Mr. Azar goes back to Washington

It's a propitious time, at least for conservatives, for Alex Azar to take the top job at HHS. All elements have aligned for him to mold the Affordable Care Act, Medicaid and Medicare according to a vision they can support.

Things have changed since Azar last served at HHS under President George W. Bush. The ACA didn't exist then, and the Bush era's major overhaul to Medicare with Medicare Advantage and Medicare Part D became Azar's signature accomplishments during his time at the department.

It's his experience with these reforms that indicate how he would reshape the ACA, grapple with rising drug prices and manage Medicare and Medicaid.

Now Azar is poised to take the helm at the mammoth department and its $80 billion budget. The Senate Finance Committee is expected to move his nomination to the full Senate in the coming weeks amid a lack of known opposition to his being confirmed as HHS secretary. During his confirmation hearings, he left little doubt that he can advance his agenda with an efficiency that eluded the embattled Dr. Tom Price.

Azar—a former HHS legal counsel and deputy secretary, as well as a powerful pharmaceutical industry executive—holds Democratic respect for his expertise even if they fear his policy positions. And, according to former colleagues, he is also respected by the career HHS staff. He will have the winds of cooperation at his back.

"HHS will like him," said Tom Scully, who, as former CMS administrator under George W. Bush, worked with Azar when Azar was general counsel.

"I think Alex will accomplish a lot as the HHS secretary," said Roman Gurule, a former CMS official under Presidents George W. Bush and Barack Obama who also worked with Azar. Gurule acknowledged he may not agree with many of Azar's policies, but he admires the nominee's smarts and expertise. "As deputy secretary, he was the substantive policy and organizational leader kind, not the usual ceremonial kind."

Similar accolades flow in, with words like "leadership," "true gentleman," "fair" and "process guy."

As Scully noted, Azar is also an Indiana person: he led U.S. operations for Indianapolis-based pharmaceutical giant Eli Lilly and Co. The geographic link to Vice President Mike Pence, an Indiana native who has been chiefly responsible for staffing senior positions at the CMS, forms a ready alliance with appointed staff. Scully also expects Azar to slide into an easy working relationship with CMS Administrator Seema Verma, another Hoosier. This would contrast sharply with the experience of Price, whose reported personality clashes with Verma—even though they supported similar policy measures—fueled Washington gossip during Price's tenure.

Former colleagues and friends say Azar is a man of his word and will accomplish what he promises—reshaping the ACA exchanges, making value- and market-based program changes along the lines of Medicare Advantage, tackling drug prices in Medicare and curbing Medicaid. And he is expected to do all of that collaboratively.

Medicare Advantage and Medicare Part D offer a key lens into Azar's approach to the policy goals he said he will tackle if confirmed.

"How we developed and finalized the (Medicare Advantage) policy, how we reached out to the American public about the drug benefit—Alex spent a lot of time on the road explaining the new coverage—through all of that he was very committed to getting the policies right and getting them out there," McClellan said.

Azar also touted his accomplishments in Medicare as the way forward through involving private companies in policy implementation.

Value-based payment models, Azar said, are the future. "We must harness the power of Medicare to shift the focus in our healthcare system from paying for procedures and sickness to paying for health and outcomes," he said. This way, the government can leverage "what is best in our programs and in the private, competitive marketplace."

Senate Democrats, though, blasted Azar for the unprecedented spikes in Eli Lilly's insulin prices that occurred during his tenure as president of the company's U.S. division.

The system is to blame, Azar told senators. Drug companies have every incentive to keep prices high.