WASHINGTON—President Trump has vilified the pharmaceutical industry and made bold promises to lower prescription drug prices. But when it comes to staffing the health care agencies empowered to oversee those efforts, he has turned regularly to the pharmaceutical industry.

His Food and Drug Administration chief, Scott Gottlieb, was a longtime industry investor and adviser to major players like GlaxoSmithKline and Bristol-Myers Squibb. A senior adviser at the Health and Human Services Department, Keagan Lenihan, joined the administration after running the lobby shop for the drug and distribution giant McKesson. Tim Clark, the White House liaison for political personnel at HHS, was still lobbying for pharma company Eisai earlier this year. And Trump has a former Gilead lobbyist, Joe Grogan, reviewing health care regulations at the Office of Management and Budget. The chief of staff at HHS, Lance Leggitt, lobbied for a whole host of drug clients, even last year.

This week the president named Alex Azar, who spent more than a decade at the pharmaceutical giant Eli Lilly, as his health secretary nominee.

It’s a lengthy list that highlights just how reliant Trump is on the industry he has promised time and again to rein in. And his picks stand out when compared with those of previous administrations. In a STAT review of the public biographies of more than five dozen top health officials and advisers across the Obama, Bush and Clinton administrations, only a handful of individuals appear to have joined the administration directly from the private sector.

“The trends in pharmaceuticals kind of run in parallel to the trends in the financial sector and Wall Street—you have an industry that Trump ran against pretty aggressively, with pretty strident language in 2016, and he is now seeing those industries as essentially farm clubs. He’s going to bring them up to the major leagues of his administration,” said Jeff Hauser, who runs the Revolving Door Project at the Center for Economic and Policy Research. “It’s unusually stark and unapologetic.”

The personnel decisions also raise ethical and conflict-of-interest concerns, Hauser and several other ethics experts said. While Trump’s hires probably don’t run afoul of the nation’s narrow ethics rules that ensure officials don’t directly profit from government work or oversee specific cases related to companies they’ve worked for, there’s still a reason to be concerned, said Kathleen Clark, a Washington University law professor who studies government ethics law.

“If you’ve been employed at Lilly, you might well have a similar kind of attitude toward another drug company, even if it’s not Lilly. Our ethics standards don’t reach that concern at all,” she said. Given that, “the health policy is likely to reflect the values, the priorities of people who have recently been making their living in pharma.”

The former pharmaceutical industry players could leverage their experience to pursue reforms. Indeed, that’s the argument from several Republican officials, including Grogan, the OMB program associate director for health, who this week suggested the administration would be better able to bring down drug prices because it has more pharmaceutical industry perspective in its ranks than the Obama administration did.

Republicans on Capitol Hill reflected a similar confidence in their statements of support for Azar, nearly all of whom praised his “private sector experience.”

“Alex Azar has the qualifications and experience to get results,” said Senate health chairman Lamar Alexander, whose committee will oversee Azar’s pending nomination and who oversaw Gottlieb’s earlier confirmation process.

Republicans have also highlighted both Azar’s and Gottlieb’s long experience in government itself. Both were former Bush administration officials; Azar was a deputy secretary at HHS and Gottlieb spent time at both the FDA and CMS. Leggitt and Grogan also served under Bush.

“The President selects the highest caliber of individuals from an array of backgrounds and experiences – including industry leaders – to fill positions in his Administration,” Hogan Gidley, deputy White House press secretary, said in a statement. “The White House takes seriously the need for appointees to resign, recuse and divest where required. The White House Counsel’s Office and agency ethics officials work closely with all presidential appointees to avoid conflicts arising from their former places of employment or investment holdings.”

But consumer advocates—and Democrats—argue that at least so far, Trump’s track record on reining in pharma has amounted to little more than showmanship. The administration has not yet delivered on any legislation or executive orders that might lower drug prices. Instead it has delivered several major industry priorities, like a major funding package for the FDA and regulatory changes to a drug discount program the industry hopes to overhaul.

“At a time when the United States pays, by far, the highest prices in the world for prescription drugs, the last thing we need is to put a pharmaceutical executive in charge of the Department of Health and Human Services,” Sen. Bernie Sanders (I-Vt.) said of Azar’s nomination.

Pointing to statements from Azar that reflect many of the industry’s positions, Public Citizen president Robert Weissman went further.

“If Alex Azar’s nomination is confirmed,” he said, “then Big Pharma’s coup d’etat in the health care sphere will be virtually complete.”

Azar is the first person nominated to the health secretary with such a direct path from industry. Every other top health official to hold the spot in the last 30 years had gubernatorial experience, served in Congress or helmed another agency. Only Donna Shalala, President Clinton’s pick for health secretary, and Louis Sullivan, President George H. W. Bush’s pick, did not—but both came from academia, not from industry.

Gottlieb, too, stands out among FDA commissioners. Nearly every former FDA commissioner in the last 30 years has joined his or her administration from an academic or medical post, a nonprofit, or another government position. The same holds true for administrators of the Centers for Medicare and Medicaid Services.

Just one of the 15 officials who held either of those posts since 1985 came from industry: Tom Scully, who helmed CMS under George W. Bush, had led the Federation of American Hospitals, a trade group for for-profit health systems. Though Bush appointee Lester Crawford did not join directly from industry, he did ultimately plead guilty to hiding financial interests in the food and pharmaceutical companies he regulated at the FDA.

The same pattern holds for all of the top officials at the Centers for Disease Control and Prevention and the National Institutes of Health and among surgeons general over the last 30 years: None worked at a for-profit company right before they joined the administration.

It’s harder to assess the career paths of less well known advisers and senior officials who often don’t go through public confirmation processes, like Grogan, Clark, Leggitt, and Lenihan. But in a review of resumes, biographies, and lobbying disclosures for dozens of health care officials, advisers, and program directors across the Clinton, Bush and Obama administrations, STAT found only a handful of individuals who joined the administration directly from an industry position. Just two came from the pharmaceutical industry.

(Lobbying disclosure reports like the ones the Trump administration officials filed were first required in 2008, making earlier industry ties harder to discern for individuals not directly employed by a given firm.)

President George W. Bush hired Doug Badger, whose lobbying clients included Biogen, Eli Lilly, and Pfizer, as a health policy adviser. He also brought on Ann-Marie Lynch, a lobbyist for the Pharmaceutical Research and Manufacturers of America, to be his principal assistant deputy secretary for planning and evaluation.

In the 1990s, President Clinton’s health care advisory task force was notoriously kept secret, ahead of a public unveiling of legislation that would ultimately fail. But the group did oust one high-ranking member, Thomas Pyle, because of concerns over his stock ownership. A 1993 New York Times article noted that there were no apparent conflicts of interest among the dozen other named individuals leading the group.

President Barack Obama put in place a clear ban that kept anyone with recent lobbying experience out of the administration. But he was nonetheless criticized for several hires that were further removed from their lobbying experience. Bill Schultz, the HHS general counsel, had lobbied for Barr Laboratories and other pharmaceutical firms, about two years before he joined HHS. Liz Fowler, who held several roles at Obama’s HHS and the White House, had previously lobbied for the insurer Wellpoint, now Anthem. And Obama appointed a Monsanto lobbyist, Michael Taylor, to oversee food safety at the FDA.

Trump’s lobbying ban weakened some of the rules Obama put in place. Now, recent lobbyists like Grogan, Lenihan, Leggitt, and Clark can join the administration as long as they don’t work on any of the issues they’d been lobbying on for two years. They wouldn’t have been hired under Obama.

Trump has also retained the Obama-era practice of granting some individuals ethics waivers, though he has not made as many public as his predecessor did. Both Leggitt and Lenihan have waivers in the public files available on the White House website, according to several reports from this summer. As of this week, however, the White House files do not list their names, nor Grogan’s, among those with ethics waivers.

Republished with permission from STAT. This article originally appeared on November 16, 2017