Emails that Protect Democracy, a watchdog group, shared with POLITICO provide a window into the real-time deliberations, as civil servants rushed to execute on the sudden political demands.
The acting communications director “is on board and stands ready to help,” Mark Weber, a career public affairs official, wrote in a Jan. 25, 2017 email to three freshly installed Trump appointees, seeking to roll back the Obamacare ads. “I conveyed appreciation for what must be hard to do and the work to be done.”
“We will never be in the room for the conversation, that is what I am guessing,” one career civil servant wrote to another later that day, as they waited to hear which initiatives would be cut.
Trump officials, buffeted by the media coverage, ultimately failed to pull back some of the pre-purchased radio and TV ads — but they were able to cancel more than $4 million in planned spending, even as Trump himself railed against the law and took other steps to weaken it. The new president had issued a Day 1 executive order where he instructed government agencies to unwind ACA regulations if they were creating burdens; the Internal Revenue Service subsequently stopped enforcing the law’s individual insurance mandate.
Analysts have said that Trump’s anti-Obamacare salvo produced immediate results. Compared to the final two weeks of open enrollment in 2016, sign-ups for coverage through HealthCare.gov, the government’s flagship website, ended up dipping about 30 percent year-over-year in 2017. Researchers have warned that less access to health coverage is linked to worse outcomes and financial hardship.
The immediate efforts to weaken the Affordable Care Act also set a tone inside the health department for the next four years, where Trump officials pursued a series of regulatory decisions intended to undermine the law’s health plans, and other parts of the ACA — like its protections for LGBTQ patients — were under constant assault too. Meanwhile, political appointees often turned to anecdotal stories to justify their decisions against a growing pile of peer-reviewed studies that argued the opposite.
“Just take Medicaid expansion,” said a former senior career official who worked on safety net health issues, referencing the ACA provision that allowed states to expand the health program for low-income Americans. “The complete ignorance and dismissiveness of the mountain of evidence that Medicaid expansion helps pregnant, low-income women, or other vulnerable patients … and yet this administration still says no, it doesn’t work.”
Many career officials said they had braced for the new administration to attempt to repeal the Affordable Care Act and replace it with another program geared to provide less expensive options, as Trump had promised on the campaign trail. But using the bureaucracy to undermine the ACA, without repealing it or offering an alternative, struck them as a violation of HHS’s entire public-health mission.
“The ideology trumped anything they wanted to do,” the former official added.
Asked to respond to claims that political appointees meddled with Affordable Care Act advertising and sought to undermine the program, a spokesperson for the Centers for Medicare and Medicaid Services said, “CMS leaders have worked to foster an environment where policy considerations go through robust discussion and thoughtful collaboration with career officials, political appointees, and various public and private stakeholders and partners.”
But nearly four years later, a great deal of ACA-related content remains scrubbed from the department’s website, from information touting its benefits to even basic publicity efforts begun under the Obama administration.
“It was hard because I had heard how the ACA helped people,” said Judy Sarasohn, a now-retired career civil servant who worked in public affairs, where she regularly spoke with people who benefited from the law — from a skeptical Republican who discovered he needed health insurance after he developed cancer, to new mothers of babies with congenital health problems — and wrote dozens of profiles of their experiences between 2014 and 2016. Trump appointees quickly stripped those profiles from the website, Sarasohn said.
“The ACA was not perfect, but I really could see that it was doing good for people,” Sarasohn added. “It did hurt to have a new administration come in and trash it.”
Ideology ahead of science
While Obamacare was an obvious early target of the Trump administration, the health department’s impending war on its own teen pregnancy prevention program came as more of a surprise.
The program was hailed as a bipartisan priority when it was first funded by Congress in 2010 — a science-backed initiative to test models to curb pregnancy among teenagers and scale up the ones proven to work.
But its focus on teaching teens about sexual health was opposed by social conservatives, who instead called for youths to be taught about abstinence. And in July 2017, the Trump administration abruptly axed more than $200 million in the health department’s teen pregnancy prevention and research funding to more than 80 organizations across the country, claiming that the program lacked evidence of success.
The decision disturbed researchers and watchdogs, who argued the opposite: that the program showed promise in curbing teen pregnancy rates.
“The Trump Administration has exploded one of our most promising evidence-based programs,” a pair of former Obama and Bush officials warned in in an op-ed in The Hill. “In striking contrast to the Trump administration, many Republicans now recognize that evidence-based policies are the wave of the future.”
A journalist and an OB/GYN physician wrote in the Washington Post: “The TPP initiative has been a poster child for evidence-based policy — that is, programs that have been scientifically demonstrated to be effective, while continuing to test and evaluate different approaches.”
And inside the health department, Trump appointees quickly found themselves facing questions from Evelyn Kappeler — a career official who had led the health department’s office of adolescent health for seven years and effectively oversaw the imperiled teen pregnancy prevention grants.
Kappeler, who in 2019 moved to a role in HHS’s lower-profile support services center and now works on federal occupational health issues, declined comment to POLITICO. But her emails and internal notes, obtained by a watchdog called Democracy Forward, paint a vivid picture of career officials’ efforts to get information from Wright, the then-acting assistant secretary for health, and Trump appointees seeking to abruptly cut the program.
“He stated that as civil servants, our responsibility is to implement the Administration’s agenda whether we like it or not, as long as it is legal,” Kappeler wrote in one note on July 17, 2017. “And if we can’t, we should consider other options. He was angry and stated that I we [sic.] needed to get in line.”
“Given recent admonishments from Dr. Wright about what he perceives as the lack of appropriateness or motivations for my questions, I felt it prudent not to ask questions about the parties involved in the conversation,” Kappeler wrote in another Aug. 7, 2017 note.
In other documents, Kappeler describes the frustration of her team being cut out of deliberations and blindsided by the resulting decisions.
“I was so rattled by our previous call, that my reaction when I got on the phone was to cry,” she wrote in a July 28, 2017 note, adding that she was instructed “that if they tell me the monies are being used consistent with the statutory authority, I should not be raising questions.”
As researchers and reproductive rights groups publicly hammered HHS for its decision, the health department hit back, insisting that claims defending the teen pregnancy prevention program were inflated.
“False Claim: The TPP Program is a good use of taxpayer money,” a fact sheet published in August 2017 asserted. “The Facts: Continuing the TPP Program as it is currently structured would be a waste of taxpayer money.”
But federal courts ultimately blocked Trump’s attempted cuts to the teen pregnancy prevention program, calling the hasty decision “arbitrary and capricious.”
Meanwhile, Wright — the career official who oversaw the cuts to the teen pregnancy program and to Novotny’s team — would go on to greater prominence during the Trump administration.
After Tom Price was ousted as HHS secretary in September 2017, the White House tapped Wright to serve as the department’s acting head, and in 2019 Trump picked Wright to be the U.S. ambassador to Tanzania, where he currently serves. The State Department declined to comment about Wright’s work at HHS, and an HHS spokesperson said the department wouldn’t discuss personnel matters.
A drug test for Medicaid?
Even as Kappeler was struggling to understand cuts to the teen pregnancy prevention program, other health department officials — and particularly its physicians and scientists — increasingly felt like they were alone on an island and their warnings were ignored.
in April 2017, then-Wisconsin Gov. Scott Walker introduced a plan to drug test applicants to his state’s Medicaid program — an idea that conservatives believed would encourage personal responsibility, and an initiative closely watched by other GOP-led states. But the plan needed federal sign-off, and the idea soon made its way to Medicaid’s most senior officials, said Ostrovsky, who was the program’s chief medical officer at the time and recalled the first time he was briefed on Walker’s pitch.
About a dozen senior officials were crowded around the table and on the sides of the room — Conference Room B in the Baltimore headquarters, Ostrovsky recalled — and there was “silence” when the drug-testing proposal was discussed.
“I’m looking around the table … and I was waiting to hear, this is a joke,” Ostrovsky said. “To me it seemed so preposterous that a governor would propose drug-testing as a prerequisite for Medicaid eligibility,” given that it would exclude so many vulnerable people who needed the program.
Grappling with what he’d just heard, Ostrovsky said he pulled up some data, did quick back-of-the-envelope math and calculated that Walker’s plan could exclude hundreds of thousands of people struggling with substance-use disorders — and upwards of 8,000 people in Wisconsin could die over a decade if they didn’t get needed care. But as he shared that quick math with the other officials in the room, Ostrovsky said, the reaction was muted; the seniormost Trump appointee was “courteous” and “said they’d take it under consideration.”
Months later, the health department formally determined that Walker’s drug-testing plan was illegal, finalizing a compromise policy in October 2018 that allowed Wisconsin to ask nonbinding questions about Medicaid applicants’ drug use. Other officials said that Ostrovsky — who had departed in December 2017 — was excluded from policy conversations where career civil servants raised similar concerns about the public health and moral consequences of the plan. Medicaid chief Seema Verma herself didn’t think Walker’s plan was a good idea, said one official with knowledge of her thinking.
“The former employee was not in a position to assess the development of the policy nor was he privy to any of the policy conversations that occurred over that year,” said Ninio Fetalvo, a spokesperson for Verma. Fetalvo also dismissed Ostrovsky as a “former disgruntled CMS employee” who never raised concerns about the drug-test plan to Verma or other leaders, and added that Verma personally worked with Wisconsin’s team to develop a more viable alternative.
But Ostrovsky says the proposal should never have made it out of the conference room, where it should have been rejected out of hand by Medicaid officials.
“We clinicians shouldn’t be playing defense to prevent clearly egregious ethical violations,” Ostrovsky said. “We should be weighing one study versus another … not conservative ideology.”
“It’s really a metaphor for the decision-making processes of the last four years.”
A new team
One persistent challenge inside the health department: simply teaching a series of Trump appointees, many brand new to federal service or deeply skeptical of it, how the government worked.
“There was presidential appointment paperwork where they got the title wrong, and they said, ‘white it out,’ like with a bottle of Wite-Out,” said a former senior career official, referencing an early 2017 mistake where the White House had tapped a Bush administration veteran named Demetrios Kouzoukas to be a top Medicare deputy — but accidentally wrote out the wrong title. “They had to be told that it doesn’t work that way.”
A CMS spokesperson didn’t respond to a question about the incident.
Other violations of what career HHS employees saw as good government popped up nearly every week. Trump appointees asked career staff to join them in prayer before meetings, said two officials. Another appointee put a rushed effort to assemble an anti-Obamacare event on a personal credit card, said a former official. The administration in December 2017 withheld thousands of public comments that were critical of a religious liberty proposal, drawing the ire of public information watchdogs.
Some political appointees also made no secret of their love for the president or disdain for government, echoing Trump’s own jibes and attacks made through his social media accounts. The political appointee in charge of the department’s digital communications drove a car with “FAKENWS” vanity license plates, occasionally parked right outside headquarters for his staff to see.
“They ran all of HHS like it was a political campaign and not an executive agency,” said one former official, pointing to a visible change overnight after Inauguration Day in 2017: the default channel on the public TVs stationed throughout the building. “In the Obama administration, the TVs rotated between Fox News, MSNBC and CNN,” the former official added. “But things changed very rapidly under Trump, with Fox News being put on all the TVs. … It’s like they only wanted the TVs to repeat the news they wanted to hear.”
Meanwhile, Republican consultants dotted the building, with Trump appointees like Verma turning to them to shape public affairs and communications strategy, despite the army of available federal staff. Verma also leaned on former GOP Medicaid directors who worked at Speire Healthcare Strategies to advise on a rule governing the Medicaid managed care market, said four current and former officials — an unusual decision to partly outsource the rulemaking process, which stretched from 2017 to last month, when the rule was finalized.
“If they’d just asked people inside the building, we could’ve done it faster,” said one former career official.
A spokesperson for Verma disputed the role of Speire, saying that the consultants didn’t play a role in drafting the rule or making policy decisions.
“Federal career employees with assistance from the federally funded MITRE Corporation drafted the managed care rule,” the spokesperson said. “Speire was brought on as a subcontractor to MITRE to provide specific subject matter expertise in the development of certain elements of our policy.”
Speire didn’t respond to a request for comment.
But the decision to lean on outside consultants went far beyond Verma, with Trump administration officials spending millions of dollars on pricey initiatives like “ReImagine HHS,” a project where outside consultants at firms like Deloitte were tasked to help remake the department.
“They were far more resistant to the permanent administrative state” than their predecessors, said one former senior official who worked for more than 20 years across both Democratic and Republican administrations.
“The administrative state wanted to help them get things done,” the former official insisted. “These guys from Day 1 right to the end just viewed it as an inconvenience, and a group actively working against them.”
“It was a war of attrition against [career officials], who were leaving left and right, because the administration was going around them,” said another former official who worked on the department’s messaging strategy. “They weren’t valued.”
From 2017 to Covid-19
Looking at the government-wide response to the pandemic, career health officials said they see similarities to how Trump and his deputies often made decisions at HHS based on politics, not public health.
Despite being warned repeatedly about the dangers of striking down Obamacare — and the risk to tens of millions of Americans who depended on the program and its protections — Trump and his team plunged ahead on fulfilling their promise to GOP voters, a quest that continues, with the Supreme Court set to rule again on the law’s fate next year. It foreshadowed how the president ignored warnings of the creeping pandemic this year, worried about the economic and political implications of acknowledging the threat posed by the virus.
And when Trump got tired of the dire predictions offered by career government infectious disease experts like National Institute of Allergy and Infectious Diseases Director Anthony Fauci and coronavirus coordinator Deborah Birx, the White House imported an outside expert — radiologist and conservative policy analyst Scott Atlas — who delivered the Covid-19 messages the president wanted to hear.
“It’s not surprising we got into the troubles we did,” Novotny said. “There was a lot more ideology brought into the department than we previously experienced.”
Now 73 years old, Novotny said he’s hoping for another go at government service — perhaps working in the health department’s California-based regional office — and that he’s “optimistic” that Biden can repair the “disaster” left behind by Trump.
“Many of us who have been in government previously, we don’t want to give up on public service,” Novotny said. “We’d relish the chance to contribute again.”