W

ASHINGTON — On Wednesday, Alex Azar, the former drug company executive nominated to take over the country’s top health care agency, will face tough questions from the senators who try to keep that department in check.

Azar heads first to the Senate Committee on Health, Education, Labor, and Pensions, whose members share jurisdiction on health care issues with the Senate Finance Committee, which will ultimately preside over his official confirmation hearing.

The last nominee for the job — former HHS Secretary Tom Price — faced nearly four hours of questions at each of his two hearings. Democrats jumped at the chance to grill President Trump’s nominee on politically charged questions about the future of popular programs like Medicare and Medicaid and controversial plans to implement and oversee Obamacare, which remains the law of the land despite repeated legislative attempts to repeal it.

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Senate Democratic aides tell STAT they have a similarly long list of questions for Azar — and particularly specific questions about his 10-year tenure as an Eli Lilly executive, a post he vacated only this year. Republicans will also be likely seeking answers on issues like drug prices and the opioid crisis.

Here’s a rundown of the questions Azar could face Wednesday.

What is his plan to bring down drug prices?

There’s rare bipartisan consensus that prescription drug prices are too high — and Azar’s tenure at Lilly will ensure that topic is front and center with both parties.

Azar oversaw the pharmaceutical giant’s U.S. business at a time when the company was increasing prices — a pattern that is already drawing scrutiny from some Democratic senators who hope the next health secretary will do more to deliver on Trump’s campaign promises to take on drug makers and lower prices. The Trump administration has already pushed several regulatory changes aimed at lowering out-of-pocket drug prices, but it has done little that would upend the pharmaceutical industry’s current pricing practices.

While Azar was at Lilly, the company increased the price of an insulin product — a move now the subject of a lawsuit filed in January, as well as inquiries by five states attorneys general.

Azar has himself offered mixed remarks on the issue. He suggested at a May industry conference that the industry hadn’t changed its pricing practices “one bit,” but also acknowledged that “patients are having to pay too much for drugs,” according to the New York Times.

He’s also pushed back on the idea of drug importation, suggesting that the idea — which supporters say would lead to lower prices — would raise major safety concerns.

Some outsiders see Azar’s experience with the business side of drugs and health care as a boon, giving him better understanding of the Byzantine world of drug pricing, while others are skeptical of the ability of an erstwhile pharmaceutical executive to bring in line his former industry.

How would he avoid conflicts of interest with pharma?

Price was dogged at his own confirmation hearing over his investments in the Australian biotechnology company Innate Immunotherapeutics.

But Azar’s recent departure from Lilly will ensure he gets even more attention. He’ll almost certainly face questions about his plans to recuse himself from decisions and administrative activities that directly involve his former employer, and he may also be asked about how he will handle regulatory decisions that involve other pharmaceutical companies with similar business interests. Though Azar’s financial disclosures show that he no longer holds any Eli Lilly stock, they also detail the millions of dollars he made as an executive at that company.

How would he implement the emergency declaration on the opioid crisis?

Late October, the acting secretary of HHS declared a public health emergency to address the opioid crisis, enabling the department to take a variety of actions, from appointing additional bureaucrats to enabling health care providers to prescribe more medicines without in-person appointments. It would be up to the new secretary to follow through.

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If he’s confirmed, Azar may also find himself on the hook for implementing some of Trump’s directives, especially since the Office of National Drug Control Policy lacks a long-term director. In announcing the public health emergency,  Trump said that HHS would “launch a taskforce to develop and update best practices for pain management across the federal government,” and that the administration would put forward a “massive advertising campaign” to warn people not to start using opioids in the first place. (The potential effectiveness of such programs has been questioned by critics.)

How would he handle the promotion and implementation of Obamacare?

Azar has been a loyal Republican foot soldier in the fight to repeal and discredit the Affordable Care Act, calling the Obamacare markets “fundamentally broken” on Fox Business Network earlier this year. He spoke on that same network in support of an early House Republican draft to repeal the Affordable Care Act, praising the bill for major changes to Medicaid and defending it from criticism at the time that its policies were simply “Obamacare-lite.”

But as health secretary, he would have to make hard decisions about the law, like whether and how to promote the open enrollment periods during which millions of Americans must sign up or renew their coverage. The new secretary will also sign off on any future regulations for the law — including potential changes to rules about how broad an insurer’s network must be, for example, or what is considered an essential health benefit. Along with Seema Verma, the administrator for the Centers of Medicare and Medicaid Services, he’d also have the authority to sign off on the many waivers states have requested to make their own changes to the program.

What restrictions, if any, would he put on the funding of women’s health programs?

If he’s confirmed, Azar will inherit a department at the center of several controversies regarding women’s health. Already, the Trump administration has slashed funding from teen pregnancy prevention programs and encouraged Congress to defund Planned Parenthood. HHS is also expected to release funding guidelines for a family planning grant program worth $300 million annually; many family planning advocates fear those guidelines could result in a de facto “domestic gag rule,” preventing any funding from reaching organizations that provide abortions or provide counseling that includes abortion as an option. Federal funding has long been barred from being used for abortions directly.

Azar hasn’t said much about controversial women’s health issues in his public remarks to date. But Democrats are likely to press the issue on Wednesday. His nomination earned praise from Marjorie Dannenfelser, president of the anti-abortion group Susan B. Anthony List, who said he would “do a great job of implementing the President’s pro-life agenda.”

How would he respond to the health crisis in Puerto Rico?

HHS works with a myriad of other federal agencies, as well as the military, to provide aid in disaster zones like Puerto Rico. The agency helped evacuate some individuals with diabetes after Hurricane Maria so they could continue to receive dialysis treatments, for example. In his role, Azar would oversee the agency in part responsible for managing a long-term solution to the public health crisis.

Separately, the hurricane has had a significant impact on pharmaceutical companies with plants in Puerto Rico, which produce critical drugs and medical devices, from pacemakers to saline bags. Now, hospitals around the country are struggling to stock basic supplies like saline bags as drug companies work feverishly to restore their operations on the island. Meanwhile, hospitals located in Puerto Rico are still dependent on an unreliable power grid; some surgeons resort to operating by flashlight.

What reforms does he want to implement on Medicare and Medicaid?

The new health secretary will have wide latitude to work with Verma on major changes to Medicare and Medicaid, the massive federal health insurance programs for older Americans and lower-income Americans.

Price, a former orthopedic surgeon, took clearest aim at Medicare in his short tenure at HHS, canceling and delaying major pilot programs and loosening other rules that would have overhauled the way the federal government paid doctors and hospitals for certain medical procedures. He worked hard to promote Medicare Advantage, the private alternative to traditional Medicare, and in September, the department began to hint at changes that could have raised premiums for many beneficiaries.

Verma, a former Medicaid administrator, has already laid out a vision for her department’s work on Medicaid — including a plan to encourage states to implement controversial work requirements that could limit access for some enrollees.

The next secretary will have wide ranging authority to speed through those changes or tweak some of the policies Price had pushed across dozens of annual regulations related to their implementation. Azar hasn’t said much publicly about whether he envisions broad changes to the Medicare program. But has publicly supported the idea of block granting Medicaid funds to individual states, a central plank that accompanied congressional GOP efforts to repeal Obamacare this year.

Lev Facher contributed reporting.

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  • What does he plan to do with the current unsustainable reimbursements for durable medical equipment? Do you want to stay in the hospital much longer because you cannot get oxygen, a wheelchair or a hospital bed? me neither.

  • Well, at least with the $9-$20M portfolio he collected while working for Lilly (see linked sidebar Health secretary nominee reaped big earnings from drug industry tenure) he can afford, like Betsy DeVos, to buy and fly his own jet to Phila for lunch, unlike his poor physician predecessor who had to depend on public largesse (which dissipated). And we can confidently predict how successful his “Just Say No to drugs and sex” approaches will be. Love the predictability of this administration. If they possibly can, they will do it wrong!

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