Midnight had passed, and Alex Azar was still in a coat and tie as he looked into a computer monitor inside the Department of Health and Human Services emergency-operations hub. It was a room built for managing responses to hurricanes and disease outbreaks, but the HHS secretary was, instead, scrambling to deal with a disaster instigated by his own boss — a “zero tolerance” immigration policy that led to thousands of children being separated from their parents.
Azar was not consulted on the zero-tolerance policy before it was announced in early May, according to people familiar with the events, even though his department is responsible for housing migrant children who are on their own.
In the months that have passed since the late June night the secretary was trying to help figure out who had been separated, HHS has managed to return more than 2,000 to their parents. That still leaves more than 130 youngsters in government-contracted shelters, at risk of becoming orphans as federal workers, civil rights lawyers and aid activists help scour remote villages of Central America for mothers and fathers deported back home.
The reunification efforts have overshadowed the other work of the department that Azar arrived to lead in January with a four-point agenda — including a promise to lower drug prices — and a role as frontman for the Trump administration’s strategy of shifting health-care policies to the right through executive actions.
The migrant crisis also has put on the line his carefully cultivated reputation as an orderly, competent executive who understands how to make government work. With the midterm elections fast approaching and public outrage over the policy an animating issue, Azar also runs a risk of drawing the wrath of Trump, who has publicly humiliated other top officials when he thinks they are hurting his standing.
As the crisis escalated and the secretary became its public face before Congress and on cable TV, Azar adhered to the administration’s talking points, betraying no hint he was caught unaware by zero tolerance. Such loyalty reflects the priority Azar has long placed on nurturing relationships, whether the recent one with Trump or with conservative legal luminaries who have long been his mentors, including the late Supreme Court Justice Antonin Scalia, for whom he clerked, and Justice Clarence Thomas, whom he considers a second father.
Those close to Azar say he has worked hard to stay in the president’s good graces from the start.
He “did a tremendous amount of thinking during the confirmation process about what it would take to be a successful secretary,” said Ladd Wiley, a former HHS colleague who has remained close to him over the years. “He knew that, to be successful internally . . . you have to be successful externally. Congress, the press, the White House.”
Azar said in an interview in the spring that he and the president talked at least three times a week.
So far, “he’s done well in his meetings at the Oval Office,” said a senior White House official who has known Azar since before he joined the administration. “Some people fall apart. He has a command of the subject matter. He’s calm . . . The president is clearly to those around him not frustrated with Alex.”
Azar, 51, also brought from the outset an insider’s working knowledge of HHS, after six years in senior positions in the government’s largest domestic agency during George W. Bush’s presidency. In activating the emergency hub to begin reuniting families, Azar was reaching back to the grim days after the September 2001 terrorism and anthrax attacks, when he served as HHS general counsel. Azar, who went on to rise to deputy secretary, oversaw the conversion of the sixth-floor conference room into a public health command center for future disasters.
In June, its new mission required officials first to figure out which of the nearly 12,000 migrant children in the department’s custody had come with their parents and been taken from them by border agents.
The database that tracks the children did not have that information.
Chris Meekins, chief of staff for the department’s office of preparedness and response, said Azar told officials: “I want a manual review of every single record so there is no question.”
That was just the first step in putting families back together. They still had no clue where the parents were in the nation’s labyrinth of immigration jails — and in more than a hundred cases still don’t.
This is not the first crisis Azar has been involved in — in fact, his years in government have been punctuated by them.
And his view of government, his ideological leanings formed early.
Growing up mainly in Salisbury on Maryland’s Eastern Shore, where his father was an orthopedic surgeon and his mother would become a surgical nurse, conversation at home was so apolitical, he said, that he did not know his parents’ party affiliations. Still, by third grade, he had his own subscription to Conservative Digest.
At Dartmouth College, he was a New Hampshire co-chair for former Delaware governor Pete DuPont’s 1988 presidential campaign and “drove him all over the state,” Azar recalled in the interview. His candidate was more libertarian than other Republicans in the primary and favored ending welfare payments unless recipients got jobs — a heretical idea then that now is in vogue in the Trump administration.
When Azar went on to Yale Law School, he quickly joined the Federalist Society — which was “both an intellectual association and almost . . . a solidarity group since they were a minority” on the liberal campus,” said Akhil Amir, a young faculty member at the time who supervised a major paper Azar wrote on the Fourth Amendment on search and seizure that was in the originalist tradition — “exactly the sort of thing Justice Scalia would have loved,” Amir said.
Azar attended summer lawn parties that Ted Olson, a leading Republican attorney, held for conservative young lawyers and law students. And he met Kenneth Starr when the then-U.S. solicitor general came to campus for a talk. “I sat with Alex at dinner and said to myself, this young man from Salisbury, Maryland, is going to go places,” Starr remembers. They stayed in touch.
Azar came to Washington in 1992 to clerk for Scalia. He also grew close to Thomas and remains one of a tiny nucleus of “adopted clerks” with whom the justice still holds monthly lunches.
From the clerkship, Starr hired his protege into his law firm, and, when Starr took over in 1994 as independent counsel for the Whitewater investigation, Azar was the first lawyer he hired as an assistant independent counsel.
In 2000, Azar joined a crowd of other well-connected Republican attorneys in Florida to wage Bush’s legal fight over a recount for the presidential election. After their victory, he was part of the transition team, screening potential senior White House staff and Cabinet members.
Azar was then picked by incoming HHS Secretary Tommy Thompson as general counsel, overseeing the department’s hundreds of lawyers, though he had no expertise in health-care law. Azar had been recommended by Leonard Leo, the head of the Federalist Society and, after a look at his résumé and one phone conversation, Wiley said, “We knew immediately that Alex was the guy.” Thompson quickly agreed Azar was what he wanted in his general counsel: a sharp intellect, prodigious work ethic and open to unorthodox ideas.
The week Azar was confirmed, President Bush announced a ban on research involving newly created strains of stem cells — a controversial policy that captured much of the nation’s attention. A month later, Azar stood in the outer office of the secretary’s suite and watched on a small television as a second jetliner flew into the World Trade Center.
With the nation’s planes grounded, Thompson turned to Azar. “I knew that I needed to get a plane into the air . . . to carry 100,000 masks and 100,000 gloves from a secret medical depot to New York City,” Thompson recalled. The two men and another department lawyer talked of declaring a national health emergency, but no HHS regulation allowed that. Azar came up with a way within an hour.
“He was willing to take the legal risk,” said a former colleague, who like many of two dozen people interviewed for this story, spoke on the condition of anonymity to share private interactions and insights.
Crisis followed crisis. Envelopes with anthrax spores began turning up in postal centers, congressional offices, news organizations. Drugmaker Bayer had the main supply of the antibiotic Cipro, and Thompson wanted 100 million pills for the federal stockpile.
“Alex figured out how I could legally negotiate a lower price,” said Thompson, who threatened to buy generic alternatives if the company did not cut its price by nearly half. Many Republicans criticized the maneuver. To this day, Azar defends it, saying in the interview it was “a bona fide commercial transaction procurement,” though he has always opposed direct price negotiations with manufacturers for medicine older Americans buy through Medicare’s Part D.
Azar shepherded a rule restricting the ability of brand-name manufacturers to get repeated patent extensions to ward off competition; the idea is now part of a blueprint Trump issued a few months ago for lowering drug prices.
Former Utah governor Mike Leavitt, Bush’s second HHS secretary, promoted Azar to deputy secretary — the department’s top manager, with oversight of new regulations.
“I laid out for Alex the things I personally wanted to approve,” Leavitt said, “and delegated to him everything else.”
The Trump administration first turned to Azar for help early last year, making trips to Washington to “educate some policy folks at the White House” about HHS, according to a Republican who spoke with him about the behind-the-scenes visits.
Azar was not Trump’s first pick to run the department — that distinction went to former Georgia congressman Tom Price, who resigned a year ago under investigation for taking expensive charter planes for official travel.
Price’s downfall opened the door for Azar, who was living in Indianapolis, where he had recently left a top job at the pharmaceutical giant Eli Lilly after he was not selected to replace the outgoing CEO.
He was offered a promotion in the company, he said, “but it didn’t involve doing what I like to do, which is running organizations and big complex problems and having me accountable for the results.
“I bet on myself and left.”
In Indiana, Azar made connections with local and statewide Republican leaders. He was encouraged to run for the Senate but never did. And he grew close to Vice President Pence, when he was a congressman and governor. According to John Hammond, an Indiana Republican National Committee member, “Alex was one of a handful of people Pence would consult on a regular basis.” Pence played “a big role” in recommending him to Trump, according to the Republican who knew of Azar’s 2017 White House visits.
Since returning to HHS, Azar said, he has felt like Rip van Winkle. He still knew many of the people at the department. Other friends and former colleagues now held prominent White House roles.
He has brought in four lieutenants from the private sector and placed one in charge of each of his four priorities, which he announced in January at his Senate confirmation. They include easing the nation’s opioid epidemic, changing how health care is paid for and making individual insurance less expensive by weakening the Affordable Care Act.
The fourth, lowering drug prices, flows from a promise Trump made during his campaign — and is tied to the central criticism of Azar’s selection to run HHS: He is the first secretary to emerge from the pharmaceutical industry, having led Lilly’s largest division as the drugmaker drove steep price increases in popular medicines. He has insisted he knows from the inside what it would take to rein in prices.
He praises the president often and speaks of his own vision for change as bold — even radical. Trump, Azar tells his staff, “does not want us here to play small ball. We’re here to play big ball.” Since the White House drug blueprint appeared in May, HHS has let Medicare managed-care plans start negotiating drug prices for cancer therapies and other medicine that doctors administer. Azar has said drugmakers should have to include prices in television ads — a possibility the department is exploring, along with a long-disputed idea of importing less expensive drugs from other countries under limited circumstances.
Through the summer’s din over migrant children, Azar has continued to give speeches on his priorities as well as his overarching preference for the private sector and states’ powers over federal programs.
The buildup of separated children in the custody of HHS’s Office of Refugee Resettlement started a few months before Azar became secretary. But the department was slow to recognize it for what it was, according to government officials and immigration and refugee advocates who were on monthly conference calls with ORR staff.
The staff was noticing an influx but had seen similar ones in recent years, as conditions in home countries deteriorated. Inside ORR, the main concern was expanding bed capacity at its network of private shelters and other facilities — not finding out why more children were arriving.
A Public Health Service commander named Jonathan White, a social worker, was in charge of ORR’s unaccompanied-children program until mid-March. In July, he testified before the Senate that he had cautioned that children could be damaged psychologically if removed from their parents — and that he and colleagues repeatedly were told there was no administration policy of separation. One government official familiar with the events said White’s warnings did not reach Azar’s level.
By April, shelters’ social workers had been hearing children say they had been pried from parents. Late that month, ORR asked the Department of Homeland Security for help in finding parents in immigration custody — and was asked to produce a list of the children’s names, the government official said.
It numbered roughly 700. ORR staff sent it to Homeland Security without consulting the secretary’s office, the official said.
In late June, two days after Trump had ended the zero-tolerance policy and four days before U.S. District Judge Dana M. Sabraw gave the administration a 30-day deadline to reunite children with their families, Azar created a process to do so. He activated the command center, put White in charge, mustered 230 staff from across Health and Human Services and hired 100 extra caseworkers.
“We know our mission, we know our tack, and we are executing on it,” Azar declared at a news briefing a week after he had read files late into the night.
At last count, 136 children were still in HHS’s custody, three of them 4 years old or younger.