Numerous top leaders of the department — including Secretary Alex Azar, Surgeon General Jerome Adams and Medicaid/Medicare chief Seema Verma — have ties to Vice President Mike Pence. | Brendan Smialowski/AFP/Getty Images health care How Mike Pence's 'Indiana mafia' took over health care policy Behind the scenes, Pence has developed his own sphere of influence in an agency lower on Trump’s radar: Health and Human Services.

Sweeping new protections for religious health care workers and an overhaul of family planning programs to effectively cut out Planned Parenthood represent something unusual in the Trump administration: a clear spotting of the fingerprints of Vice President Mike Pence.

From topics ranging from trade to the president’s scorched-earth attacks against the Mueller investigation, Pence has been the loyal foot soldier while often appearing uncomfortable amid the administration’s biggest fights.


Despite having earned Trump’s gratitude for his loyalty, Pence has had a far lower profile than his recent predecessors.

But behind the scenes, Pence has developed his own sphere of influence in an agency lower on Trump’s radar: Health and Human Services. It’s also the agency with the ability to fulfill the policy goal most closely associated with Pence over his nearly 20 year career in electoral politics: de-funding Planned Parenthood.

Numerous top leaders of the department — including Secretary Alex Azar, Surgeon General Jerome Adams and Medicaid/Medicare chief Seema Verma — have ties to Pence and Indiana. Other senior officials include Pence's former legislative director from his days as governor and former domestic policy adviser at the White House.

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“He has clearly recruited people connected to him who share his very extreme views on sexual and reproductive health care," said Emily Stewart, the vice president of public policy at Planned Parenthood. "This has been one of the most active administrations ever on rolling back reproductive rights and there's no way that happens unless you have people in the White House driving the effort to put out policies at such a rapid clip.”

Had courts not stepped in, HHS was set to implement this month newly rewritten federal policies to curb abortion and cut funds to Planned Parenthood, tightening rules of the Title X federal family planning grants so clinics can’t even refer women to a separate abortion provider. In addition, the agency this month boosted religious conscience protections for providers who refuse on moral grounds to perform certain medical services, including abortion.

The changes to Title X are the culmination of a battle Pence waged first as a member of Congress, then as governor and now in the White House. The Title X rules, which force providers of federally funded family-planning programs to separate themselves from abortion providers, are aimed squarely at Planned Parenthood, which relies heavily on such funding. The Title X changes don’t cut off Medicaid funds from Planned Parenthood — although cutting off that big pot of money is on the GOP wish list as well.

In 2007, as a U.S. congressman, Pence introduced the first bill to strip federal funding from the organization, creating an issue that eventually became almost a litmus test for GOP candidates.

“I don’t think the largest abortion provider in America should be the largest recipient of Title X family planning funding,” he said at the time.

Despite the clear link between Pence’s agenda and the administration’s changes to Title X, multiple current and former officials insist Pence isn’t dictating policies to HHS, though the White House credited him with pushing its anti-abortion health agenda.

“There have been many staff level meetings on pro-life issues with HHS. He and the president will always advocate for pro-life policies," a White House official said of Pence's involvement at the health department.

Pence doesn't need to dictate policies, however, to have his priorities advanced at HHS. Rather, the cadre of officials that one HHS official called “Indiana mafia” make policies that advance Pence's — and their own — agenda.

Azar, who succeeded ousted HHS Secretary Tom Price in January 2018, was a top executive at Indiana-based drug company Eli Lilly when Pence was governor; Verma was his Indiana health adviser, and is now championing Medicaid reforms around the country that he embraced in Indiana; Verma’s deputy chief of staff, Brady Brookes, is Pence’s former Indiana legislative director; Adams, the surgeon general, is a former Indiana public health official. Rebekah Armstrong, who oversaw domestic policy in the vice president’s office at the start of the Trump administration, is also now stationed at HHS’ legislative affairs office.

At the outset of the Trump administration, Pence was involved in identifying like-minded nominees “particularly in roles Trump didn’t really care about,” as one GOP operative put it.

Other allies say his state’s efforts to reduce regulation and federal oversight of health programs, defend religious conservatives who refuse to carry out policies antithetical to their opposition to LGBTQ rights or abortion rights, and impose coverage restrictions for recipients of federal aid are models for Trump administration initiatives.

Pence was “perhaps the key leader, or one of them” in the GOP effort to scrap Obamacare, said Americans for Prosperity President Tim Phillips, a Koch-funded group that pushes free-market policies but doesn’t get involved in social issues. But beyond any particular policy, Phillips said, Pence is “an invaluable source of intelligence gathering for the administration for where key constituency groups and key Senate and House groups stand.”

“I think that’s probably the most important role he plays,” he added.

Pence is far from the only administration official with deeply held anti-abortion views; HHS and the White House staff include numerous appointees with roots in anti-abortion organizations or the offices of conservative Republican lawmakers most active in opposing abortion rights.

“Pro-lifers have more of a seat at the table now,” said Kristan Hawkins, the president of Students for Life of America, an influential anti-abortion group that has met with the White House several times. “We have more active pro-lifers now in the West Wing and throughout the administration, and that’s a definitive shift from past administrations.”

The new Title X rules mark a major victory for these officials — as much as Pence himself — even though multiple federal courts have blocked them from taking effect until courts can resolve legal challenges by the state officials and abortion rights groups. The Trump administration is confident it will win in the end, particularly because similar, though less restrictive, funding rules signed by President Ronald Reagan were upheld by the Supreme Court in the 1990s. And with higher courts increasingly packed with recently appointed conservative judges, the administration may have an even better chance of prevailing than in the Reagan era.

Advocacy groups are also considering litigation to halt new HHS “conscience” rules issued this month that make it easier for health care workers to refuse to provide care that violates their religious or moral beliefs. Even somewhat smaller projects appear to bear the vice president’s ideological imprint — for example, a recent HHS decision to grant South Carolina a waiver that allows foster care providers to reject potential families who have different religious beliefs.

These conservative and religious views have played into the administration’s foreign as well as domestic policy. Internationally, Trump and Pence have gone beyond even other Republican administrations in curbing access to abortion and contraception by expanding the so-called Mexico City policy barring U.S. foreign aid to groups that promote or provide abortion.

“With some people, it’s a political calculation. With Mike Pence, it’s a personal conviction and there’s never been any doubt about how sincerely he believes it,” said Rep. Tom Cole (R-Okla.), referring to Pence’s efforts to fight abortion. “So he’s helping the president, not hurting him, and he’s doing things that most of us in the House who served with him are glad he’s doing.”

“He believes very strongly that this is the direction we need to go in,” said Sen. John Boozman (R-Ark.), who was part of Pence’s incoming class in the House. “I’m pleased he hasn’t really backed off from that any since he first came to Washington.”

This record has made Pence Enemy Number One for Planned Parenthood. For years the group has encouraged supportersto make donations in Pence’s honor and flood his office with thank-you notes. To date, more than 87,000 people have done so, and 11,000 have set up recurring monthly donations in Pence’s name, Planned Parenthood told POLITICO. In the month following the 2016 election, more than a quarter of all donations to the women’s health organization were made in the vice president’s name. The group has also utilized a Pence impersonator to raise more money, and consistently refers to the “Trump-Pence administration” in its press releases in order to highlight the vice president’s role.

“Our supporters across the country recognize the dangerous impact of Mike Pence’s policies,” Planned Parenthood President Leana Wen said in an interview. “So we make sure that every donation goes towards specifically countering his misogynistic policies.”

Meanwhile, LGBTQ groups have held Madonna-blasting, glitter-strewn dance parties outside the vice president’s Washington home to call attention to his efforts to expand religious exemptions to people violating gay and transgender rights. Protesters dressed as the “handmaids” from Margaret Atwood’s dystopian novel have also repeatedly shown up at Pence’s events, equating the vice president’s anti-abortion views with the system of forced pregnancy and breeding described in Atwood’s Handmaid’s Tale.

Pence’s war with Planned Parenthood began in earnest during the four years he spent almost single-handedly building opposition to the group until his defunding amendment finally passed the House in 2011. The bill never made it out of the Senate.

Still, Pence’s efforts helped elevate the idea of defunding the network of clinics to the top of the Republican agenda. Since then, the House has voted nearly a dozen times to strip the group’s public funding, and conservatives nearly shut down the government in 2011 and again in 2015 over Planned Parenthood’s continuing receipt of federal dollars.

“There is a clear pattern dating back many years,” Wen said in an interview. “He has worked relentlessly to cut off access to women’s health care.”

After he was elected governor of Indiana in 2012, Pence pushed the state to be first to cut off Medicaid funding to Planned Parenthood — although the courts prevented it. He also signed several bills curtailing access to abortion, some of which were also blocked by federal courts. Nonetheless, a law Pence signed spurred funding cuts to several Planned Parenthood clinics and the closure of at least one, which some Pence critics have cited as a contributing factor to the state’s HIV outbreak from 2011 to 2015.

As vice president, Pence has on a handful of occasions cast a tie-breaking vote in the Senate, including in 2017 when he weighed in to ensure passage of a bill that makes it easier for states to cut federal funds to Planned Parenthood. Pence also hosted two recent meetings at the White House for anti-abortion groups and faith leaders, and maintains close ties to Marjorie Dannenfelser, president of the anti-abortion juggernaut Susan B. Anthony List, according to multiple sources. A spokesperson for the group declined to make Dannenfelser available for an interview.

“You can definitely tell the VP has been behind the scenes working to fulfill his promises to the pro-life movement,” said Students for Life’s Hawkins, who has met twice with Pence since he took office. “And he assured us they’re doing all they can in the administration to defund the nation’s largest abortion vendor.”

In contrast to Pence’s decades-long anti-abortion crusade, Trump is a relative newcomer to the cause. The president, who described himself in a 1999 interview as “very pro-choice,” was as recently as 2017 unaware of major anti-abortion touchstones like the annual “March for Life” -- which takes place on the national mall to mark the anniversary of Roe vs. Wade — and has reportedly relied on Pence to explain their significance to him.

However, many administration allies insist that Trump has come around to the cause. For example, Trump decided to attack Democrats in New York and Virginia for pushing controversial legislation expanding women’s access to abortions later in pregnancy, and made the issue a feature of his State of the Union address. In a proclamation declaring this week National Women’s Health Week, the White House highlighted opioid addiction, heart disease, surprise medical bills and even maternal mortality, but made no mention of abortion or reproductive health issues.

“I think President Trump really believes in the life issue. I think secondly, he knows that the pro-life community supported him in the last election and he has their support now and he wants to retain his support,” said Travis Weber, vice president for policy for the Family Research Council.

While Pence’s influence reverberates through HHS via the “Indiana mafia,” individuals in and outside HHS emphasize that Trump, too, exerts significant influence over certain parts of the administration’s health care agenda, such as the push to lower prescription drug prices.

Still, the president’s No. 2 is never far behind when the president touts HHS’ work.

“Just today we finalized new protections of conscience rights for physicians, pharmacists, nurses, teachers, students and faith-based charities,” Trump said earlier this month in a Rose Garden speech on the National Day of Prayer.

“They’ve been wanting to do that for a long time, right, Mike?”

Gabby Orr contributed to this report.