The fact that this careful practical system still pumps out so much bs is very problematic. I think it's the same problem as other research areas, not the fault of the NIH system itself.
breakthrough ideas typically come from unconventional ideas, i.e., risky ideas or ideas likely to fail -- and thus waste taxpayer money.
yet the funding process is mostly about conforming to traditional assumptions, which naturally gates scientific breakthroughs.
the problem lies upstream. politicians don't allow the NIH to fund risky research and waste money.
how about NIH funding those gain-of-function coronavirus experiments (which included human testing) in Wuhan? And when DARPA refused to fund as too risky the additional human targeting coronavirus genetic manipulations in Wuhan, it was NIAID (led by Dr. Fauci - the top politician in life sciences today) which funded it.
Politicians expressly disallowed those experiments. Don't stir stuff up just to stir. It was a non-political agency exec (Fauci?) who apparently sidestepped the typical review process where they would have been killed, and funded them anyway
I also learned from that if you want to get funded by a study section, you volunteer for that section for several years and then you know exactly what to say to get funded.