[Editor’s note: On October 25, the Senate HELP committee voted 15-6 to advance Bertagnolli’s nomination to a full floor vote.]

A Senate committee finally held a hearing Wednesday on President Joe Biden’s pick to lead the National Institutes of Health. But the panel’s chair, Sen. Bernie Sanders (I-Vt.), was focused on drug prices — an issue over which the NIH has very little control.

After introducing the nominee, Monica Bertagnolli, at a hearing of the Health, Education, Labor and Pensions Committee, Sanders quickly pivoted to the high prices Americans pay for prescription drugs.

“Let me say a few words about my concerns,” he said, using his opening statement to detail the failures of the country’s “broken” health system. “Very relevant to the hearing that we are conducting right now,” he said, “we spend, as a nation, the highest prices — we pay the highest prices in the world for prescription drugs, in some cases 10 times more than the people in other nations.”

The way the hearing began — introducing issues and politics that are not necessarily on point — highlights how much the job of leading the NIH has changed. The agency has a budget of more than $47 billion, making it the largest funder of medical research in the world. But the responsibility of its director has, since the pandemic, taken on new layers of complexity.

It has become “an enormous job of bridging between the world of policy, the world of the public, and the world of science,” said Larry Levitt, executive vice president for health policy at KFF.

“COVID turned the scientific health agencies into political footballs like never before,” he said in an interview.

The nomination of Bertagnolli, a surgical oncologist and the director of the NIH’s National Cancer Institute, was applauded by much of the medical research community, especially the oncology world. But after she was tapped for the role in May, progress stalled.

The confirmation of Bertagnolli’s predecessor, Francis Collins, a physician and geneticist, took just four weeks in 2009, Sen. Tommy Tuberville (R-Ala.), observed. Bertagnolli’s, he told her, has “faced a much different nomination process. Your nomination was held up by Chairman Sanders.”

Sanders agreed to hold the hearing only after the Biden administration announced a contract with biotech company Regeneron Pharmaceuticals for a next-generation monoclonal antibody to prevent COVID-19 that required the list price of any resulting drug to be equal to or lower than the price in other major countries.

During the hearing, he returned to the issue, suggesting NIH should seek more such agreements with drugmakers that depend on the agency’s research. He asked Bertagnolli if she could “commit to us that you will work to make sure that Americans do not pay higher prices for prescription drugs in this country than people around the world.”

She responded noncommittally. “It would be a great honor to be able to work with you to make sure that the American people have access to the care that they need to live long and healthy lives.”

As part of his criticism of Sanders, Tuberville also pointed out that the NIH has been without a confirmed director for 21 months. Tuberville, meanwhile, has for months been holding up nominations to military leadership positions over abortion policies.

If she’s confirmed, Bertagnolli would lead the NIH at a time of high scrutiny and skepticism of public health agencies. HELP Committee Ranking Member Bill Cassidy (R-La.) told her that part of her duty would be “to rebuild the relationship with Congress and the public, being a leader that represents the interests of all Americans and not just of the scientific community.”

To this end, senators asked Bertagnolli about how she would lead the agency’s research on maternal health and diabetes, and about how she would address both opioid addiction and mental health crises. She was pressed on how accessible NIH’s data would be to the public.

Roger Marshall (R-Kan.) asked if she thought taxpayers should “fund gender reassignment experiments.” She dodged the question, noting that transgender youth are some of the most vulnerable in the country.

Bertagnolli kept a cool tone throughout the hearing as she shared her vision of “making sure that American people have access and availability and can afford the health care that can save lives.”

Senators also questioned how well-rounded Bertagnolli’s experience is and whether she would favor the NCI over the agency’s 26 other institutes and centers. Sen. Susan Collins (R-Maine) asked Bertagnolli if she would be able to find a balance.

She explained that, as an oncologist, she “took care of patients of all ages, all walks of life, all different health states. I am very familiar to working with colleagues in cardiology, in mental health, in opioid use disorder, in kidney disease, to take care of my patients with cancer.”

The HELP Committee has scheduled a vote on Bertagnolli’s nomination October 25.