Alex Azar, President Trump's pick to lead the Department of Health and Human Services, faces questions from both Democrats and Republicans about how he would handle Obamacare and what he would do to reduce spending on prescription drugs, issues he has discussed openly in media interviews in recent months.
Azar, who worked at pharmaceutical giant Eli Lilly and is a former health official in the George W. Bush administration, has called Obamacare "fundamentally broken" and "failing," while lamenting that Republicans were not adequately working to sell their healthcare replacement to the public.
"The president, the HHS secretary, leadership, they've got to be out there talking, educating people ... It's got to be 24/7. That's how Obama got Obamacare through," Azar said in April.
Echoing the same frustration roughly two months later, he said, "Folks have to be out there talking about this to the point that they almost want to throw up they are so tired of explaining all the good things in the change. Unfortunately, that's not really happening right now."
The Republican effort failed in July, but some Republicans plan to bring it back next year. Azar's nomination, announced Monday, comes after Trump's former secretary, Dr. Tom Price, resigned in September because he was discovered to have used charter jets for travel. Both repealing Obamacare and lowering drug prices were central healthcare promises to Trump's campaign for the Oval Office. When announcing Azar as his pick for health chief, Trump touted that Azar would help him deliver on "better healthcare and lower drug prices."
Happy to announce, I am nominating Alex Azar to be the next HHS Secretary. He will be a star for better healthcare and lower drug prices!— Donald J. Trump (@realDonaldTrump) November 13, 2017
If confirmed, the Trump administration would inherit a health secretary who understands federal regulatory actions and has put thought into how he would make changes to Obamacare. The law gives a wide range of discretion to an administration for implementing its details.
"I would do a top-to-bottom comprehensive rewrite of the regulations of Obamacare imposing as much free-market, localized flexibility as humanly possible," Azar said in one interview.
Some of those changes began under Price, who shortened Obamacare's open enrollment and cut funding for advertising and navigators. Democrats have charged the changes were intended to "sabotage" Obamacare, but sign-ups, since open enrollment started Nov. 1, are outpacing those under the Obama years.
The next health secretary can take other actions that proponents of Obamacare say would weaken the law. Some proposals would include loosening the individual mandate requiring Americans to purchase health insurance or pay a fine. Such a move, Azar has said, would "hasten its demise." He further has suggested reducing regulations or interference in the health insurance industry, changes he said would lower premiums.
As the GOP healthcare plan was being debated in March, Azar mostly emphasized that he believed the legislation Republicans had introduced was better than the current system.
"From a conservative, free-market perspective, this repeal legislation is quite bold," he said.
He later called the Senate bill the "largest structural reform to an entitlement program in our history" because of the changes the bill made to Medicaid. Under the legislation, which failed in the Senate, Republicans sought to cut the rate of growth in Medicaid as a way to reduce long-term spending on the program.
In interviews on Fox Business in March, he sided with the Republican stance by saying evaluations from the Congressional Budget Office of the healthcare bill were off target. Estimates showed that roughly 23 million more people would be uninsured in a decade if the bill were to become law.
"CBO is notoriously bad at predicting dynamics of the insurance market," Azar said. "They have never gotten it right. They do a fine job as normal economists. But when United Healthcare, Aetna, Anthem, when they can't even predict their risk pool, their enrollment levels for the coming year in Obamacare, how the devil do we think that a bunch of health economists in Washington, in the government are going to a better job than them 10 years out?"
Azar also has indicated he believes Obamacare is on its last legs.
"It's certainly circling the drain," Azar said in response to a question about whether Obamacare was dead. "Obamacare plans are following the laws of economics. If you're running an insurance company you've got to be able to make money. To make money running an insurance company you have to be able to predict risk."
Azar went on to say that one way the federal government could help stabilize Obamacare would be to create a reinsurance fund. The program allows for federal dollars to go toward paying for medical claims of more costly enrollees, thereby keeping the premiums for other customers lower.
"I don't think there is going to be a lot of appetite for doing that either in the Trump administration or up in Congress," he said.
While many of Azar's recent interviews have focused on Obamacare, Democrats are expected to question his ties to Eli Lilly. During his campaign, Trump had said that drug companies were "getting away with murder," and he has met with Democrats, including Rep. Elijah Cummings, D-Md., to discuss solutions.
Cummings panned Trump's HHS choice on Twitter Monday, noting that he had sent a letter last year to the drug maker about its pricing of insulin.
"#Potus said PHRMA has been 'getting away with murder,' so why is he nominating a former #EliLilly drug exec to lead HHS?" Cummings tweeted Monday. Eli Lilly, Cummings continued, had "raised drug prices by double digits under his watch" and choosing Azar was "like a fox guarding the hen house. This is a slap in the face to millions of Americans who are waiting on POTUS to take action to lower drug prices."
Azar has shed some light on his stance on lowering drug prices in media interviews and other public appearances, saying he is opposed to one proposal that would allow drug importation from Canada. Like other drug executives, he has said such a move would be unsafe for patients.
"The U.S. distribution system is a crown jewel. Let's not mess that up," he said.
Instead, he has suggested that the president tell his trade negotiators to go after Europe and "get off the free ride on the investment and innovation."
"They have such radical price controls over in Europe, get on them for those unfair practices and see if we can get more investment from them," he said, arguing that the U.S. pays a disproportionate share of the cost. He also proposed accelerating approvals of generic drugs and touted a GOP healthcare bill for repealing certain taxes on drug companies, a move he said would allow for more moderate increases in prices.
"We need a policy environment that recognizes rewards and speeds innovation," Azar said in 2014 at the MIT Sloan BioInnovations Conference.
The Trump administration has signaled it believes Azar will be confirmed. Ryan Murphy, a spokesman at HHS, noted in an email that Azar had been confirmed unanimously as general counsel and confirmed later as deputy secretary of the agency under Bush, putting him at second-in-command under then-Secretary Mike Leavitt.
Republicans control 52 seats in the Senate and Azar needs 51 votes to be confirmed, including a possible tie-breaking vote by Vice President Mike Pence.