDA support Big Pharma and “Big Farma.” You might also say that NIH is becoming a misnomer. It is the National Institutes of Drugs and Treatments — that’s where the money is.

A possible example is the growing number of Americans who are becoming dependent on antidepressants — which can have many side effects and do not appear to “cure” anything, e.g., suicides are up dramatically, more than 30 percent in half of the states over the past 20 years.  Another example: A study published in 2017 in JAMA Cardiology found statin use increased 80 percent in a decade (221 million prescriptions per year) and yet, preventable heart disease is the No. 1 killer for men and women, taking almost twice as many lives per year as COVID did. Top heart surgeons in the country cite these deaths as preventable with optimal diet and lifestyle — but where is the pressure from NIH on this?

The bottom line is that health costs are skyrocketing but Americans are not healthier. Americans are becoming sicker, taking more drugs, and living shorter lives. We Americans love superheroes who save the day and prevent widespread death and disaster. Now may be the time for a new breed of superheroes to swoop in and smash the Health Care Iron Triangle. 

Grady Means is a writer and former corporate strategy consultant. He served in the White House as a policy assistant to Vice President Nelson Rockefeller and a staff economist in the U.S. Department of Health, Education and Welfare. He was the White House liaison to the National Health Insurance Experiment, chaired the Food Stamp Reform Task Force, and helped write and implement the HMO Act of 1973. Follow him at and on Twitter @gradymeans1.

Tags Anthony Fauci Big pharma Francis Collins Health care in the United States National Institutes of Health prescription drugs Vaccines

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