On the campaign trail, Democratic presidential candidate Hillary Clinton has sharply criticized the health care industry, accusing pharmaceutical companies of profiteering and vowing to control skyrocketing costs.
But Clinton's tone was often more conciliatory before her presidential campaign when she addressed medical companies and trade groups as part of her brief but lucrative career delivering speeches for pay.
Elements of the speeches, some of which were delivered behind closed doors, were revealed in a hacked email that WikiLeaks made public in recent weeks.
"I know how critical the role that you play is," Clinton told the Advanced Medical Technology Association, a medical device trade group, in a 2014 speech. She avoided a direct question about a 2.3 percent tax on medical devices that was intended to fund the Affordable Care Act but was suspended until the end of 2017 after intense industry lobbying.
That appearance, for which Clinton was paid $225,000, was one of 15 paid speeches she gave to health care industry audiences, drawing a total of $3.5 million in fees. Overall, between the end of her tenure as secretary of state in February 2013 and the start of her 2016 White House bid, Clinton was paid about $21.6 million in speaking fees, according to her federal financial disclosure forms.
The health care speeches, largely overshadowed by the political storm over Clinton's paid presentations to big banks, provide another example of an industry with much at stake during the next administration adding to the personal wealth of the woman who is now the Democratic presidential nominee.
Clinton campaign spokeswoman Julie Wood said that the candidate has a long record of "standing up to special interests in health care," noting that the industry waged an aggressive push against her efforts as first lady in the early 1990s to overhaul the system.
"In this campaign, she has put forward proposals to hold drug companies accountable and ensure they put patients before profits and strengthen scrutiny of insurance companies," Wood said. "She's called out drug companies by name when they try to jack up prices with no apparent justification, like Mylan and the EpiPen, or exploit tax loopholes to shift profits overseas, like Pfizer's proposed inversion, or insurance company mergers that threaten to raise prices and restrict choice."
Transcripts and excerpts of Clinton's paid remarks show a cautious speaker treading delicately between flattering her hosts and avoiding compromises on policy that might complicate a presidential run in a time of public antipathy toward the drug industry and rising insurance costs.
One internal email published by WikiLeaks that gained attention this month, for showing an aide flagging politically dicey comments Clinton made to financial institutions, also compiled Clinton's potentially controversial remarks on issues such as single-payer health care, universal coverage, medical devices and pharmaceutical price controls.
The difference between Clinton's tone as a candidate and her paid remarks to the industry is evident when it comes to her comments on how drugmakers deal with the burden of paying high U.S. taxes and issues of costs.
In 2014, Clinton seemed sympathetic to the struggles of the drug industry when she appeared alongside Jim Greenwood, chief executive of the Biotechnology Innovation Organization (BIO), a trade association that includes large drugmakers such as Pfizer and Gilead Sciences.
"I don't want to see biotech companies or pharma companies moving out of our country simply because of some kind of tax -- perceived tax disadvantage and potential tax advantage somewhere else," she said, according to an excerpt included in the email released by WikiLeaks.
The group paid Clinton $335,000 for the speech, according to her disclosure form.
But as a candidate, Clinton has attacked the industry on several fronts. Her campaign website, for instance, singled out the now-defunct proposed merger of Pfizer and Allergan -- which would have allowed Pfizer to avoid taxes by moving its headquarters to Ireland -- for "eroding the U.S. tax base." And Clinton sent biotechnology stocks tumbling last year when she rebuked "price gouging" by the specialty drug market, tweeting a link to an article about Turing Pharmaceuticals and then-chief executive Martin Shkreli.
Greenwood, the BIO executive who sat with her in 2014, criticized Clinton's jab, saying at the group's convention two years later that "even a lone tweet by a candidate for high office can have unintended, market-moving consequences."
BIO did not respond to requests for comment.
Clinton resisted the idea of drug price controls during a 2014 dinner with the Drug, Chemical and Associated Technologies Association, at a venue the moderator described as being "filled with individuals from the pharmaceutical industry." She was paid $250,000 for the speech, the content of which has previously not been reported.
"Well, I have to start by saying I don't think we proposed price controls," Clinton said in reference to her efforts in the 1990s, according to the WikiLeaks email. "We proposed more competition, more transparency, state exchanges, if those sound familiar, to entice greater negotiation over price."
In her 2014 appearance before the Advanced Medical Technology Association, Clinton addressed the group's conference in Chicago and participated in a question-and-answer session with the group's chief executive, Stephen Ubl, according to a news release from the group.
Ubl has since become chief executive of the industry's largest trade association, Pharmaceutical Research and Manufacturers of America, and has been critical of Clinton's negative comments about the industry during the campaign.
A spokeswoman for the association, Wanda Moebius, said asking Clinton to speak was in keeping with the group's outreach to important policymakers "to address our members on key issues of the day and to share their policy perspectives."
The speech excerpts show that Clinton has consistently supported the Affordable Care Act. She applauds government-provided health care but is cautious about applying those lessons to the U.S. market.
Clinton expressed resignation to the current private insurance market in a 2013 address to the Economic Club of Grand Rapids -- whose board includes the president of Blue Cross Blue Shield Michigan.
"People are entitled to make a profit," she said.
Despite Clinton's criticism, the pharmaceutical and health products industry is the 10th-largest industry among her campaign contributors, giving about $11.6 million to her campaign and outside groups supporting her, according to the Center for Responsive Politics, which analyzes Federal Election Commission data. Hospitals and nursing homes have donated $3.8 million. Republican nominee Donald Trump has received $1.5 million from health professionals.
Although Clinton has campaigned on improving the Affordable Care Act, she also has accepted speaking fees from groups that opposed aspects of the health law, including the National Association of Convenience Stores and Fuel Retailing and the Society for Human Resource Management.
Elizabeth Lucas contributed to this report.
