Secretary of Health and Human Services Alex Azar and administrator of the Centers for Medicare and Medicaid Services Seema Verma look on as President Donald Trump speaks in 2019. | Evan Vucci/AP Photo

Even after Donald Trump had urged them to end their feud, the president’s top two health deputies couldn’t resist competing for his attention — and undermining each other on Twitter and cable TV.

Seema Verma, who runs Medicare, Medicaid and Obamacare, last Tuesday heaped praise on Trump’s recent order that requires hospitals and health insurers to post their prices. "The federal agency I lead, the Centers for Medicare and Medicaid Services, is taking swift action to implement it," Verma wrote in an accompanying Chicago Tribune op-ed that day.

But on Friday, Health and Human Services Secretary Alex Azar went on “Tucker Carlson Tonight” — one of Trump’s favorite TV shows — and claimed credit for driving the same initiative.

“POTUS and I envision a healthcare system with patients in the center,” Azar tweeted from the Fox News set. “We’re fighting powerful interests to deliver honesty and transparency in healthcare.”

The clash has riveted Washington and could be speeding toward a conclusion: Azar and Verma made their case Wednesday evening to Mick Mulvaney, the acting White House chief of staff. A decision on the fate of one or both could come at any time.

The vicious fight has pitted Verma, a former health care consultant who’s now lashed out at two HHS secretaries, against Azar — a Washington-hardened infighter who assembled a trail of damning memos about Verma’s behavior that have steadily leaked to the media. Their battle also hinges on allegations of sexism, mismanagement and whether Verma squandered millions of dollars in taxpayer funds.

"It’s a cold war that got hot" in the past few weeks, said one official who’s been in meetings with both Azar and Verma staffers this month. "Lies, leaks… there's no trust right now."

Meanwhile, White House officials and other Trump supporters say that Azar and Verma’s feud has put the president’s health agenda at risk ahead of next year’s election. If Trump opts to fire one official, the other could end up shaping the rules for patients, doctors and hospitals across the nation.

Some colleagues of Azar and Verma are still hoping for them to mend fences, however unlikely. "I don't think it's sustainable to go on like this,” said Tom Scully, who ran CMS during the George W. Bush administration. "But can you sit down and find a way to get through this silliness? Yeah, absolutely."

POLITICO spoke with more than two dozen current and former health department officials, many of whom requested anonymity to discuss sensitive matters, and reviewed federal documents obtained via Freedom of Information Act requests.

Verma’s office declined to comment on elements of this story and disputed several anecdotes. “These recent leaks and gossip are part of a targeted campaign to smear the Administrator and undermine the accomplishments of CMS and the administration,” a CMS spokesperson said. “The administrator’s number one priority is continuing to deliver on the president’s bold healthcare agenda to ensure Americans have access to high quality, affordable healthcare.”

Azar’s office similarly declined comment. “On behalf of President Trump, for the past two years, Secretary Azar and Administrator Verma have delivered monumental, historic reforms to our healthcare system on behalf of the American people,” an HHS spokesperson said.

“Re: Re: Draft tweet”

After Trump ousted Tom Price as HHS secretary over a charter-jet scandal in September 2017, Verma’s allies floated her name as his possible replacement. But six weeks later, Trump instead nominated Azar — a former pharmaceutical executive at Indiana-based Eli Lilly, with deep GOP ties — to be his new top health official.

Trump’s announcement was months in the making; even before Price was fired, Azar had met with HHS and White House officials about taking a senior role in the administration, said two individuals with knowledge of the meetings. HHS declined to comment.

“He will be a star for better healthcare and lower drug prices!” Trump tweeted on Nov. 13 2017.

Inside the health department, Verma’s team scrambled to craft a congratulatory tweet of her own, relying on outside communications consultants — being paid hundreds of dollars per hour — to help draft a message praising Azar, according to documents that POLITICO obtained via a Freedom of Information Act request. Verma’s messaging team included Marcus Barlow, a longtime aide who she’d brought on as a shadow staffer after the White House blocked his hiring because of anti-Trump sentiments he’d expressed in an Indianapolis newspaper.

More than two hours and a dozen emails later, Verma’s team pushed out their post: “Congrats to fellow Hoosier Alex Azar on being nominated @HHSGov Secretary! Alex is an experienced leader in the healthcare community who will work hard to advance @POTUS ' agenda!” Verma tweeted.

For Verma and her close-knit team, the vague platitudes carried high stakes — a second chance at a first impression after Verma’s rocky relationship with Price had soured over hostile workplace allegations and other clashes. The two had been picked shortly after the 2016 election, with Trump touting House Budget Committee Chairman Price and Verma, a consultant who advised then-Gov. Mike Pence, as a package deal.

“Together, Chairman Price and Seema Verma are the dream team that will transform our health care system for the benefit of all Americans,” Trump wrote in a November 2016 statement. Their partnership was rocky from the start and lasted less than a year. Price disappointed Trump with his failure to craft a popular enough plan to persuade senators to replace Obamacare. He then resigned after revelations that he spent more than a million taxpayer dollars on charter-plane travel.

But Verma impressed Trump when she challenged other officials and gave the president her unvarnished opinions, two people with knowledge said. Verma also stood in the Rose Garden in May 2017 as House Republicans touted their vote to repeal Obamacare — the only woman of color to speak to cameras amid a sea of white men.

After Price resigned, Verma’s name circulated as his potential successor — further antagonizing Price’s allies, convinced that she’d worked to undermine him with the president and in the press. Price loyalists oversaw a review of Verma’s emails looking for evidence that she’d leaked details of his charter-jet flights, said two individuals briefed on the review.

Administration officials heralded Azar’s January 2018 arrival at HHS as a hard reset for Trump’s health agenda after 2017 was widely viewed as a lost year of chasing Obamacare repeal. The health department was also seen as a “turnaround project,” according to Azar’s new chief of staff, and the incoming secretary imported a team of loyalists — many of whom, like Azar, had held senior roles in previous Republican-led health departments.

Multiple White House and HHS aides urged Azar's deputies to fire Verma as part of a broader effort to "clean house," former administration officials said. That message was communicated to the incoming secretary, too. “When Azar first came to HHS, he was advised by multiple White House officials to fire her for leaking and for her notorious claims of sexism,” said an individual familiar with Azar’s hiring. Another person close to the process told POLITICO in January 2018 that Verma wasn't likely to make it more than 30 days under the new regime.

But Azar chose to keep Verma, telling allies that he wanted to minimize disruption after Price’s abrupt departure and give her an opportunity to prove herself.

Seeds for a confrontation

Both Verma and Azar pursued ambitious plans across 2018, trying to chalk up victories for the Trump administration after the Obamacare repeal debacle. Verma rolled out a controversial policy to allow states to impose work requirements on poor people enrolled in Medicaid, the government’s safety-net health program for low-income Americans — a long-sought goal for many conservatives. Meanwhile, Azar unveiled a plan that he said would lower the nation’s drug prices, channeling Trump’s aggressive rhetoric as he took on his former colleagues in the pharmaceutical industry.

Inside HHS, Azar worked to make over the department, ushering out a series of Trump appointees who had drawn negative headlines. But while Azar’s moves were widely seen as bringing stability, Verma cycled through a series of deputies — four different Trump appointees have served under Verma as the nation's Medicaid director since February 2018 — and several long-serving career staff left her agency too. She also increasingly moved to rely on outside contractors, as previously detailed by POLITICO, to script her communications and raise her profile.

Those contractors also were involved in planning Verma’s July 2018 trip to California, helping rent the SUV that was burglarized while parked on a busy San Francisco street, said two individuals with knowledge of the trip. CMS declined comment on whether the contractors helped plan the trip. Verma ended up submitting a $47,000 claim to cover stolen jewelry and other goods, although HHS reimbursed her just $2,852.40.

Meanwhile, Verma clashed with Azar and his team of largely white, male advisers over his vision for the department.

“There’s a lot of guys on the sixth floor” of HHS headquarters, where Azar and his senior staff sit, said one former official, adding that Verma long resented “the boys club” at the health department — “especially the boys club who told her what to do.” Verma and her team sit on the third floor.

Two former HHS officials described a 2018 heated meeting where Verma told one Azar adviser that if he pursued a drug-pricing plan affecting insurance rebates, she’d “make sure he’d never work in this town again,” said one of the officials familiar with the meeting. A CMS spokesperson denied that Verma made the remark. Azar and his team ended up pursuing the plan regardless but Verma helped torpedo the idea in an Oval Office meeting in July 2019.

Still, Azar avoided an open leadership fight with Verma, and she made no plans to leave — even after Paul Mango, a former McKinsey executive and GOP gubernatorial candidate in Pennsylvania, was hired in July 2018 as her new chief of staff over candidates that she preferred. Verma told others that she viewed Mango as unsuited for the role and that Azar had hired her eventual replacement, two former officials said.

Verma immediately assigned Mango to oversee CMS' day-to-day operations in Baltimore, where most agency staff are based, effectively shutting him out of the tight inner circle she's constructed within Washington and eventually outlasting him. Mango in July 2019 was promoted to a new role as HHS deputy chief of staff, taking him out of Verma’s orbit. But even that was not without controversy: HHS initially planned not to tell Verma ahead of time they were elevating her chief of staff. Mango ultimately told her about the promotion himself, less than an hour before it became public.

Azar also worked to navigate the Trump administration’s ever-shifting politics, even as he spent much of 2018 tied up by fallout from the administration’s widely despised policy to separate migrant children from their families at the U.S.-Mexico border and remand them into HHS custody. While Azar had objections to the policy, advisers said, he avoided condemning it in public — partly because the policy was driven by immigration hardliner Stephen Miller, the White House senior adviser with the ear of the president. Instead, Azar positioned himself as a fixer when the policy was blocked in court and the administration was ordered to reunite thousands of separated families.

But Azar’s fortunes shifted when Trump nominated Andrew Bremberg — a longtime Azar ally who led the White House Domestic Policy Council, the West Wing’s internal policy clearinghouse — to be an ambassador to the United Nations in Geneva. That opened the door to a new dynamic: Verma increasingly teaming up with White House officials like Mulvaney and Joe Grogan, Bremberg’s successor, to stymie Azar’s agenda.

Building to a confrontation

Tensions reached a breaking point this fall, after Verma and Azar feuded over policies to lower drug policies and replace Obamacare — top priorities for Trump, who’d personally tasked them ahead of next year’s election — and grappled with personal disputes like Verma’s complaint that Azar tried to block her from Air Force One.

The unspooling clash has pitted Azar, a skilled infighter with deep connections in the GOP establishment, against Verma — who’s in her first significant Washington job but remains close to Pence — and domestic policy staff in the White House who have frequently sparred with Azar, too. But their war reached new levels this month as it played out in the media, driven by leaked documents and unflattering reports that some in both camps now concede backfired on both officials.

Azar in recent days privately lamented that the conflict had spun beyond his control, multiple people familiar with the matter said. Another official wondered out loud why Verma and her allies thought she could survive a public airing of grievances while her own contracting decisions are under inspector general review, with a report due by spring 2020.

Throughout their feud, allies of both Azar and Verma sought to paint the other as an incompetent leader, unable to effectively deliver on Trump’s agenda. For instance, a federal judge blocked Verma’s Medicaid work requirements in multiple states, and it’s not clear whether some of her other Medicaid plans, like shifting funding toward a “block grant” model, also will clear likely legal battles.

But her allies say that CMS depends on Verma, partly because she’s spun such a tight circle around her and a few trusted deputies. “If she goes, that agency will stop,” one former official said of Verma. “There’s just no apparatus. She is it.”

Meanwhile, major elements of Azar’s original 2018 drug plan have been blocked by the courts or dismantled inside the administration. He’s also reversed his position and is now working to fulfill Trump’s goal of allowing the importation of drugs from other countries — a priority for Gov. Ron DeSantis of Florida, a state that Trump is eager to win again in the 2020 election.

Yet that policy has been repeatedly delayed amid concerns about its safety and effectiveness, said two individuals with knowledge of the regulation, and an announcement tentatively scheduled for earlier this month also was postponed.

If Trump fires Azar, it's not clear who's poised to run the department and opens the door to an acting secretary's regulations being challenged under the federal Vacancies Act, said two officials.

Loyalists in both camps are still holding out hope that Azar and Verma can reach a truce that would allow both appointees to keep their jobs. But even as some worked furiously to tamp down the attacks and find a resolution, others had already begun to level blame.

"When you're the subordinate, you need to know who is the boss,” said one Azar ally, echoing several Azar partisans who blamed Verma for starting a war that she could not win.

The Verma camp, meanwhile, has cast Azar as a bad manager who has actively worked to undermine his CMS administrator — and took no concrete action to stamp out the leaking of confidential documents or hold any administration officials to account as the conflict played out in daily news stories.

Multiple people familiar with the situation said it remains unclear what comes next, and whether Azar and Verma can rebuild a working relationship. But both officials have already made one public show of support: Lavishing praise on Trump and his agenda in dozens of tweets this month, including a pair posted near-simultaneously last Friday.

“@POTUS’s recent executive order on Medicare is a powerful illustration of the bold future he sees for the program,” Verma posted at 1:30 p.m. “Its provisions will result in lower costs, higher quality & a flurry of innovation – providing sorely needed security for America’s seniors.”

“Retail drug prices fell last year for the first time in more than 40 years⁠,” Azar followed two minutes later, at 1:32 p.m. “@POTUS is delivering on his promise to tackle the high price of prescription drugs and put American patients first!”