The minority party's efforts during the Senate Finance Committee hearing did not appear to halt his path toward joining the president's Cabinet. Republicans bestowed superlatives on Azar and highlighted his senior roles at the Department of Health and Human Services for a half-dozen years in the early 2000s. And during nearly 2½ hours of questioning, the nominee delivered a polished, informed performance in the witness chair, assuring senators, who have at times felt slighted by administration officials, that he is eager to work with them.
Azar distanced himself from a long-simmering idea that President Trump has intermittently supported: allowing the government to directly negotiate prices with pharmaceutical manufacturers for the drugs sold through Medicare. He insisted that such a system would not save money and could restrict access to some medications.
On other issues, Azar clung to Republican orthodoxy like the conservative that he is. He suggested that he favors converting Medicaid from its half-century history as an entitlement program open to anyone who is eligible into a system of block grants with more freedom for states to set the rules. He acknowledged, however, that "the devil is in the details."
Pressed by Democrats, he also addressed the issue of requiring that able-bodied adults work or prepare for jobs to qualify for Medicaid — a fundamental change that has gained currency within the administration. Azar said he did not have a definition of able-bodied but did not distance himself from the idea.
As for the Affordable Care Act, Azar subtly endorsed a Trump executive order and recent Labor Department proposal to make it easier for individuals and small businesses to buy health plans that do not meet the law's requirements for covered benefits and other consumer protections. While not mentioning the administration's moves, he said the government should find ways within the law to promote "more choice of insurance . . . that fits [consumers'] needs."
Azar, 50, would succeed Trump's first HHS secretary, Tom Price, a former Georgia congressman who resigned under pressure in September while being investigated for having flown in private charter planes to official events at taxpayers' expense.
In contrast with Price, who ended the long-standing practice of HHS secretaries meeting regularly with Senate Finance Committee members, Azar told senators, "I would love to learn more from you" and "I'd love to hear any ideas you have."
As he did during a courtesy hearing in November before another Senate committee, Azar cited drug prices among four issues he would treat as HHS priorities if confirmed. Reiterating that "drug prices are too high," he said he favors fostering different incentives for pharmaceutical companies in setting list prices, along with greater competition from generic drugs and biosimilars.
Still, he said, "There is not one action that all of a sudden fixes this."
Tommy Thompson and Mike Leavitt — former governors who served as HHS secretaries under George W. Bush — introduced Azar at the hearing, praising the competence and character they said they saw in him when they were his boss in Washington.
They and other Republicans have focused on the fact that Azar would come to the job with greater working knowledge of the sprawling agency, with its budget of more than $1.1 trillion and far-flung staff of nearly 80,000, than many of his predecessors. During Bush's two terms, Azar spent four years as the department's general counsel, then two years as deputy secretary.
Leavitt said he does not know of any previous HHS secretary nominees who have been "in position to hit the ground running like Alex Azar."
His nomination has drawn support from leading organizations across the health-care realm, including the American Public Health Association and American Medical Association, the main trade group for health insurers and the hospital industry's two major associations.
But Public Citizen and about five dozen other liberal groups dispatched a letter last week to every senator, citing his criticism of the ACA and his work at Lilly as reasons to reject his nomination.
Azar would be the department's first secretary with a background in the pharmaceutical industry. After he left HHS a dozen years ago, he joined Indianapolis-based Lilly, becoming president of its largest affiliate, Lilly USA, in 2012. He resigned a year ago, saying he wanted to explore other opportunities.
He testified that his other broad priorities would be making health care more affordable, altering Medicare to reward providers for promoting good health and tackling the opioid epidemic.
During the hearing's opening, the committee's top Democrat took a strong swipe at both the president's judgment and Azar's history as a top Lilly executive. "The same Donald Trump who said almost exactly one year ago that price-hiking drug companies were 'getting away with murder' has nominated a drug company executive with a documented history of raising prescription drug prices to captain the administration's health-care team," Sen. Ron Wyden (D-Ore.) said.
Sen. Debbie Stabenow (D-Mich) asked Azar under what conditions he would support the government negotiating with drug companies in an effort to curb prices. He identified specific instances but refused to endorse extending that to all of Medicare's Part D drug benefits.
Later, the nominee told Sen. Claire McCaskill (D-Mo.) that the government would not save money through direct negotiations with drugmakers on prices charged in Medicare, compared with the current system of private companies doing such negotiations.
"What you are telling me with a straight face is, if you remove the provision [in a 2003 law] that prevents direct negotiation, there would be no savings?" McCaskill asked. Azar stood by his position.
The committee's minority senators tried to mine his position on conservative ideas for redesigning Medicaid and Medicare. Wyden contrasted what he branded the administration's "sabotage policy" toward the ACA, with Azar's enthusiastic efforts on behalf of Medicare Part D during the Bush administration. "When it came to supporting the Medicare prescription drug benefit, he toured like he was in the Grateful Dead," Wyden said.
The Finance Committee is expected to vote later this month on whether to recommend Azar's confirmation to the full Senate.