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WASHINGTON — Amid mounting desperation about his reelection odds, President Trump has increasingly come to rely on an unorthodox campaign tool: the Department of Health and Human Services.

As the Nov. 3 election draws closer, HHS and the agencies within it have rolled out several initiatives clearly motivated as much by the election as by policy considerations. Most notably, the administration has announced plans to spend billions of taxpayer dollars on seemingly political projects like a mass marketing campaign to “inspire hope” about Covid-19 and a pending plan to mail $200 pharmacy gift certificates to millions of seniors.

While it’s common for incumbent presidents to use the office as a campaign advantage, governance experts and Trump administration critics say the White House’s current approach far exceeds established norms. Trump’s willingness to effectively use government personnel and taxpayer dollars in support of his reelection, they say, raises questions not only about the agencies’ conduct and integrity, but also about the legality of the actions themselves.

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The Trump administration’s apparent use of government resources for campaign purposes is most pronounced among health care agencies, which have recently announced plans to spend roughly $7 billion without congressional authorization. In the campaign’s closing weeks, Trump has aggressively highlighted the $200 discount cards and continually claimed that his campaign has “banned” surprise medical bills and issued protections for patients with preexisting conditions, even though his recent executive orders on those topics carry no legal weight.

“They’re seriously considering rushing out a letter to almost 40 million senior citizens, promising them money right before the election,” said Eliot Fishman, a former Obama administration health policy official and the senior director of health policy at the progressive advocacy group Families USA. “That’s diverting Medicare trust fund dollars into, essentially, a campaign activity.”

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Neither the Covid-19 PSAs nor the drug coupons are the first examples of Trump’s administration blurring the lines between campaigning and governing. For months, Trump openly pushed the Food and Drug Administration to authorize a Covid-19 vaccine by Election Day. In August, his health secretary and FDA commissioner were widely criticized for overselling basic statistics about an experimental coronavirus treatment. And earlier this month, Anthony Fauci, the top government infectious disease researcher, sharply criticized Trump’s campaign for a TV advertisement in which he was quoted, out of context and without his permission, praising the administration’s pandemic response. Fauci, in response, called the ad “really unfortunate and really disappointing” and warned the campaign not to include him in other commercials.

Rather than deny that his motivation is mainly political, as other presidents have in the past, Trump has acknowledged it directly.

“I will always take care of our wonderful senior citizens,” he said last month in North Carolina, following the event at which he announced his plan to send millions of Medicare beneficiaries the $200 prescription drug gift certificates. “Joe Biden won’t be doing this.”

The health care agencies’ apparent politicization even extends to basic communications about day-to-day efforts to combat the pandemic. Press releases concerning incremental scientific advances have taken on an openly political tone: Health secretary Alex Azar in August called the emergency approval of a blood plasma therapy for Covid-19 a “milestone achievement in President Trump’s efforts to save lives.”

The inflated rhetoric at HHS and FDA reached a fever pitch in late summer under the leadership of Michael Caputo, a right-wing conspiracist who Trump appointed as the top HHS spokesman, and Emily Miller, a onetime gun-rights activist and GOP operative later appointed to lead communications at FDA. (Caputo has since taken medical leave. Miller was demoted after 11 days on the job, though an FDA spokesman told STAT that she remains on the agency’s payroll as a senior adviser to the chief of staff.)

Rep. Donna Shalala (D-Fla.), who served as HHS secretary during the Clinton administration, said Trump’s willingness to manipulate the agency for political gain was unprecedented.

“It’s terrible and it compromises the scientists’ integrity,” she told STAT in an interview. “I hope it’s an anomaly and that we go back to integrity in politics and in government.”

Trump isn’t the first president to campaign on the job, though he is far more open about the political nature of his efforts. Former President Barack Obama, and specifically his top health care officials, also weathered accusations that taxpayer money had been used for political gain. In 2012, months before Obama’s successful reelection bid, his administration announced a roughly $8 billion plan to increase payments to high-performing health insurance plans.

The move was less direct than Trump’s — it provided money for businesses, not directly to individual voters — and Obama never hinted, as Trump has, that the action was politically motivated. Nonetheless, congressional Republicans accused Obama of trying to prevent health insurance premiums from spiking during an election year, and issued subpoenas in an attempt to investigate the project’s origins.

It remains unclear whether the Trump administration has the legal authority to implement the coupon-card proposal. By law, Trump and Vice President Mike Pence are exempt from the Hatch Act, which restricts government figures from campaigning on the job. Democrats, however, have focused on the spending itself: A trio of key lawmakers who chair committees with health care jurisdiction wrote to Azar on Tuesday accusing Trump of “attempting to buy votes” and demanding legal justification for the move.

While Trump’s boasts might seem ethically dicey, Fishman said, they’re not necessarily abnormal during the height of a campaign.

The use of taxpayer dollars for campaign-adjacent activities, he argued, is far more concerning.

“There’s a line that’s crossed between that and using the communications office at HHS to say nice things about the president during an election year, which I think is more within the normal parameters for using the advantages of the incumbency,” he said.

The Trump campaign did not respond to STAT’s requests for comment. In a statement, an HHS spokeswoman said the marketing campaign was meant to “address an urgent and compelling need for consistent and coordinated public health messaging about COVID-19 prevention, treatments available and ultimately vaccine safety and efficacy,” but added that Azar has ordered a “strategic review” to determine whether the effort is working. Judd Deere, a White House spokesman, said Trump’s surprise announcement regarding the prescription drug coupons had “nothing to do with politics.”

Trump’s last-ditch moves on drug pricing, in particular, come amid frustration that his administration has not done more to lower prescription drug costs. In August, he revived a number of efforts that his administration had previously appeared to abandon, including an effort to ban many rebates paid by drug manufacturers to insurers and another to cap some drug prices within Medicare based on what pharmaceutical companies charge in foreign countries.

During a debate last month, Trump falsely claimed his administration had made insulin “so cheap, it’s like water.” In advertisements, his campaign has cast Joe Biden, the Democratic presidential nominee, as the preferred candidate of “Big Pharma.”

Trump’s aggressive vaccine rhetoric has remained controversial — especially as Biden and his running mate, Sen. Kamala Harris of California, have cautioned that they don’t trust Trump’s word, alone, on vaccine safety and efficacy. Instead, they say, they would rely on the opinion of Fauci and other scientists outside government. In response, Trump’s campaign has called Harris an “anti-vaxxer.”

Despite Trump’s efforts to highlight the substantial progress that drug companies and federal scientists have made on a Covid-19 vaccine since early 2020, Americans increasingly say they won’t seek a vaccine immediately after it becomes available.

Only 58% of Americans said they’d get vaccinated as soon as possible, according to a recent STAT-Harris poll — down from 69% in mid-August.

Nicholas Florko contributed reporting.

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