The United States has long had the world’s most effective and competitive system for discovering and developing new drugs—and for more than a half century, there has been a bipartisan consensus that there are two reasons for that success: First, the federal government provides robust funding for scientific research, mostly through the National Institutes of Health (NIH). Second, the U.S. system encourages vigorous innovation in the private sector by providing strong intellectual property protections and a drug reimbursement system that together allow companies to earn sufficient revenues to reinvest in highly risky research and development.1 But today that consensus is fraying as populists on the left and libertarians on the right question both the policy means and the end result. If the center cannot hold and the longstanding bipartisan policy framework falls apart, then the future of U.S. biomedical innovation will be in peril.