Chaos and Questions: New Public-Access Policies Put Journals in Flux

When the White House announced plans last year that all federally funded research must be made available to the public as soon as it’s published, the announcement shook up the highly profitable world of academic publishing, including medical journals.

The announcement essentially means that researchers must publish their federally funded work in a manner that is freely available to everybody, rather than in a journal with a subscription-based paywall. Many publishers have been preparing for the seismic change—it’s been floated for years—but the ramifications of the decision are still being felt as publishers and editors strive to work out the details of just what the new “public access” policy means for medical research and the journals that publish it.

Y.S. Chandrashekhar, MD (University of Minnesota, MN), editor-in-chief of JACC: Cardiovascular Imaging, said “it’s a highly chaotic environment” for publishers and journal editors right now. “Journals are going to completely change,” he told TCTMD. “The future is very, very uncertain.”

The push for open-access research has been decades in the making, and there is near universal agreement that having access to the most up-to-date data translates into better care for patients. Still, some journal editors have concerns with the new approach from the White House Office of Science and Technology Policy (OSTP)—expected to go into effect in 2026—because it may come with unintended consequences, throwing the current subscription-based model into flux.

In Europe, there’s a similar initiative, Plan S, which was adopted in 2021.

“At the simplest 35,000-foot view, sure, it sounds like a great idea to make taxpayer-funded research available immediately,” Joseph Hill, MD, PhD (UT Southwestern Medical Center, Dallas, TX), editor-in-chief of Circulation, told TCTMD. “Of course, it does. How can you justify putting it under a blanket for a year for whatever reason? However, when you scratch the surface a little bit, it's way more complicated than that.”

The current subscription-based model of academic publishing is spectacularly profitable and also much criticized. RELX, the parent company of Elsevier, reported revenue of more than $3.5 billion in 2022, with a profit of $1.5 billion. This translated into a profit margin of nearly 40%, which has been noted is higher than margins reported by Google and Apple. Springer Nature, the second-largest publisher after Elsevier, reported revenue of $1.9 billion in 2021 and profits of $500 million, up 12% from the year prior.

With numbers like that, another way of doing things is attractive to many in the scientific community.

“I believe that both this OSTP business and [the European] Plan S are in many ways efforts to rectify the situation where there is a glut of money that goes into the publishing houses and they know it,” said Hill. “Elsevier is one of the most profitable corporations in the world. I will argue, in my view, both the OSTP and Plan S are very good intentioned, but they are ham-handed in the specifics.”

The Nelson Memorandum

In 2013 under President Barack Obama, the White House OSTP issued a memorandum on increasing access to the results of federally funded research. That memorandum, known as the Holdren Memo after OSTP Director John Holdren, required that all federal agencies with budgets exceeding $100 million annually create policies to ensure public access to government-funded research.

The OSTP pulled its punch a little a bit because it didn’t require the ensuing academic paper be available immediately upon publication. The government suggested a 12-month postpublication grace period, which was adopted by many agencies, that allowed publishers to keep the data behind a paywall for a year before it was available to the public. The embargo was seen as a compromise that allowed the subscription-based model—and revenues generated—to continue without any major changes.

In August 2022, however, Alondra Nelson, PhD, the deputy director of the OSTP, issued a memorandum eliminating the 12-month embargo period. By the end of 2025, all federally funded research must be freely available to the public once the manuscript—either the version of record or the author accepted manuscript—is published. The decision, just like the Holdren Memo before it, affects a wide range of research that receives funding from the US government, including the National Institutes of Health (NIH).

The embargo continued to create situations where immediate access was available only to those who could pay for it or those with privileged access through libraries or other institutions, writes Nelson.

The decision ensures that US citizens avoid paying for research twice, first through their taxes to fund the study and then to see the results when published in a journal. Importantly, the White House is not mandating federally funded studies be published only in open-access journals, which is known as “gold” open-access publishing. While the research can be published in open-access journals, researchers can also choose to make their work available in agency-designated repositories, which is known as “green” open-access publishing.

Some of the most influential trials in cardiology have been funded by the NIH, including the Framingham Heart Study, ALLHAT, COURAGE, SPRINT, ISCHEMIA, and most recently, the REPRIEVE trial.

The new OSTP policy is not unlike the Plan S initiative adopted in Europe. Plan S is backed by a coalition of funders, known as cOAlition S, and requires that all research funded by public or private grants from national, regional, and international research councils and funding organizations be published in open-access journals or made available on open-access repositories without embargo. The policy, which went into effect in 2021, includes research funded by the European Union, as well as the Wellcome Trust, the Bill and Melinda Gates Foundation, the Howard Hughes Medical Institute, and World Health Organization, among others.

Making Science Publicly Available

Michael Clarke, a managing partner at Clarke & Esposito, a firm that provides consulting services to professional and academic publishers, said the major source of revenue for medical publishers, such as Elsevier, Nature Springer, and Wolters Kluwer, among others, is from institutional subscriptions. If federally funded research is publicly available without the embargo, one possible consequence is that academic libraries may cut back subscriptions to some medical journals.

This might not affect the big names in medicine, such as the New England Journal of Medicine, Journal of the American Medical Association, or Journal of the American College of Cardiology, but smaller publications might not survive. Even if they did, researchers who rely on libraries would no longer be able to access the articles published in the smaller, often more specialized journals.   

“For many other journals they might decide to save some money, and say, ‘This journal is not quite as ‘core’ so we're going cancel these,’” Clarke told TCTMD. “The question becomes, well, what then? Publishers will respond by saying, ‘Well, we can't make subscription revenue so we're going to switch to open access for these journals that no longer have viable subscriptions.’ That means charges for authors.”

With open access, researchers, or their institutions, pay to publish their study in a journal. This model also has its share of critics, namely because article processing charges (APCs) can be as high as five figures. For example, gold open-access publishing in Nature costs $11,500, while Cell Press, which includes the prestigious journal Cell, has APCs that range from $1,750 to nearly $10,000.

At the moment, there are five open-access journals available from JACC, with APCs that run from $800 (JACC: Case Reports) to $3,400 (JACC: CardioOncology). The Journal of the American Heart Association is also open access, with an APC of $1,850 for American Heart Association/American Stroke Association members and $3,700 for nonmembers.    

Earlier this year, more than 40 editors from the editorial board of two neuroscience journals published by Elsevier resigned in protest of the high APCs. By some standards, the APCs weren’t even all that high, with NeuroImage charging $3,450 and NeuroImage: Reports running $900, but the editors said the charges “were unethical and unsustainable.”    

Paying for What Is Valued

Kirsten Bibbins-Domingo, MD, PhD (University of California, San Francisco), editor-in-chief of JAMA, said that she understands the challenges of APCs, noting that she spent the bulk of her career as a researcher and author.

“The challenge here is that when we look at peer-reviewed journals, especially clinical journals—and I want to make this point because I think it's especially true at clinical journals—the journals do a lot to make sure we're thinking about the exact words and the ways in which a clinical benefit might be communicated so that it's accessible to clinicians,” she told TCTMD. “We think a lot about figures, tables, and graphics that make the work more accessible.”

In addition, editors ensure that the version of record is corrected if there are mistakes, so that clinicians, scientists, health system leaders, policymakers, and others are working with accurate research, she said. This is critical with clinical journals as the goal with solidly, conducted research is to translate those results into practice and to make the data accessible to the broadest possible audience.

We know those fees, while they allow the reader to have access, they can pose restrictions for the author. Kirsten Bibbins-Domingo

“We have built a team to make sure that we can do that across our 13 journals,” said Bibbins-Domingo. “When you translate that to say, ‘We want to make it open access,’ the fees then come out high once you look at what that entails. That feels unfair to authors.”

This year JAMA and its family of journals adopted a new policy aimed at increasing public access to clinical research. All authors of original research—regardless of funding source—are now able to place their peer-reviewed manuscript in a public repository on the day the manuscript is published by the JAMA Network. This “author accepted manuscript” is deemed ready for publication, but “additional edits, refinements, and enhancements” will still appear in the final version of record that is published in the JAMA Network. The policy, according to journal editors, helps authors share their research and aligns with the NIH’s guiding principle, as well as the White House policy, that encourages data sharing.

In addition to the public repository, there are two fully open-access journals—JAMA Network Open and JAMA Health Forum with APCs of $3,000—as well as a hybrid option for researchers. All JAMA journals, including JAMA Cardiology, allow authors to make their work open access at the time of publication, said Bibbins-Domingo. While other studies would remain behind the paywall as part of the subscription, authors who pay the APC can have the work freely available online at the time of publication.

“We have a variety of options,” said Bibbins-Domingo. “They're all built on this principle of trying to make science accessible, but also not trying to put up barriers to publish. We know those fees, while they allow the reader to have access, they can pose restrictions for the author.”

Chandrashekhar said the shift to publicly accessible information is the inevitable future of academic publishing, noting that the COVID-19 pandemic highlighted the importance of making clinical research available as soon as possible. The current model where research is locked behind a paywall doesn’t fit with the speed in which science is moving.

“It is an inefficient way to disseminate information,” he told TCTMD. “So, absolutely. All scientists would support the quickest possible way to send out information to the widest possible audience.”

However, the devil is in the details, said Chandrashekhar. “Traditional publishing has to differentiate itself from somebody just putting their findings on Twitter,” he said. Putting the information together in a readable, easy-to-comprehend, and searchable format falls to the publishers, and there’s a cost associated with that process. 

To TCTMD, Chandrashekhar said the default mentality is that “nobody likes to pay” when it comes to reading information online. “If you ask a scientist if they want to pay $11,500 to publish in some of the leading journals, but there’s a way not to pay, everybody is going to choose not to pay,” he said. Unless publishers provide a platform to distribute original research in a cost-effective manner, some scientists and researchers might turn to cheaper paper mills and poorer quality journals without sufficient editorial safeguards, such as peer review.   

“They will gravitate to all these alternate sources, which will probably be a bigger danger to society down the road,” said Chandrashekhar.

Preprint servers, such as MedRxiv, are one way around the high APCs that allow researchers to get their results into the public. The downside is that the results have not undergone peer review. Hill said that while preprint publications might have role in other disciplines, medicine is different. 

“We're not playing around with computers and numbers,” he said. “This is the real thing.” Moreover, some studies are years in the making—grant writing, resubmissions, launching the trial, following patients, analyzing results, and then writing the paper—so to wait a little longer for peer review should not be too onerous, said Hill. “After a decade of work, I can't wait 6 more weeks for a thorough peer review process? That little bit of extra time at the end to make sure it was done correctly is vital.”

Suppositions and Assumptions

Clarke said the Nelson Memo makes the supposition that the publishing industry will more or less continue to operate as it currently does, the exception being the 1-year embargo will no longer exist. It assumes that universities, teaching hospitals, healthcare systems, pharmaceutical and device companies, large insurance companies, and others won’t cancel subscriptions if the content is freely available—either in a repository or on the journal’s website—when it’s published. The thinking is that the subscribers will still pay for the final version of record.

“I think [all] that’s a pretty big open question,” said Clarke.

Even for publishers of open-access journals, as well as those who have adopted a hybrid model, most of the APCs are subsidized by the subscriptions, he added. For the top-tier journals, there is no price point where open-access publishing is going to work financially because they are highly selective and publish so few papers.

Traditional publishing has to differentiate itself from somebody just putting their findings on Twitter. Y.S. Chandrashekhar

Many clinical journals, including the many published by the American College of Cardiology, American Heart Association/American Stroke Association, and American Medical Association, also print a range of commentaries, editorials, reviews, and other articles that aren’t original research, so institutions may still see value in a subscription. Moreover, the financial future of these large professional associations isn’t in jeopardy if they lose revenue from subscriptions, but it could affect smaller societies that rely on them to help fund not only the publication but also the group’s activities.

“The publication process is a money-making venture for some of the small societies,” said Hill. “If that went away, many of these societies would evaporate. Society has to decide if that's a worthwhile step to take.”

In their editorial last year, the JAMA editors stated that “as stakeholders, we must be willing to pay for the things we value in building and supporting a robust scientific ecosystem.” If the community wants timely public access to the data, in addition to editorial and publishing processes that help bring that work to wider audiences, then there must be a financial investment to make that possible.”

Open Questions?

One of the main goals of the shift toward quicker public access with the updated Nelson Memo, as well as with the European Plan S, is that it eliminates inequities around access. Instead of limiting the research only to those with subscriptions or financial means, the policy is intended to make research broadly available to everybody.

However, as Clarke pointed out, the plan could widen other inequities when it comes to publishing, noting that some researchers with limited government funding may be unable to pay the rising APCs. Additionally, it might create a two-tiered system between funded and unfunded researchers, with only funded researchers being able to publish in open-access journals.

“There will be some researchers with plenty of funding and they won't have issues, but other researchers will have problems,” he predicted.  

Hill agreed.

“If you publish a paper in an open-access journal and you live in a low- or lower-middle-income country, you could be financially challenged,” he said. “If anything, the OSTP is at risk of exacerbating disparities in that respect and not limiting them. Somebody like me with grants, if I have to pay $3,000 or $4,000 to publish an open-access paper, I can handle that. If I live in a low- or lower-middle-income country, I may not be able to.”

As a result, the research appearing in journals could be largely from the same regions, said Hill.

Anticipating such disparities in terms of access, Springer Nature announced that researchers from low-income and lower-middle-income countries could publish their research open access in Nature and other clinical science journals, including Nature Medicine and Nature Cardiovascular Research, without any cost. Several other publishers, including Elsevier, Oxford, and Taylor & Francis, have policies in place to waive the APC if the corresponding author lives in a low-income or lower-middle income country.  

Left unanswered is the question of who would most be affected by the change, said Hill. For example, if there are 15 different authors on a paper, but only one investigator receives NIH funding, does that research need to be made immediately available? What if that federally funded researcher is neither the lead nor senior author?

“We don't know the answer to that right now,” said Hill. “That question has been posed of the government, and to my knowledge an answer has not been forthcoming. There are many, many, many uncertainties.”