Alex Azar Confirmed as HHS Secretary After Doubling Insulin Prices at Eli Lilly

On January 24, 2018, the Senate confirmed Alex Azar as Secretary of Health and Human Services by a vote of 55-43, installing as the nation’s top healthcare regulator a pharmaceutical executive who had overseen dramatic insulin price increases during his decade at Eli Lilly. As President of Lilly USA from 2012 to 2017, Azar presided over a doubling of insulin prices—Humalog rose from $123 per vial in January 2012 to $255 in early 2017, with annual price increases of 20.8 percent (2014), 16.9 percent (2015), and 7.5 percent (2016). Senator Ron Wyden noted during confirmation hearings that Azar “never, not one time, signed off on a decrease in the price of a drug” during his Eli Lilly tenure. Azar’s confirmation exemplified the pharmaceutical industry’s regulatory capture of HHS, installing a former drug company executive to oversee the very industry he had enriched through aggressive pricing strategies.

Azar’s Pharmaceutical Industry Career: Three Decades of Revolving Door

Alex Azar’s career epitomized the revolving door between pharmaceutical companies and federal health agencies:

First Government Stint (2001-2005): Azar served as General Counsel of HHS (2001-2005) and Deputy Secretary of HHS (2005-2007) under President George W. Bush. In these roles, Azar helped shape policies governing drug approval, Medicare, and pharmaceutical industry regulation—gaining deep knowledge of regulatory processes and agency operations.

Eli Lilly Career (2007-2017): In June 2007, Eli Lilly CEO Sidney Taurel hired Azar as the company’s senior vice president of corporate affairs and communications—essentially its top lobbyist and spokesman. Azar’s value to Lilly stemmed from his HHS insider knowledge, relationships with current officials, and understanding of regulatory vulnerabilities. In April 2009, Azar became vice president of Lilly’s U.S. Managed Healthcare Services organization. In 2012, he was promoted to President of Lilly USA, overseeing the company’s entire U.S. pharmaceuticals business until 2017.

Return to HHS (2018-2021): President Trump nominated Azar for HHS Secretary on November 13, 2017, returning him to the agency he had left a decade earlier. His confirmation made him the first former pharmaceutical executive to lead HHS, creating unprecedented conflicts where the regulator was a recent employee of the regulated industry.

Post-HHS Industry Return (2022-present): After leaving HHS in January 2021, Azar became chairman of the board of LifeScience Logistics in January 2022, a company managing Florida’s Canadian drug importation program. Remarkably, Azar’s HHS had certified the safety of drugs imported from Canada in September 2020—a decision directly benefiting his future employer. This fourth spin through the revolving door demonstrated how officials can profit from their own policy decisions by joining companies that benefit from those policies.

Insulin Price Increases: 108 Percent in Five Years

Azar’s tenure at Eli Lilly coincided with dramatic insulin price inflation:

Humalog Price Trajectory: When Azar joined Eli Lilly in 2007, Humalog insulin cost $74 per vial. By the time he became President of Lilly USA in 2012, the price had risen to $123 per vial. By early 2017 when Azar left to join the Trump administration, Humalog cost $255 per vial—a 108 percent increase in five years under his leadership and 244 percent increase over his decade at Lilly.

Annual Price Increase Pattern: Under Azar’s leadership of Lilly USA, Humalog prices increased by 20.8 percent in 2014, 16.9 percent in 2015, 7.5 percent in 2016, and 7.8 percent in the first quarter of 2017 before Azar’s departure. This pattern of double-digit annual increases occurred despite insulin being a century-old drug with minimal manufacturing cost changes, proving prices reflected profit maximization rather than cost recovery.

Humulin Similar Pattern: Humulin, Eli Lilly’s other major insulin product, followed a similar price trajectory during Azar’s tenure, demonstrating a systematic pricing strategy rather than product-specific factors driving increases.

Industry-Wide Collusion Allegations: Eli Lilly, along with Novo Nordisk and Sanofi, controlled the U.S. insulin market and implemented nearly identical price increases simultaneously. A 2017 class-action lawsuit accused the three companies of exploiting the drug pricing system to increase profits through coordinated pricing. Eli Lilly was also fined in Mexico for colluding on insulin prices, providing evidence that price coordination extended beyond U.S. borders.

Senate Confirmation Debate: Pharmaceutical Fox in Healthcare Henhouse

Azar’s nomination generated intense controversy:

Ron Wyden’s Opposition: Senator Ron Wyden (D-OR), ranking member of the Senate Finance Committee, became Azar’s most vocal critic. During confirmation hearings, Wyden asked whether Azar had ever signed off on decreasing a drug’s price during his Lilly tenure. When Azar could not cite a single price reduction, Wyden declared: “That is what this nomination is really about. You never, not one time, signed off on a decrease in the price of a drug.”

Congressional Progressive Caucus Statement: The CPC warned that “Mr. Azar’s appointment would send a very clear signal that your Administration is happy to put the pharmaceutical fox in charge of the health care henhouse. It would also be a perfect example of revolving door practices that are undermining the public’s trust in their federal government.”

Industry Insider Criticism: Healthcare reform advocates noted that Azar represented “the ultimate pharmaceutical industry insider: he has gone through the revolving door from government to lobbying several times to ascend to the helm of pharmaceutical giant Lilly USA.” They argued that Azar’s decade enriching Eli Lilly through price increases made him fundamentally unsuitable to regulate drug pricing or protect patient interests.

Trump’s Contradiction: President Trump had repeatedly attacked pharmaceutical companies for “getting away with murder” and promised to bring down drug prices. Nominating a pharmaceutical executive who had dramatically raised drug prices contradicted Trump’s populist rhetoric, exposing his healthcare promises as empty campaign slogans.

55-43 Confirmation Vote: The Senate confirmed Azar with seven Democrats supporting him and one Republican (Rand Paul) opposing. Democratic supporters argued Azar’s government experience made him qualified despite industry ties, while opponents viewed his pharmaceutical career as disqualifying. The party-line vote reflected partisan polarization that prevented ethical concerns from blocking nominees.

Conflicts of Interest: Regulating Former Employers and Industry

Azar’s HHS appointment created profound conflicts of interest:

Regulating Eli Lilly: As HHS Secretary, Azar oversaw the FDA (which approves Eli Lilly drugs), CMS (which sets Medicare payment rates for Eli Lilly products), and OIG (which investigates pharmaceutical fraud). His decade at Lilly meant he would regulate his former employer and colleagues, creating obvious conflicts between his public duties and personal loyalties.

Industry Relationships: Azar maintained extensive relationships throughout the pharmaceutical industry from his lobbying and executive roles. These connections made him potentially susceptible to industry influence through personal friendships, future employment prospects, and shared worldview with pharmaceutical executives.

Financial Holdings: While Azar divested direct Eli Lilly stock holdings as required, ethics experts noted that his wealth came primarily from his pharmaceutical career. This meant his financial interests remained aligned with industry profitability even after divesting specific stock positions.

Revolving Door Expectations: Azar’s career path—government to industry to government to industry—created expectations that favorable treatment of pharmaceutical companies might lead to lucrative post-government opportunities. His subsequent position at LifeScience Logistics confirmed these expectations, demonstrating how officials anticipate future industry employment while still in government.

HHS Actions Under Azar: Industry-Friendly Policy

Azar’s HHS tenure reflected pharmaceutical industry priorities:

Drug Importation Certification: In September 2020, just two months before Trump lost re-election, Azar certified the safety of drugs imported from Canada—a policy the pharmaceutical industry had opposed. However, Azar’s certification benefited LifeScience Logistics, whose board he would chair 16 months later. This decision raised questions about whether Azar was positioning himself for post-government employment while still serving as HHS Secretary.

Limited Drug Pricing Action: Despite Trump’s rhetoric about lowering drug prices, Azar’s HHS took minimal action to reduce pharmaceutical costs. Proposed policies like international reference pricing and importation faced implementation delays and industry lobbying that prevented meaningful price reductions during Azar’s tenure.

COVID-19 Vaccine Contracts: During the COVID-19 pandemic, Azar’s HHS negotiated Operation Warp Speed contracts with pharmaceutical companies, providing billions in federal funding for vaccine development. While these contracts successfully accelerated vaccine production, critics noted generous terms that protected pharmaceutical profits rather than maximizing public value.

Medicare Part D Protected: Azar defended the Medicare Part D noninterference clause that prohibited direct drug price negotiation—the same provision that enriched pharmaceutical companies including his former employer. His opposition to Medicare negotiation aligned with industry interests rather than taxpayer protection.

Insulin Crisis: Patients Rationing Life-Saving Medication

The insulin price increases Azar oversaw had devastating human consequences:

Patient Deaths: Multiple diabetic patients died from insulin rationing due to unaffordable prices. Alec Smith, a 26-year-old Minnesota man, died in 2017 after rationing insulin because he couldn’t afford $1,300 monthly costs after aging off his parents’ insurance. His death occurred while Azar was transitioning from Eli Lilly to HHS nomination, linking Azar’s pricing decisions directly to patient mortality.

Rationing Epidemic: Studies found that one in four diabetic patients rationed insulin due to cost, skipping doses or using less than prescribed to stretch supplies. This rationing led to emergency room visits, diabetic ketoacidosis, permanent complications, and deaths—all resulting from pricing decisions executives like Azar approved.

Financial Devastation: Even patients who didn’t ration faced financial hardship, with insulin costs consuming disproportionate shares of household budgets. Families chose between insulin and rent, food, or other medications—the kind of impossible choices that Azar’s pricing strategies forced onto vulnerable patients.

Bipartisan Outrage: Insulin pricing became one of few healthcare issues generating bipartisan anger, with Republicans and Democrats agreeing that price increases were unjustifiable. This consensus made Azar’s nomination particularly controversial, as both parties recognized the harm his policies had caused.

Regulatory Capture: Industry Employee as Industry Regulator

Azar’s confirmation exemplified pharmaceutical industry regulatory capture:

Captured Agency Leadership: HHS’s mission includes protecting public health and controlling healthcare costs. By appointing a pharmaceutical executive who had enriched his company through price increases, Trump ensured HHS leadership would prioritize industry profitability over patient protection—the definition of regulatory capture.

Industry Worldview: Azar’s decade in pharmaceutical industry leadership meant he internalized industry perspectives on pricing, regulation, and competition. This worldview made him unlikely to challenge industry practices or pursue aggressive regulation, as doing so would contradict the beliefs that had guided his corporate career.

Revolving Door Incentives: Knowing that favorable treatment of pharmaceutical companies could lead to lucrative post-government employment, Azar faced strong incentives to maintain good industry relationships while serving as HHS Secretary. His subsequent board position at LifeScience Logistics confirmed that industry rewarded officials who protected its interests.

Bipartisan Capture: Azar’s confirmation with seven Democratic votes demonstrated that regulatory capture transcends partisan politics. Both parties accept pharmaceutical industry influence and revolving door practices, with only vocal minorities in each party challenging these arrangements.

Comparison to Previous HHS Secretaries

Azar’s pharmaceutical industry background departed from historical norms:

Traditional Backgrounds: Previous HHS Secretaries typically came from government service, academia, state government, or healthcare delivery (hospitals, clinics). While many had industry consulting or board experience, none had spent a decade as a pharmaceutical executive immediately before appointment.

Tom Price Precedent: Azar replaced Tom Price, who resigned amid private jet scandals after seven months. Price was a physician and congressman with healthcare stock investments, but not a pharmaceutical executive. Azar represented an escalation in industry capture, moving from an investor/legislator to a direct industry employee.

Industry Influence Evolution: The progression from traditional public health officials to physician-investors (Price) to pharmaceutical executives (Azar) reflected the pharmaceutical industry’s increasing success in capturing HHS leadership positions. Each step normalized greater industry involvement in regulating itself.

The LifeScience Logistics Board Position: Profiting from Own Policy

Azar’s post-HHS career confirmed revolving door corruption:

January 2022 Board Chairmanship: Thirteen months after leaving HHS, Azar became chairman of LifeScience Logistics’s board, a company managing Florida’s Canadian drug importation program. This position paid Azar for expertise and connections gained through public service.

Benefiting from Own Policy: As HHS Secretary, Azar certified the safety of Canadian drug imports in September 2020, a necessary step for Florida’s program. His certification directly benefited his future employer, raising questions about whether Azar’s policy decision was influenced by future employment prospects.

Unusual Reversal: Azar’s certification of Canadian imports contradicted the pharmaceutical industry’s traditional opposition to importation. This unusual position suggested Azar was positioning himself for opportunities in the importation business, prioritizing personal career prospects over industry consensus.

Conflict of Interest Accusations: Yale professor Ivana Katic stated that Azar’s position “can appear as a conflict of interest,” because his HHS policy decision later benefited him professionally. This case illustrated how officials can personally profit from their policy decisions by joining companies those policies help.

Systematic Corruption: Revolving Door as Legalized Bribery

Azar’s career trajectory exposed revolving door mechanics:

Delayed Compensation Model: Rather than accepting bribes while in office, officials like Azar pursue industry-friendly policies knowing they’ll be rewarded with lucrative employment after leaving government. This delayed compensation model achieves the same corrupt outcomes as bribery while technically remaining legal.

Information and Access Value: Azar’s value to employers came primarily from insider knowledge of government processes, relationships with current officials, and ability to navigate regulatory systems. This information asymmetry makes former officials valuable regardless of explicit quid pro quo arrangements.

Bidirectional Influence: The revolving door operates in both directions—industry employees enter government knowing they may return to industry, while government officials pursue policies that maintain their industry employability. This creates continuous pressure toward industry-friendly positions at every career stage.

Bipartisan Tolerance: Despite public criticism, both Republican and Democratic administrations have appointed pharmaceutical industry insiders to health positions, demonstrating that revolving door practices persist regardless of which party controls government. This bipartisan tolerance suggests industry capture extends beyond individual administrations to the overall system.

Public Health Consequences

Azar’s appointment had measurable impacts on healthcare policy and outcomes:

Drug Pricing Inaction: The Trump administration took minimal effective action on drug pricing despite repeated promises, with Azar’s industry loyalty likely contributing to implementation delays and weak policy design. Insulin and other prescription drug prices continued rising during his tenure.

Industry Confidence: Appointing a pharmaceutical executive as HHS Secretary signaled to the industry that it faced no serious regulatory threat, allowing companies to maintain pricing and marketing practices without fear of aggressive enforcement.

Public Cynicism: Azar’s appointment reinforced public perceptions that government serves corporate interests rather than citizens, contributing to declining trust in institutions and political disengagement—corrosive effects that extend beyond healthcare policy.

Precedent for Future Capture: By confirming Azar despite obvious conflicts, the Senate established a precedent that pharmaceutical executives are acceptable HHS nominees. This normalization makes future appointments of industry insiders more likely, deepening regulatory capture over time.

The January 24, 2018 confirmation of Alex Azar as HHS Secretary—following his decade at Eli Lilly where he doubled insulin prices—exemplified pharmaceutical industry regulatory capture, installing as healthcare regulator a former drug company executive whose career demonstrated prioritization of corporate profits over patient welfare, a pattern he continued through policy decisions that later benefited his post-government employers.