Unlike past NIH directors, Monica Bertagnolli — President Biden's newly official nominee to lead the agency — may not face the easiest path to Senate confirmation, Victoria reports.

Why it matters: The NIH is currently facing a barrage of demands from Congress on both sides of the aisle, and any new director is going to have to navigate enhanced political pressures while also staring down potential budget cuts to the agency.

State of play: Congressional Republicans are becoming increasingly frustrated with the agency's funding of gain-of-function research and a recent renewal of a grant to EcoHealth, while HELP Chair Bernie Sanders has said he won't vote for any nominee who doesn't produce a plan to reduce drug prices.

What they're saying: Senate HELP Committee members would need to see specific guarantees before voting to confirm a new director, they told Victoria last week.

• "I want to see the administration telling us what they are going to do so that we don't pay twice as much for prescription drugs as the people of other countries," Sanders said. "I will not support any nominee who was not prepared to do that."
• Sen. Roger Marshall said a new NIH director would need to show a "commitment to being honest with America to not have the attitude that the CDC and NIH are all knowing."
• Marshall, who has also introduced legislation to ban gain-of-function research, said he has concerns about the NIH renewing the EcoHealth grant, and that he would like to know what the new director's stance is on gain-of-function research before confirming her.

Sens. Mike Braun and Rand Paul had similar concerns about gain-of-function and the agency's COVID response.

• "I would hope that whoever is going to get that [NIH director position] would be out front that they're going to learn from some of the mistakes that the NIH made especially vis-à-vis coronavirus," said Braun.
• "It's a huge mistake to reward malfeasance with more money," said Paul, referring to the EcoHealth grant. He added that his most likely questions would focus on "additional restrictions on gain-of-function."
• The new NIH grant to EcoHealth does have a lengthy set of restrictions, including forbidding any research being done in China or that would make viruses more virulent or collecting samples from bats, according to Nature.

Yes, but: "I don't have a checklist of things they can't have ever said or have ever done," said Sen. Mitt Romney. "I look for a person who is outside of politics and is inside the world of science."

What we're watching: It's essentially guaranteed that any House Labor-HHS appropriations bill will include cuts which could hit NIH — even though senators at a Senate Appropriations NIH budget hearing two weeks ago seemed to support keeping the agency's funding levels steady.

• Labor-HHS is "one of the largest [appropriations bills] other than defense, and defense is not going to have a lot of cuts. Since we are one of the largest, we will obviously have some cuts and we're preparing for it," Rep. Robert Aderholt, chair of the House Labor-HHS Subcommittee, told Victoria.

Our thought bubble: Former NIH director Francis Collins, who served for 12 years, may have been the last agency leader to work under both Republican and Democratic presidencies.

• With increased politicization of research and the pandemic response, it seems likely that scientific agency leadership confirmations are going to become more contentious.

Flashback: Collins was confirmed by unanimous voice vote without even holding a confirmation hearing in the HELP committee. The two previous NIH directors before Collins, Elias Zerhouni and Harold Varmus sailed through their own HELP confirmation hearings with little conflict.

It's not going to be the avalanche of hearings we had last week, but there are a few you might want to keep your eye on.

• Also, the Energy and Commerce health subcommittee is marking up 17 bills Wednesday. So ... a markup avalanche?

1. E&C markup: Sorry, E&C, we're not listing all 17 bills in our smart brevity newsletter (the full list is here), but here are the highlights:

• PBM bills, including the Drug Transparency in Medicaid Act — which targets spread pricing tactics in Medicaid — and the PBM Accountability Act, which would make benefit managers file lots of data reports to employers. (Maya and Peter wrote about them in our handy PBM bill guide.)
• A 340B transparency and oversight bill. It doesn't have a catchy title, but it's by Rep. Larry Bucshon, if that helps.
• The Transparent PRICE Act, a discussion draft by E&C Chair Cathy McMorris Rodgers.
• A bill to cancel some Medicaid DSH payment reductions. The name? The Supporting Safety Net Hospitals Act.
• A bill to extend funding for community health centers and the National Health Service Corps.

Between the lines: One major policy that is largely not included is site neutral payments.

• An E&C GOP aide said the committee is still working through the details when asked about site neutral, and noted the markup does include "significant policies that will make a real impact on lowering costs for patients and increasing price transparency in health care."

Also happening this week:

2. Ways and Means on health care transparency: Witnesses include Healthcare Bluebook co-founder Bill Kampine and former CMMI director Rick Gilfillan. Tuesday at 10am ET.

3. Ways and Means health subcommittee on anticompetitive and consolidated markets: Witnesses include Oklahoma Insurance Commissioner Glen Mulready. Wednesday at 2pm ET.

4. Senate Finance on health care access in rural communities: Witnesses include Erin Aune of Frances Mahon Deaconess Hospital in Glasgow, Montana and Sara Rich of Choptank Community Health System in Denton, Maryland. Wednesday at 2:30pm ET.