White House officials have soured on HHS Secretary Alex Azar, a deepening quarrel that threatens to derail President Donald Trump’s health care agenda as he gears up for his 2020 reelection campaign.
The divide has led to stalled projects, disputes over Medicaid and fetal tissue research, duplicated work on Trump’s drug pricing priorities — and bitter personal attacks, say a dozen current and former White House and HHS officials as well as multiple other people familiar with the conversations.
The stakes are further heightened because health care is expected to play a crucial role in the 2020 election, and Trump has repeatedly pledged to soon unveil a plan that is higher quality and less expensive than Obamacare — an ambitious promise that his team of rivals is not ready to deliver on.
“You have two teams with two visions,” said an individual who’s been in heated meetings with HHS and the White House. “Alex is outnumbered and keeps losing.”
HHS downplayed policy disputes between Azar and White House officials. “Sec. Azar has a productive and close working relationship with President Trump, Vice President Pence, and senior White House officials,” said HHS spokesperson Caitlin Oakley. “That’s why the Secretary has been able to execute on so many of the President’s objectives and deliver real results for the American people.”
The White House framed the disagreements as part of a deliberative policy process. “The Department of Health and Human Services, under Secretary Azar, is leading on a number of the president's priorities, including combating the opioid epidemic, protecting the dignity of human life, lowering prices for care and prescription drugs even further, and ending HIV transmissions in the U.S. within 10 years,” said White House spokesperson Judd Deere. “The White House and the Department are working hand in hand on these important priorities and will continue to do so for the benefit of all Americans."
Despite the recent tensions, Azar is not perceived to be at risk of losing his job — although the president is famously fickle and, by some accounts, Trump’s trust in his health secretary has eroded. A former Jeb Bush fundraiser, Azar entered the Trump administration without ties to the president but he did have ties to Mike Pence from his time as a top executive at Eli Lilly in Indiana.
Trump, who is officially launching his reelection campaign Tuesday in Florida, has grown frustrated that his appointees have not lowered drug prices as he had promised, something that numerous polls show is a priority for voters, particularly senior citizens. “It’s totally political,” a former White House official said. “You can’t ignore the political angle.”
Azar has spent months battling White House domestic policy chief Joe Grogan, acting chief of staff Mick Mulvaney and other officials over proposals targeting high drug prices, Medicaid and Obamacare, individuals inside and outside the administration said. But Azar has been repeatedly overruled, including on Trump’s decision to reverse a Justice Department stance in a high-profile Texas lawsuit and urge courts to strike down the entire Affordable Care Act.
Azar “hasn’t exactly been in line here recently,” said one administration official.
A former drug company executive-turned-Cabinet secretary, Azar also resisted letting Florida import drugs from Canada, a plan sought by Republican Gov. Ron DeSantis, a Trump ally.
The simmering clash has pitted the ideological bent of officials like Grogan and Mulvaney — who see themselves as upholding Trump’s hard-line agenda — against Azar, a conservative but pragmatic former George W. Bush administration official.
Trump also overruled Azar on a recent decision to limit researchers’ access to fetal tissue obtained from abortion. Azar objected to the administration’s plan to ban government scientists at the NIH from doing such research. Pence strongly disagreed, as stopping fetal tissue projects is a top priority for him.
Oakley, the HHS spokesperson, said Azar supported the administration’s stance. HHS "led the rollout of the president’s decision regarding research involving human fetal tissue from elective abortions,” she said, calling the administration’s anti-abortion work a top priority. HHS also recently moved to freeze Planned Parenthood out of the largest federal grant program for family planning.
While current and former officials say that some tension is inherent in the administration’s high-pressure jobs — as officials hammer out changes that could reshape the $3 trillion U.S. health system — the relationship between this White House and its health department has devolved into regular sniping and, at times, personal attacks. Azar has openly disparaged Grogan in front of colleagues, a half-dozen individuals say, and gotten into shouting matches with other staff, ultimately barring one senior White House economist from his meetings.
"The friction just got worse and worse over time behind the president’s back," said one person familiar with the matter, who described the dynamic as constant, day-to-day “combat" between Azar and Grogan, who also worked in the pharmaceutical industry.
High-level HHS staffers have also escalated conflicts, adding to tensions with the White House and forcing Azar to personally litigate disputes. “They’ve thrust [Azar] onto the front line rather than reserve him for the big fights,” said a person familiar with the White House dynamics.
Meanwhile, White House officials have used their access to bypass Azar and directly lobby Trump — and have won nearly all of this year’s high-profile health policy battles, according to five current and former administration officials. More fights still loom on granting states additional Medicaid flexibility, boosting transparency of health care prices and other drug pricing issues.
“It’s Joe, Russ [Vought, acting OMB director], Mick, the whole cabal … they’re all fighting him,” said one former official who’s been in tense meetings with Azar and his White House counterparts. “They’ve slowed his rules and made everything difficult.”
Azar retains support from Trump and his allies remain confident he can weather this current wave of attacks. The HHS secretary has cultivated a close relationship with Trump, who has hailed him repeatedly for his bid to slash drug prices.
Azar also has strong relationships in several other corners of the White House, three individuals say, including Jared Kushner — the president's son-in-law and close adviser — and First Lady Melania Trump, who has traveled with Azar to the border and to tout the administration’s opioid response. The Trump administration also has come together on several health priorities, including a rule released last week intended to expand health coverage options for small businesses. Azar helped steer an initiative to fight the HIV/AIDS epidemic, announced in the president’s State of the Union, that aims to end the spread of the virus in the U.S. by 2030.
But the deep divide between Trump’s top health policy officials is causing staff confusion and repeated delays, even as the administration tries to hammer out several drug price rules and reach a potential drug pricing deal with congressional Democrats — tricky political terrain going into an election year. Trump has also appeared frustrated when his allies’ priorities have been delayed by fights within his administration, witnesses said.
At an Oval Office meeting last month, Trump repeatedly pushed Azar about what HHS was doing to help DeSantis import prescription drugs to Florida from other countries. But Azar instead focused on other efforts that he said would lower drug prices — a tactic that frustrated Trump, said Rep. Matt Gaetz, the Florida congressman who also attended the meeting.
Azar’s “lack of enthusiasm was palpable,” according to a person familiar with the meeting. “Sec. Azar was challenging the wisdom of approving this.”
Trump also demanded staff move forward on a $20 million children’s hospital initiative requested by golfing buddy Jack Nicklaus after HHS’ funding got held up by Grogan’s team of White House budget officials, say two individuals with knowledge of the request.
Most of the tension, however, has been between HHS and the White House’s policymaking apparatus. While Azar bristled over Grogan’s leadership of the health division inside the Office of Management and Budget — an internal clearinghouse that frequently slow-walks Cabinet members’ initiatives due to budgetary concerns — their battles have intensified since Grogan was elevated to run the White House Domestic Policy Council, which has more authority to shape Trump’s agenda.
A recent flashpoint: HHS’ effort to lower drug prices through a controversial rule that would effectively eliminate rebates given to drug makers. Grogan had fought the so-called rebate rule over its approximately $177 billion cost to the government over a decade — even as Trump and Azar have touted it as a strategic piece of the president’s longstanding vow to lower drug prices. The rule is now on track to be finalized, sources on and off Capitol Hill said, though it's yet to clear budget officials’ review.
“If you are a fiscal crazy hawk — Joe is — there’s nothing worth paying money for,” said an individual briefed on the matter.
Azar and Grogan also are pursuing twin efforts to craft drug price reforms with Congress, with Azar focused on a bipartisan effort emerging in the Senate and Grogan working with House Speaker Nancy Pelosi’s office. Their efforts are largely parallel, according to lawmakers and aides, in what several people pointed to as a sign of the frosty relations between HHS and the White House policy shop.
Meanwhile, Azar has personally involved himself in disputes with Grogan and other White House officials that would traditionally be left to staffers. For instance, Azar has clashed with White House economist Tomas Philipson in multiple meetings, said three individuals who have attended, a long-running feud that was accelerated when Philipson criticized Azar’s drug-pricing plan last year. The two men also loudly battled after Philipson presented findings that suggested Medicare Part D — the prescription drug benefit enacted by the George W. Bush administration, of which Azar was a part — contributed to the nation’s opioid epidemic by lowering prices.
Azar subsequently had Philipson barred from meetings, two individuals said, although the policy was ultimately reversed. Philipson is expected to be tapped as the next head of the White House Council of Economic Advisers, where he would be further empowered to evaluate the economic effects of Azar’s policies.
Azar is not expected to leave HHS before the 2020 election, according to four individuals. He announced an agency-wide leadership reorganization on Monday that strengthened his lieutenants. Trump’s second HHS secretary who received Senate confirmation in January 2018, Azar has prioritized good governance of the agency and is conscious of not appearing to bow to a particular side for political expediency.
“Mick and Joe are not going to kick Alex out of his job,” a source familiar with the dynamics said, pointing to Azar’s ties to Trump and his family. “If that side of the house is in good shape, I don’t see the acting chief of staff who gets yelled at for coughing as the individual who’s going to get rid of him.”