US President Donald Trump has picked a former top pharmaceutical and government executive to be his health and human services (HHS) secretary.
If confirmed by the Senate, Alex Azar will oversee a $1trn department responsible for major health insurance programmes, medical research, food and drug safety, and public health.
In making the pick, Mr Trump turned to an industry he has rebuked.
The Azar nomination is unusual because HHS secretaries have tended to come from the ranks of elected officials such as governors – not industries regulated by the department.
Mr Azar, 50, a lawyer by training, has spent the last 10 years with pharmaceutical giant Eli Lilly, rising to president of its key US affiliate before leaving in January to start his own consulting firm.
He is seen as an expert on government healthcare regulation.
“He will be a star for better healthcare and lower drug prices!” Mr Trump tweeted in announcing the nomination on Monday morning.
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
As HHS secretary, Mr Azar would have to avoid conflicts with Lilly’s far-reaching interests, from drug approval to Medicare reimbursement.
The drugmaker has drawn criticism from patient advocacy groups for price increases to one of its biggest products: insulin.
Americans consistently rank the high cost of prescription drugs as one of their top healthcare priorities, putting it ahead of divisive issues like repealing “Obamacare” in public opinion polls.
Mr Trump has been a sharp critic of the industry.
“The drug companies, frankly, are getting away with murder,” he said at a Cabinet meeting this autumn.
Prices are “out of control” and “have gone through the roof”, Mr Trump said.
In the spring, a Trump tweet sent drug stocks tumbling after he said he was working on a new system that would foster competition and lead to much lower prices.
In meetings with industry executives, however, Mr Trump has focused on speeding up drug approvals, a cost-reducing tactic they would back.
Professionally, Mr Azar has another set of skills that may be valuable to Mr Trump.
As a top HHS official during the George W Bush administration, the Yale law graduate developed an insider’s familiarity with the complex world of federal healthcare regulation, serving first as the department’s chief lawyer and later as deputy secretary.
Frustrated by fruitless efforts to overturn the Affordable Care Act in Congress, Mr Trump might see the regulatory route as his best chance to make a mark on healthcare.
Congressional Democrats are likely to pounce on Mr Azar’s drug ties, reminding Mr Trump of his promise to “drain the swamp” of Washington influence peddling.
Azar admirers say his industry experience should be considered an asset, not a liability.
“To the extent that the Trump administration has talked about lowering drug prices, here’s a guy who understands how it works,” said Tevi Troy, who served with Mr Azar in the Bush administration and now leads the American Health Policy Institute, a think tank focused on employer health insurance.
“Would (Azar) have been better off if he had been meditating in an ashram after serving as deputy secretary?” he added.
If confirmed, Mr Azar would be Mr Trump’s second HHS secretary, replacing former Georgia congressman Tom Price, who stepped down after just seven months, when his use of private charter planes for government travel created a public controversy that displeased the president.