W

ASHINGTON — Drug prices finally have lawmakers’ attention.

After years in which the debate over Obamacare has dominated all health policymaking discussion on Capitol Hill, U.S. lawmakers are increasingly turning their attention to the prices that everyday Americans pay for their prescription drugs.

Less than one year ago, when the Senate health committee spent four hours grilling Tom Price, President Trump’s nominee as secretary of health and human services, Democrats focused their most aggressive attention on his support for repealing Obamacare and for making major changes to the Medicare and Medicaid programs, as well as his investments in an Australian biotech company.

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On Wednesday, the same panel heard from Alex Azar, who has been nominated as the next official to take over the helm of HHS. This time the grilling was bipartisan: All but four of the 18 lawmakers, on both sides of the aisle, used their opening remarks and questions to press Azar about different drug pricing and pharmaceutical issues.

Chairman Lamar Alexander of Tennessee and the panel’s top Democrat, Sen. Patty Murray of Washington, made drug prices the subject of their very first questions. Sen. Johnny Isakson (R-Ga.) pressed Azar to draft a list of proposals to “end the gaming of the system” by drug makers and other companies before next July. And Sen. Rand Paul (R-Ky.) suggested he could even oppose Azar’s confirmation unless he receives clearer answers on the safety risks of drug importation.

Most of the Obamacare questions, if they came at all, came as the hearing wound down. Other issues, like Medicare payment initiatives, got almost no attention. It was a stark contrast to the same panel’s focus even just in June, when Democrats derailed a hearing on drug pricing to focus on Republican efforts to repeal Obamacare.

Even Alexander noticed something different was taking place on Wednesday.

“For the last, oh, seems like forever, we have focused on health insurance,” he said in his closing remarks. “There’s so much other important [work] we should we working on when we talk about health, health care and the agencies that you work on. Drug pricing is one this committee has a great interest in.”

The debate over Obamacare is hardly over; a tax reform bill approved by the House and a similar version up for consideration in the Senate this week, for instance, would repeal the law’s individual mandate, a provision that has prompted outcry among Democrats.

It’s also true that congressional interest in drug prices isn’t entirely new. Lawmakers turned their attention to drug pricing in the wake of state-budget-busting drugs like the hepatitis C treatment Sovaldi, headline-grabbing increases like Martin Shkreli’s 5,500 percent price spike for the HIV medication Daraprim, and widespread public outcry. Trump made the issue a central tenet of his campaign for president, and lawmakers on both sides of the aisle have introduced legislation aimed at tackling aspects of the issue.

For the most part, however, lawmakers’ interest has yielded few concrete results. They have largely avoided any policymaking on the issue, even as they delivered major priorities for the industry, like a package of so-called user fees and the 21st Century Cures Act to spur medical innovation.

Azar, a former pharmaceutical executive at Eli Lilly, was sensitive to the shift in tone over drug prices on Wednesday, and gave far longer and more detailed answers to related questions than to queries about issues like access to contraception. He took an early stand on the topic himself, saying the issue would be his top priority for his time at the agency and declaring emphatically, in his opening remarks, that prices are “too high.”

For the most part, the policy solutions he offered are more in line with other conservative thinkers than with Trump, who broke with some Republicans to support more liberal policies like drug importation and Medicare price negotiations on the campaign trail. Azar pushed back on importation in his testimony and dodged questions about negotiation, highlighting instead efforts to increase generic competition and deter abuses of the patent system.

He, like other Republicans and pharmaceutical executives, also shifted some blame from drugmakers and highlighted the role other industry players play in the pricing debate.

“Everybody in the system owns a piece of this,” he said, as Sen. Tammy Baldwin (D-Wis.) pushed him to admit that drug makers, too, had a role. “The system has to get fixed. That’s the problem. … What we need to do is work to fix the system so that [consumers] have insurance that covers that insulin, so they have low out-of-pockets. We’ve got to get the list prices down, also.”

If not for Azar’s tenure at Lilly, drug pricing might be considered an unusual focus for a hearing ostensibly aimed at vetting Azar as health secretary. Few of Azar’s day-to-day responsibilities — or even his authority — would center on drug pricing if he is confirmed. Most of the concerns senators raised would need to be addressed with congressional action, not regulatory changes at the Health and Human Services Department.

Sen. Maggie Hassan of New Hampshire, for example, pressed Azar to opine on the drug company Allergan’s efforts to avoid patent challenges by selling its intellectual property to a Native American tribe. Azar said he shared her concerns — but even he noted he wouldn’t have jurisdiction on the issue. Indeed, any of the major patent system changes he suggested Wednesday would fall to the Patent and Trademark Office Director or, more likely, to Congress.

Major changes to spur generic competitors to existing prescription drugs — the subject of questions from Sen. Susan Collins (R-Maine) — would likely require congressional action. Lawmakers, too, would have to make changes about who is held liable in cases like a Lilly lawsuit, focused on its marketing for the drug Zyprexa, that Sen. Elizabeth Warren (D-Mass.) made the centerpiece of her questions. The same goes for efforts to speed changes to over-the-counter drug marketing, as Sen. Lisa Murkowski (R-Alaska) raised.

In the handful of areas in which Azar could, if confirmed, actually affect pricing policy, his attitude was mixed.

Though he would legally have the authority to encourage the importation of drugs from other countries, he expressed great skepticism of that idea when pressed by Paul and other senators. That skepticism is in line with his earlier comments on the issue, though notably differs from Trump’s.

Interestingly, Azar suggested he would like to explore changes to the way Medicare pays for drugs administered by doctors — an area over which he would have jurisdiction alongside the administrator of the Centers for Medicare and Medicaid Services, Seema Verma. His remarks were notably vague, but offered insight into policies he may try to pursue if confirmed.

“How could we think about the ways to take the learnings from Part D and actually bring lower costs to the system, but also lower costs to the patient because they pay a share of whatever Medicare reimburses in part B?” he asked. “That’s a double win. Lower for the system and lower for the patient on their out-of-pocket costs. That’s the kind of thing I would have energy to see, where we could really save money and actually improve things for our patients.”

Many senators used their second round of questioning to press harder on Obamacare — and lawmakers on the Senate Finance Committee, which has jurisdiction over Medicare policy, will have another chance to question him on those and other issues when that panel takes up Azar’s nomination officially.

That hearing has not yet been scheduled. But Alexander used his remarks Wednesday to announce a few future hearings for his panel, including a Dec. 12 meeting — on drug prices.

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