Azar has taken a hard line on some culture war issues important to Trump’s evangelical base, like the ban on federal Title X family planning dollars to abortion providers, but has largely avoided tangling with Democratic critics to the extent Verma has. He's also played a prominent role in some of the administration’s bipartisan health initiatives, such as trying to eradicate HIV transmission and overhauling care for kidney disease.

Azar has been particularly focused on forging a close relationship with Trump — privately vowing to have “no daylight” with the president. That’s even meant reversing his opposition to importing cheaper drugs from Canada, a policy priority for Trump that Republicans have traditionally viewed skeptically and Azar just last year dismissed as a “gimmick."

Verma, though nominally Azar’s deputy, has cultivated her own line to the White House and become a favorite of senior officials as a prominent woman in the administration who readily attacks Democratic health policies, aiding Trump’s efforts to cast their ideas as extreme.

Several officials say Azar and his top aides have made changes within the department meant to marginalize Verma, exercising greater control over her public appearances and staffing decisions.

Azar in recent months has required that senior CMS officials report directly to him or his aides. In some instances, Verma has been excluded from internal policy meetings her subordinates have attended, four officials said.

"A lot of this is sort of, 'Just remember, we are in charge,'" said one official. "It's not so subtly making that point over and over."

Last month, the two officials sparred over the announcement of a plan to help health care providers better coordinate patient care. When Azar heard that Verma was set to lead the announcement, he insisted on being included, said three individuals with knowledge of the discussions. The White House then pushed to be included in the rollout as well, prolonging an agency turf war by days.

Health officials eventually agreed to make the announcement in stages. Azar and Verma would brief reporters on a phone call, and Verma — accompanied by HHS Deputy Secretary Eric Hargan and Grogan — the next day would make an in-person announcement at a health industry association in Minnesota.

But that second part of the plan was scuttled after HHS aides realized the industry-hosted event could expose the health department to ethical risks. That forced a scramble to find a new location — a Mayo Clinic satellite facility — just hours ahead of the major announcement and after invitations had already gone out.

An HHS spokesperson said the secretary had been involved in the rollout from the start.

Azar aides have also intervened in CMS personnel decisions to a degree that three current administration officials described as highly unusual.

In one case that illustrates the tensions, top HHS officials over a year ago encouraged Verma to hire Paul Mango, a former Republican gubernatorial candidate in Pennsylvania, to run CMS’ daily operations as her chief of staff and principal deputy administrator. Then, in July, Azar plucked Mango from CMS and gave him a top role at HHS — without consulting Verma. She didn’t find out until Mango told her less than an hour before the move was announced publicly, two officials said.

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Verma spent the following months without an official chief of staff, largely because HHS officials hadn’t signed off on giving that role to Brady Brookes, a former aide to Pence who had been Verma’s right hand for months. She was formally approved for the job last week.

CMS has encountered similar roadblocks trying to make acting Medicaid director Calder Lynch the program’s permanent leader, officials said. He enjoys wide support in the agency.

In other instances, Azar has established a direct line with Verma’s top aides to advise him on major policy efforts. Shortly after Verma hired Adam Boehler to run CMS' innovation center last year, Azar tapped him to serve simultaneously as a senior HHS adviser on value-based care.

Azar also asserted his authority over John Brooks, a senior CMS official overseeing Medicare, who simultaneously became a senior adviser to Azar on drug pricing.

In another case earlier this month, Azar’s top aides told Alec Aramanda, the top CMS liaison to Capitol Hill, that he would report directly to Azar's staff instead of Verma, although CMS has its own legislative division, three officials said.

Officials said the confusion over who reports to whom undermines the administration’s work. Without a clear chain of command, the policy making process can be easily scrambled and break down.

"It just makes it so much harder, and our jobs are hard enough already," one official said. "I don't see what the net positive outcome is."

An HHS spokesperson defended Azar, saying, "The secretary believes firmly in one goal and one team and put these reporting structures into place to better communicate and operationalize subject-matter experts to work on implementing the president's agenda at HHS."