In a sweeping social policy shift, the Trump administration is seeking to remake health rules at home and abroad for women, gay and transgender people, restricting access to abortion, curtailing support for contraception and narrowing the scope of civil rights in healthcare.

The turnaround has its foundations in the quiet, behind-the-scenes influence of Vice President Mike Pence, who has been driven throughout his political career by his evangelical Christian beliefs to restrict abortion and prioritize the rights of religious conservatives.

Pence has been in the spotlight for leading the administration’s failed effort to repeal and replace Obamacare. But other changes, affecting health policy domestically and abroad, are moving ahead with far less attention.

Under the direction of two secretaries recommended by Pence, the Department of Health and Human Services has moved to slash funds from teen pregnancy-prevention programs, curb abortion both in the United States and abroad and strip civil protections for transgender patients.

The administration has emphasized abstinence programs, led by appointees who believe contraception harms women, and pushed to cut government funds for Planned Parenthood – a longtime cause for Pence while he was in Congress. Planned Parenthood, a national network of healthcare providers, offers infertility services, contraception and abortions.

Public health civil rights offices, marshaled to strengthen LGBT rights under Obama, have been retooled into a new Office of Conscience and Religious Freedom. This month, the office unveiled a final “conscience rule” to strengthen protections for healthcare workers who object to performing abortions and sterilizations or treating gay and transgender patients.

And the HHS, along with the State Department – headed by Pence ally Mike Pompeo, also an evangelical Christian – has expanded the campaign beyond U.S. borders. Trump-appointed officials are seeking to delete language in international documents at the United Nations they contend promotes access to abortion and expands healthcare rights to transgender individuals.

“There has never been anything like it,” Marjorie Dannenfelser, president of the Susan B. Anthony List, an anti-abortion group, said of her working relationship with Pence. “The policy I believe can’t get done without Vice President Pence and his team.”

A cadre of religious conservatives appointed in the early days of the administration is driving the changes, largely from within HHS, which administers most government health programs, along with the State Department and White House. Many appointees come from religious and conservative groups, some of whom regularly protested outside abortion clinics during the Obama years.

In the Trump-Pence West Wing, “everywhere I turn are colleagues, mentors and friends who have fought in the pro-life trenches for decades,” Katy Talento, who handled health policy in the White House, told an anti-abortion group in Texas. She last week announced plans to leave the administration. “I still can’t believe they let us all in the complex every day.”

Emboldened by the movement and by the new conservative majority on the Supreme Court, states including Alabama and Missouri have passed laws in recent weeks that nearly outlaw abortion, spurring nationwide protests.

The shift has generated legal challenges, and chunks of the agenda are bottlenecked in the courts. Recently, a federal judge in Washington State blocked new rules meant to cut funding from facilities offering abortion.

The campaign has been more successful abroad. Pompeo in March held a rare news conference to say the administration was strengthening an effort to combat abortion globally. “We’re determined to make sure that we don’t allow taxpayers’ dollars to get to those places,” he said, citing groups performing or referring abortions, and announcing a cut in funds to Latin America.

Pompeo’s declaration marked an expansion of the Mexico City Policy, which requires foreign non-governmental groups that receive U.S. health aid not provide, refer or counsel on abortions. Implemented by every Republican administration since 1984, the policy in the past applied to U.S. family planning funds, or about $600 million. In one of his first acts as president, Trump signed an order expanding the rule to cover nearly all U.S. global health aid, or more than $8 billion.

Nationally, this public health battle has often been pushed to the background by the nonstop churn of Trump’s tweets and controversies.

“One of the benefits of Trump’s Twitter approach is it creates headlines, and that’s what it’s intended to do, and underneath those headlines, everyone else in the administration can go about peacefully doing their job,” said David McIntosh, president of the conservative Club for Growth and a longtime Pence friend. HHS has “released several very important, significant regulations that changed the nature of Obamacare, of healthcare, with very little coverage in the press.”

The effort has startled some public health veterans. “It’s very, very extreme,” said Megan Huchko, director of the Center for Global Reproductive Health at Duke University. “It seems we’re moving backward in pretty profound ways.”

The vice president declined interview requests for this article. Administration officials say his voice matters. Kellyanne Conway, senior counselor to the president, praised Pence’s advocacy on cutting federal support for Planned Parenthood.

“It means a great deal to the president to hear that from somebody who had been a legislator on Capitol Hill for 12 years, a governor for four, and somebody who like the president is trusted by the small c conservative movement as a full-spectrum conservative,” Conway said.

One senior HHS official told Reuters the agency is correcting the course set by the Obama administration on the government’s role in enforcing LGBT rights and whether providers have to perform abortions. “Our rights to religious freedom have too long been treated as a second-class right compared to others and it’s time for that to change,” said Roger Severino, director of the agency’s Civil Rights Division.

“It seems we’re moving backward in pretty profound ways.”

The Pence effect

When Trump secured the GOP nomination in 2016, he had yet to win over skeptical evangelical voters who questioned his varying stances on critical issues, most notably abortion. Trump previously had said he supported a woman’s right to choose whether to terminate a pregnancy.

His selection of Pence as his running mate helped him win over those voters. The Trump-Pence ticket ultimately secured 80 percent of white born-again and evangelical Christians.

In a White House marked by turnover, the amiable Pence has been a quiet presence prodding the administration to align with his faith-based agenda. Aides describe him as a man whose effectiveness is rooted in a willingness to shun the limelight and put like-minded proteges in crucial jobs.

“Pence’s influence has come from … getting people who have the same worldview as Pence in key positions at things you care about and then trusting them to make decisions,” said Paul Winfree, who served as deputy director of the White House Domestic Policy Council under Trump and is now at the conservative Heritage Foundation think tank.

The vice president’s allies and former aides are salted throughout the administration, carrying out significant shifts in federal health insurance programs. One change cheered by the religious right made it easier for employers to not cover contraception.

A key Pence ally is Seema Verma, a healthcare consultant who worked with him in Indiana, now administrator of the Centers for Medicare and Medicaid Services. Under Verma, the agency has worked to roll back Obamacare’s expansion of Medicaid, the insurance program for the poor and disabled that covers more than 70 million Americans.

Both HHS secretaries under Trump were pushed by Pence: Tom Price, an ally in Congress who was fired in 2017 for using expensive charter flights for public business, and Alex Azar, who worked as a senior pharmaceutical company executive and lobbyist in Indianapolis while Pence was governor. At a January event, Azar called Pence “my friend and mentor.”

The agency took on a new religious tone. Price hosted a Bible study on Wednesday mornings for members of Congress and political appointees, a former senior HHS official said.