Harry Lewis presents his thoughts on how the cost-cutting approach of the second Trump administration could pose a serious threat to the continued existence of US-funded internet resources crucial to work in HTA, and argues for immediate contingency planning to prepare for a worst case scenario.
There is a tendency among some politically engaged people in the UK and Europe to focus overly on news stemming from America, something taking place thousands of miles away that has little effect on everyday life compared to the actions of national and local governments. Yet it is foolish to overcorrect for that by assuming that everything that goes on stateside is irrelevant, something which is happening to ‘them’ and not ‘me’. The US is the most powerful and influential country in the world, and as such the radical and far-reaching nature with which the second Donald Trump administration has upturned both domestic and international politics bears paying close attention to.
The Department of Government Efficiency (DOGE), run by Elon Musk with the aim of cutting supposedly wasteful government expenditure, is one of the most striking examples of this upheaval. Since Trump’s inauguration in January, DOGE has implemented what can only be described as wholesale takeover of the infrastructure of the US federal government, with its officials (who have for the most part received no security clearance) now able to access critical IT systems, including the one used to distribute payments from the Treasury [1],[2]. Workers affiliated with the group now also control the Office of Personnel Management, the government’s HR department [3]. This control has enabled DOGE to fire swathes of civil servants, end programmes or services with little or no notice, and even to de facto abolish entire government agencies [4],[5],[6],[7]. These actions, despite serious questions over their legality [8], have proceeded with the full support of the Trump administration, which is ostensibly committed to eliminating the US government’s $2 trillion budget deficit.
What is of specific concern for the purposes of this article is the DOGE programme of cuts to the National Institutes of Health (NIH), and the broader attitude of the Trump administration towards scientific research. On 7th February, it was announced that the NIH would make be making deep cuts to the money it allocates to research grants [9]. After the department stopped considering new applications for grants entirely, a court order forced this process to reopen again; it has since been re-frozen through a loophole, before being only partially reopened [10],[11]. Specific grants which conflict with the Trump administration’s worldview, such as those covering LGBTQ+ health issues, have also been unilaterally cancelled [12].
Collectively, these actions could have a profound and lasting impact on scientific progress in the US and the world over, with the effects particularly concentrated in those areas specifically targeted by the administration. This has all taken place in the less than two months since Inauguration Day. For those working in health technology assessment (HTA), this means considering what continued DOGE activities over a four-year presidential term might mean for services run by the NIH, namely PubMed, MEDLINE, and clinicaltrials.gov.
All of these play a crucial role in the day-to-day of life of HTA professionals, forming a readily available repository of information to build out submission documents and other market access materials and, perhaps even more importantly, providing data for systematic literature reviews (SLRs). Yet they are currently provided free of charge at the expense of the American government, and as such could become the target of cutbacks implemented by DOGE. This is particularly true given the fact these services host the type of materials which the Trump administration has attempted to end all government involvement with, such as research into LGTBQ+ and ethnic minority issues. Losing access to any of the NIH resources would create significant disruption for HTA professionals and inevitably lead to a decline in the quality of research done in the market access space and elsewhere.
The idea that DOGE would aim to end the provision of resources like PubMed and MEDLINE which provide a clear benefit to the public may seem absurd, especially when their cost is compared to other sources of government expenditure. However, a closer look at the activities of DOGE thus far reveals their cuts have not been based on traditional cost-benefit analyses, which would seem to push the department towards looking at outlays much larger than anything the NIH is spending on database upkeep. Instead, DOGE appears to be prioritising areas which serve a broader political goal, namely advancing the public image the Trump administration wishes to project. This is why one of the first sources of savings was the Agency of International Development (USAID), which before it was effectively dismantled made up just 0.3% of US government spending [13]: it fits with Trump’s railing against American money being sent abroad. Threats to cut education funding unless states end diversity, equity, and inclusion policies [14] serve this purpose, as well, in that they aim to show that the government is taking action against the various ideologies and communities Trump has set himself against. Indeed, recent estimates have shown that despite all the political noise and disruption to the US bureaucracy, DOGE has saved far less than the $105 billion it claims [15],[16]; this seems, for now, to be far more an exercise in political signalling than an honest effort to cut ‘waste’.
Given this, it is not hard to envisage how Musk and Trump could present ending free access to NIH resources as being a good thing for Americans. The US government really is spending money to present results of scientific research to foreign, non-taxpaying citizens who may then use that information for whatever purposes they choose. Even if the cost of upkeep of PubMed, MEDLINE, and clinicaltrials.gov is vanishingly small in the context of the federal budget, reducing or eliminating it could easily be broadcasted as an example of cutting unnecessary spending. This argument could be bolstered by pointing to examples of seemingly absurd or pointless research stored on the databases, a strategy which has been used to justify cuts to research grants. Trump’s views on global warming are well known, and Robert F. Kennedy Jr., recently appointed as head of the Department of Health and Human Services (which oversees the NIH), has a history of anti-vaccine views [17]. Research which opposes the new government’s position on these two topics might also be cited as a reason to pull the plug.
DOGE does not need to completely remove NIH resources from the internet to cause upheaval. A scenario where the workers responsible for updating and maintaining the databases are fired would make them no longer suitable for SLRs, which by their very nature require their data sources to be constantly refreshed. Charges might be introduced for foreign users, adding significant extra costs to research activities as well as threatening the principle of free access to science on which the services are based. An approach aiming to strip databases only of research which conflicted with Trump administration goals would also have dire effects, and not just for those working in fields which might be directly targeted. The methods used to identify research grants to put up for cancellation have been extremely haphazard [18],[19], and it seems very unlikely that an effort to purge PubMed of all papers relating to a specific topic would be done with much care.
It seems impossible to predict where Musk’s attention might turn next, and as such contingency planning for the disruption or even complete cancellation of NIH resources should be a priority for those who make regular use of them in HTA work. At the company level, this should involve identifying alternative methods of obtaining clinical trial data and indexing of scientific papers and creating a plan to quickly switch to them if needed. These are unlikely to fully replace the functionality of existing services, but knowing where to turn in a worst-case scenario will make the transition much easier. At an industry level, the creation of alternative systems that do not rely on the whims of a single country’s government for their continued existence must be seriously considered.
The situation described above is not inevitable; its coming to pass will depend on the continued existence of DOGE and the power granted to it, as well as the priorities of its leaders. Neither is the possible demise of NIH resources anywhere near the top of the list of the most significant consequences of the new administration’s policies. However, it is eminently conceivable and would undoubtedly have a drastic effect on the everyday operations of those working in HTA were it to happen, and as such it bears keeping in mind. To fail to prepare is to prepare to fail.
[1] https://www.forbes.com/sites/siladityaray/2025/02/17/doge-is-seeking-access-to-critical-irs-system-that-holds-taxpayer-data-heres-what-to-know/
[2] https://www.france24.com/en/live-news/20250213-musk-s-doge-team-raises-major-cyber-security-concerns
[3] https://www.wired.com/story/elon-musk-lackeys-office-personnel-management-opm-neuralink-x-boring-stalin/
[4] https://apnews.com/article/doge-firings-layoffs-federal-government-workers-musk-d33cdd7872d64d2bdd8fe70c28652654
[5] v. https://www.politico.com/news/2025/03/05/trump-doge-firings-agriculture-employees-reinstated-00214204
[6] https://www.theguardian.com/us-news/2025/feb/11/doge-education-department-cuts-trump
[7] https://apnews.com/article/trump-musk-doge-usaid-federal-workers-bfb69a0bf38419b7518555de42169ca1
[8] https://www.theguardian.com/us-news/2025/feb/10/elon-musk-doge-agency-illegal
[9] https://grants.nih.gov/grants/guide/notice-files/NOT-OD-25-068.html
[10] https://www.nature.com/articles/d41586-025-00540-2
[11] https://www.npr.org/sections/shots-health-news/2025/02/26/g-s1-50920/trump-nih-funding-freeze-medical-research
[12] https://www.fiercebiotech.com/research/nih-cancels-grants-lgbtq-health-research-effective-immediately-stat
[13] https://usafacts.org/explainers/what-does-the-us-government-do/agency/us-agency-for-international-development/
[14] https://www.politico.com/news/2025/02/15/doge-education-department-dei-cuts-019574
[15] https://www.nytimes.com/interactive/2025/03/04/upshot/doge-musk-contracts-cuts.html
[16] https://www.wfxrtv.com/news/no-savings-expected-from-nearly-40-of-doge-canceled-contracts/
[17] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02603-5/fulltext
[18] https://www.propublica.org/article/ted-cruz-woke-grants-national-science-foundation
[19] https://www.cbsnews.com/newyork/news/doge-cuts-911-related-cancer-research-funding/
