WASHINGTON — During his State of the Union address Tuesday, President Donald Trump vowed to make health insurance more affordable, bring down prescription drug prices and tackle the opioid addiction crisis.
One man will hold primary responsibility for executing these sweeping goals, and many others, the president enumerated during his hourlong address: Alex Azar II, the new secretary for Health and Human Services (HHS), who was sworn into office Monday, after a divided Senate confirmed his nomination, 55-43.
A former pharmaceutical company president and HHS official in the George W. Bush administration, Azar will control a $1-trillion annual budget that funds Medicaid and related federal programs and supervise 79,000 employees. And transforming or replacing the Affordable Care Act (ACA) will be a top priority.
“The Affordable Care Act has failed millions of Americans who have lost the plans they liked and the doctors they liked,” Azar told senators during his confirmation hearings.
Azar is also expected to defend Trump’s broad religious exemption from the HHS contraceptive mandate. “We have to balance a woman’s choice of insurance with the conscience of their employers,” he said during a Senate hearing.
Likewise, those with knowledge of his moral beliefs say he will back conscience protections for health care workers who oppose abortion and assisted suicide on moral or religious grounds.
“He is a deep-in-the-bones social conservative, and that becomes relevant around” policy issues that deal “with abortion and scientific research,” Yuval Levin, the vice president of the Washington-based Ethics and Public Policy Center and the editor of National Affairs magazine, told the Register.
“He is pro-life and a big believer in the importance of bringing that to bear in agency decisions” that reflect current laws, Levin added. “That kind of leadership makes a difference.”
Indeed, Levin predicted that HHS’ newly established Division of Conscience and Religious Freedom, which will investigate claims by health care workers who face pressure to perform abortions or prescribe life-ending drugs for assisted suicide, will also get a boost from Azar.
“This new division is not well defined, so it matters that the secretary believes it should exist,” said Levin.
Azar’s Past Roles
During Azar’s swearing-in ceremony Monday, however, Trump focused on two issues with strong bipartisan support: skyrocketing prescription drug prices and the opioid scourge that has devastated families and communities across the nation.
The president directed Azar to “unravel the tangled web of special interests that are driving prices up for medicine and for really hurting patients.”
The president and Republican Party lawmakers contend that Azar’s regulatory background and his grasp of the underlying issues that fuel the rise in drug prices and opioid use make him a strong candidate for fixing these problems.
“You’re one of the best public servants that I’ve seen in the whole time that I’ve been here,” Sen. Orrin Hatch, R-Utah, the chairman of the Senate Finance Committee, told Azar, in a reference to previous experience as general counsel and then deputy secretary of HHS in President Bush’s administration. A graduate of Yale Law School, Azar also clerked for Supreme Court Justice Antonin Scalia.
Democrat lawmakers, for their part, take a very different view of Azar’s résumé.
As they see it, his five-year stint as president of the pharmaceutical company Lilly USA, a unit of Eli Lilly and Co., makes him complicit in the contentious practices of drug companies and thus a poor choice for controlling drug costs or mounting a broad federal response to opioid addiction.
Eli Lilly “has been criticized for raising the price of insulin and other widely used medications,” leaving patients to pay more out-of-pocket costs, Fox News reported this week.
Levin, who has known Azar since the two men worked at HHS during the Bush administration, dismissed such criticism, saying Azar joined Lilly after becoming deputy secretary of HHS.
“The relevant experience he brings in is largely as a government executive and senior HHS official” who has “managed a massive federal agency,” Levin said. “That is what a deputy secretary does.”
“And I wouldn’t say he comes in with strong ideological predispositions on health care [policy],” he added, emphasizing the new secretary’s reputation as a strong manager.
That said, Levin acknowledged that Azar could use his standing in the prescription-drug industry to secure reforms designed to bring down drug prices.
“Perhaps a former drug company executive will be the best person to put pressure on drug prices,” he said, by using “Medicare as leverage.”
Once he takes up his duties, Azar may seek to avoid the kind of partisan combat that has dogged the health care-reform debate since the ACA was rammed through Congress in 2010 without one Republican vote. But any effort to secure a consensus — even within the White House and the Republican-majority Congress — will be tough going.
Tough Task Ahead
“The largest policy failure of the past year is the GOP’s inability to dismantle any part of Obamacare besides the individual mandate, after Paul Ryan, Mitch McConnell, Trump and the rest of the party had campaigned against it for the past seven years,” said Dan McLaughlin in his recent report card on Trump’s first year for National Review.
Since that legislative defeat, policy analysts say, the White House has sent conflicting signals on whether it wants to shore up the struggling state insurance exchanges authorized under the Affordable Care Act, dubbed “Obamacare,” or let them fail under the weight of rising premiums that have forced insurers and consumers to flee the exchanges.
During his State of the Union speech Tuesday, Trump spoke about giving Americans “choice in their health care decisions,” but offered few specifics. He was more enthusiastic about other policies with a health care focus, like providing terminally ill patients with greater access to experimental treatments.
The president also promised to address the opioid crisis and vowed to “get much tougher on drug pushers.” But details of a more robust federal response must still be worked out, and specialists and Church leaders suggest that local communities should take the lead.
“The opioid crisis must be addressed at the local level,” close to communities battling this scourge, Bishop Frank Dewane of Venice, Florida, the chairman of the U.S. Bishops’ Committee on Domestic Justice and Human Development, told the Register.
However, the federal government can give the issue more exposure and help fund grassroots outreach led by Catholic Charities’ affiliates and other local agencies, he said.
In the coming months, Church leaders can be expected to share their ideas and concerns with the new secretary, as they have whenever major health care policy initiatives and legislation are on the table.
Last summer, for example, when the Senate approved its own health care-reform bill, Bishop Dewane said the legislation was “unacceptable.”
“[M]ore is needed to honor our moral obligation to our brothers and sisters living in poverty and to ensure that essential protections for the unborn remain in the bill,” read Bishop Dewane’s July 13 letter.
The Bishops’ Approach
As in the past, the bishops’ evaluation of Azar’s agenda will be grounded in Catholic social teaching, from Pope John XXIII’s 1962 encyclical Pacem in Terris, which affirmed medical care as a human right (11), to the Second Vatican Council’s pastoral constitution on the Church in the modern world, Gaudium et Spes, and the Catechism of the Catholic Church.
Bradley Lewis, a political philosopher at The Catholic University of America, told the Register that the U.S. bishops’ approach to health care policy and their insistence on universal access echo elements of Pope Francis’ teaching. The Pope has criticized health care policies that restrict access to medical care, a fundamental human right, and transform it into a consumer product subject to market forces.
But Lewis stressed that the Church has not embraced a particular model for expanded access to affordable, quality health care.
There is a separate issue “of how it is to be organized,” said Lewis. “This seems to be a question best left to experts and to the political process.”
In past years, the U.S. bishops have also evaluated policies designed to reduce the role of Medicaid, the federal program that provides health care to more than 100 million low-income Americans. If Azar moves ahead with a controversial proposal to include work requirements for able-bodied recipients, the bishops may speak out forcefully.
“There is an argument that work is better for [Medicaid recipients], and so states should be able to fix such a requirement in their administration of the program,” said Lewis. “This is an empirical question. … But if we say that health care is a human right, can we then make it conditional on the recipient’s working?”
Joseph Zalot, a staff ethicist at the National Catholic Bioethics Center, offered a more nuanced “personal” view of such a proposal.
“The devil will be in the details,” Zalot told the Register. “In and of itself, the proposal doesn’t seem problematic. But recipients could have child care challenges,” among other hurdles.
HHS Mandate’s Fate
Then Zalot turned to a matter of special importance to the U.S. bishops: the fate of the “ongoing HHS [contraceptive] mandate,” which sparked an explosion of legal challenges from nonprofit and for-profit employers who for moral and religious reasons opposed the provision of contraception in their health plans.
While the National Catholic Bioethics Center applauded Trump’s interim final rule, which granted a broad religious or moral exemption, Zalot noted that some HHS cases are stuck in legal limbo.
The center, an advisory body that provides guidance to U.S. Catholic dioceses and health care institutions, is “concerned” that the HHS mandate still remains on the books.
The new secretary, he said, should “drop the mandate as a whole.”
“Why can’t HHS drop it and not include contraception and sterilization as preventive care?” he asked. “They are not preventive care.”
At present, Zalot’s suggestion seems like a long shot. National surveys confirm broad support for access to free contraception, a trend that received a boost from the past White House administration, which defined oral contraceptives and sterilization as essential “preventive” health care.
Six years after President Obama’s HHS Secretary Kathleen Sebelius issued the contraceptive mandate, Alex Azar, Trump’s point man on health care policy, is in the position to challenge that controversial policy. And by the end of the president’s first term, perhaps he will begin to move national opinion in a very different direction.
Joan Frawley Desmond is a Register senior editor.