Congress
The think tank driving health policy on Capitol Hill — and dividing Republicans
One small think tank is driving health policy within the GOP. It has also created friction on Capitol Hill and in the White House as Republicans clash over the future of Obamacare.
Paragon Health Institute was established in 2021 and has only 11 full-time staffers, but founder Brian Blase is credited with formulating many of the proposals that became the basis for nearly $1 trillion in Medicaid cuts enacted as part of the GOP megabill. The group’s success is thanks in large part to its vast alumni network spread out across the highest levels of government, from the speaker’s office to the Trump administration.
Now Blase is looking to exert his clout again, mounting a fierce campaign to convince lawmakers to let enhanced Affordable Care Act tax credits expire at the end of the year. Democrats have made an extension of the boosted Obamacare subsidies, first approved by Congress in 2021, as their centerpiece demand in the current government funding fight. Republicans need to figure out if they’re willing to deal — and Paragon doesn’t want them to bend at all.
“Brian is exceptionally smart, principled, and motivated by good intentions,” said Paul Winfree, the president and CEO of the Economic Policy Innovation Center — another conservative think tank — who served as a top economic official in the first Trump White House. “He truly wants to solve problems in health policy and believes — I think correctly — that the government is the cause of many of them.”
But Paragon is making a key segment of congressional Republicans uncomfortable, according to interviews with a dozen House GOP lawmakers, senior aides, White House officials and people close to the administration, many of whom were granted anonymity to provide their candid views or describe private conversations.
Though conservatives are largely complimentary of the think tank, a swath of House Republicans, including some of the conference’s most vulnerable incumbents, privately say Paragon is dead-set on notching conservative policy wins irrespective of the damage they might do to the GOP’s fragile majority in the midterms.
“Kind of feels like they’re giving Brian Blase the keys to the castle,” said an aide to a moderate House Republican of the access given to Paragon on Capitol Hill.
As a government shutdown begins with few off-ramps in sight, Republicans soon will have to make a choice about how closely to heed Paragon’s advice. They have already been working to overcome negative messaging around the drastic Medicaid cuts in their sprawling tax and spending package from over the summer. Now, they’re confronting warnings from pollsters, advisers and vulnerable incumbents that allowing the ACA subsidies to expire at the end of the year will cause out-of pocket insurance premiums to skyrocket and kick millions of people off their health coverage.
Rep. Greg Murphy (R-N.C.), a member of the tax-writing Ways and Means Committee and a practicing surgeon, said Paragon brings a “30,000 foot view” to the health policy debate. But, he added, “Does that always translate to what’s better for patients? … I don’t know.”
A presence on Blue Light News
Mindful of the possible political blowback from inaction, at least a dozen moderate House Republicans support a one-year extension of the subsidies. Some GOP senators are working on their own proposal.
Yet Paragon is forging ahead with its crusade to kill the credits outright. It complains about the cost — an estimated $350 billion through 2035 if extended permanently — and argues the subsidies have proven to be a huge windfall for the health insurance industry. The group also contends Obamacare itself is rife with fraud and “phantom enrollment” — scenarios where people are on health plans but don’t file any medical claims.
The talking points are flowing directly to congressional conservatives. The Republican Study Committee hosted Blase and members of his team for a staff briefing in August on the expiring subsidies, which was followed by a Paragon-led Hill briefing in September featuring remarks from a top health policy adviser on the House Energy and Commerce Committee.
Paragon isn’t alone in pushing for the Obamacare subsidies to expire. The Club for Growth and Americans for Prosperity are among other prominent conservative groups pushing against an extension, while anti-abortion advocates oppose the tax credits because they cover the costs of terminating pregnancies.
But Paragon’s uniquely close relationship with lawmakers has unnerved many House GOP centrists. Some of them raised concerns with senior members of their party when Blase presented at the RSC staff briefing, according to two people with direct knowledge of the matter.
“We had to hold these people off once before; we will do it again,” said one moderate House Republican who favors an extension, referring to how colleagues successfully mobilized their conference in resisting Paragon’s megabill proposals for even deeper Medicaid cuts.
A spokesperson for the RSC did not respond to requests for comment.
In a statement, Blase said that “Paragon did not draft any language on Medicaid provisions” in the GOP’s new tax and spending law. But Paragon did play a leading role in building support for two major changes to Medicaid payments to states.
One proposal limited the states’ use of provider taxes, the revenue from which allows hospitals to get higher Medicaid payments at federal expense. Paragon derided the status quo as a form of “money laundering.” The group also pushed for a new cap on state-directed payments, which enables states to better direct Medicaid dollars; Paragon said the program lacked transparency.
Paragon’s influence was quiet but not completely unseen: PDF metadata revealed that Blase was the author of a letter the hard-right House Freedom Caucus circulated in May calling for more aggressive Medicaid cuts.
Ultimately, Congress didn’t go as far as Paragon wanted on either priority. But the final provisions were lauded as historic achievements among conservative health policy wonks — and continue to cause political headaches for Republicans in swing districts.
An administration divide
Blase, who holds a doctorate in economics and was special assistant to the president for economic policy during the first Trump administration, disputed the suggestion that Paragon is touting controversial positions. In his statement, he pointed to a recent, Paragon-commissioned poll showing a majority of voters want the enhanced subsidies for insurance premiums to expire.
“We appreciate the difficulty that leaders have in shepherding legislation through Congress,” said Blase. “That’s why President Trump, Speaker [Mike] Johnson, [Senate Majority] Leader [John] Thune and members and staff involved with the reforms of the past year deserve enormous credit for enacting the most meaningful health policy reforms in a generation.”
When asked to address concerns from some vulnerable Republicans about letting the ACA subsidies expire, Blase replied that premiums would rise anyway as a result of “flaws in the original design of Obamacare” and that Congress could respond by pursuing other legislative overhauls of the American health care system.
Just as Paragon is driving an ideological split among Republicans on Capitol Hill, a similar dynamic has played out inside the White House over the future of the ACA credits.
According to five people familiar with administration dynamics, including two White House officials, Paragon alumnus Theo Merkel — who now serves as a senior domestic policy adviser at the White House — hasn’t seen eye-to-eye on the issue with members of Trump’s political team and other influential political advisors close to the administration.
That includes White House deputy chief of staff James Blair and Trump pollster Tony Fabrizio, who are more of the mind that extending the credits in some form would be politically advantageous for Republicans, those people said.
While Trump has not yet come out publicly for or against extending the subsidies, he privately said he was willing to negotiate on the matter and other health care proposals during a closed-door meeting with Democratic leaders Monday. Fabrizio in July touted findings in a poll published by his firm showing that a failure to preserve the credits “could hand the GOP majority to Democrats.” He did not respond to a request for comment.
Merkel, however, has been promoting the Paragon view that the subsidies are bad policy in meetings with staff and lawmakers. While still at the think tank in September 2024, he testified before the Senate Finance Committee that the credits amounted to “paying insurers more to hide the flaws of the ACA” and should be “allowed to expire.”
“Generally speaking, the political people want it, and the policy people don’t,” said one of the people aware of internal conversations taking place inside the administration.
A House Republican aide described Merkel and Corey Ensslin — another domestic policy advisor in the administration who has been working on the ACA policy — as “conservative brainiac guys” who “don’t give a shit about politics.”
Merkel and Ensslin do appear to be coming around to the political demands of their current jobs, however, as the White House is privately readying a variety of options around the ACA subsidy issue, according to two other people with direct knowledge of the matter.
When reached for comment, Kush Desai, a White House spokesperson, declined to share the Trump administration’s current stance on the matter of a subsidies extension but denied there was a rift inside the president’s circle.
“Every member of the Trump White House is playing from one playbook — President Trump’s playbook,” he said in a statement. “The idea that there is any daylight between Special Assistant Merkel and Deputy Chief of Staff Blair is completely fake news.”
Far-reaching influence
Blase said in his statement he founded Paragon to provide “high quality research” and “show how important incentives are in health care” — while also “expos[ing] the incentives that reward the manipulation of government programs to draw down more funding and more corporate welfare.”
Regarding the expanded ACA subsidies, Paragon says its research shows the enhanced subsidies have led to the improper enrollment of more than 25 percent of all individuals with insurance through Obamacare marketplaces — more than 6 million people.
The conservative activist orbit has responded favorably to Paragon’s work. According to tax records obtained by InfluenceWatch, Stand Together — a right-leaning organization connected to Charles Koch — donated $2 million in 2021; the 85 Fund, which has ties to the conservative judicial activist Leonard Leo, gave $1 million in 2022.
Paragon’s influence is also reflected in its alumni network, with think tank veterans now serving in prominent places throughout the Trump administration — from Merkel at the Domestic Policy Council to Abe Sutton, who leads the Center for Medicare and Medicaid Innovation, and Marty Makary, the head of the Food and Drug Administration.
Joel Zinberg, a former director for a public health initiative at Paragon, was tapped by Trump in January to serve on the National Economic Council with a focus on health care and deregulation.
Paragon itself also counts several health policy heavyweights among its advisers, including the Economic Policy Innovation Center’s Winfree, American Enterprise Institute’s Yuval Levin and the Bipartisan Policy Center’s Tevi Troy.
Other alumni have regularly cycled in and out of GOP congressional leaders’ offices as senior health policy advisors. For instance, Johnson brought on Drew Keyes, a former senior policy analyst at Paragon, to be his senior policy advisor in 2023 following his ascension to the speakership.
Keyes took the spot formerly held by Ryan Long, the senior policy advisor to then-Speaker Kevin McCarthy, who was ousted before Johnson won the gavel. Now Long serves as director of congressional relations at Paragon and has spoken to Republicans in at least one Hill briefing this fall on the expiration of the enhanced Obamacare subsidies.
Johnson said in an interview with Fox Business over the weekend he thinks the subsidies are “bad policy.”
Rep. Kevin Hern of Oklahoma, a member of House GOP leadership, said Paragon has been effective in highlighting the message that the enhanced subsidies were intended as Covid-era relief, not a permanent tax credit.
“Democrats and reporters, from time to time, forget about what the premise was,” said Hern. “And so Paragon does a great job of reminding us of the policy conversation at that time.”
Rep. Chip Roy (R-Texas), a vocal member of the Freedom Caucus, said Paragon adds “a lot of value because they get the health care issue in figuring out ways to manage the problems created by the obviously failing ACA and subsidies.”
“Brian and the guys have been publicly talking about this stuff,” Roy continued. “We are having conversations.”
President Donald Trump is showing little urgency in sending nominations to the Senate even as the GOP’s control of the chamber beyond 2026 is increasingly in doubt.
There are more than two dozen federal court vacancies. Labor secretary, FDA commissioner and scores of other open positions do not have nominees, and a senior White House official said Trump is in no rush to fill them.
“Ultimately, we need to have the right people in those positions,” said the official, who was granted anonymity to describe internal thinking. “So if it’s acting for now, so be it. If [it] takes a little while to find that perfect person, then it takes a little while.”
That’s unsettling some Republican senators who are anxious to fill spots ahead of the midterms, a daunting task given the legislative calendar and host of competing GOP priorities.
“We’re running short on time,” said Sen. Tommy Tuberville (R-Ala.), a member of the Senate HELP Committee, which oversees health, labor and other issues. “We’d love to get at least one or two of them and get it in the next tranche.”
As far as judges, Tuberville said he wants to see “as many as we can get” nominated, adding, “I don’t know why we don’t have more.”
Trump’s apparent nonchalance — particularly over judges — is a marked departure from his first term, when he opined that appointing people to the bench might be the “single most important thing you do” as president. But as the Senate left for a two-week recess Thursday, there were only 10 nominees pending for 29 judicial vacancies.
The vacancies come amid ongoing tensions between the Senate and Trump, who has put pressure on the chamber to pass the GOP elections bill known as the SAVE America Act, going so far as to cancel a planned Wednesday signing of a bipartisan housing bill.
Sen. Ted Cruz (R-Texas), a member of the Judiciary Committee, said he “absolutely” wants to see the president nominate more judges before the end of the year. Texas has three court vacancies with zero nominees.
“And that’s one of his greatest legacies, both first term and second,” Cruz said of Trump.
Trump is on pace with his first term in total confirmations in part because Republicans changed the Senate rules last year to confirm slates of civilian posts at once by a simple majority vote.
One tranche confirmed in Mayincluded 49 nominees, from ambassadors to midlevel posts at various federal agencies. So far, 502 of Trump’s second-term nominees have been confirmed, compared to 509 at this point during his first term and 601 at the same point during former President Joe Biden’s term.
Federal judges and members of the Cabinet still have to be confirmed individually, despite the rule change for other posts.
Trump inherited only about 40 judicial vacancies for his current term, fewer than any president since Ronald Reagan. Judiciary Committee Chair Chuck Grassley (R-Iowa) previously complained that the White House hasn’t nominated more judges. More recently, though, he’s blaming his committee for not acting more quickly on the already pending nominees.
“Right now it’s hard for me to blame the White House when in the last three executive weeks, we were supposed to have meetings to vote judges out, we couldn’t have enough members present,” Grassley said in an interview.
A White House official said “Trump plans to nominate well qualified individuals to fill these vacancies.”
Sen. John Kennedy (R-La.) said he’s had “a couple good discussions” with the White House about a circuit court vacancy, which he expects the administration to fill. As a Judiciary Committee member, he can block any nominee that doesn’t get support from Democrats.
“If it’s somebody I support, I’ll vote for them. If it’s somebody I don’t support, I’ll vote no,” Kennedy said. “It’s an important spot. They know I’m on Judiciary, and they know I’ll vote no if I don’t agree.”
The Labor secretary and FDA commissioner picks, meanwhile, go through the HELP committee — chaired by Sen. Bill Cassidy (R-La.), who lost his primary last month after Trump endorsed a challenger.
Republicans have been left in the dark about those nominees, some on the panel say.
Sen. Roger Marshall (R-Kan.) said he’s heard “nothing at all” and “radio silence” from administration. Another GOP senator, granted anonymity to speak candidly, said they’ve heard nothing from the administration about its thinking or plans for a Labor secretary nominee specifically.
The HELP Committee membership poses challenges for the administration. Sens. Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) previously expressed concerns about Casey Means’ nomination as surgeon general before Trump pulled her, for example. And the dynamic between the president and the chair could be a hurdle, three people granted anonymity to comment on the process said.
“Why give Cassidy a platform to get back at DJT?” one of them said.
Another, a GOP senator, predicted Cassidy would “play games” with nominees who have to go through his committee.
“I really don’t think a lot of senators are in any mood to give the president any wins because they’re frustrated with him,” said the third person, who is close to the White House.
But confirming nominees before he leaves the Senate could be a priority for Cassidy, one of the few Republican doctors to push the administration toward public health nominees who align with established science on issues like vaccines.
A potential successor — Republican Sen. Rand Paul of Kentucky — is a critic of the vaccine and masking standards set during the pandemic and would likely set the committee on a different path.
Recent appointees such as Nicole Saphier for surgeon general and Erica Schwartz for Centers for Disease Control and Prevention director are more mainstream than some past HHS appointees like Means and Dave Weldon, who was nominated for CDC director before the administration determined he didn’t have the votes.
Those nominees have been moving through the regular process, including meeting with Cassidy and other senators ahead of confirmation hearings.
Cassidy told reporters after he lost his primary that he would “vote for the good of my country and the good of my state.”
“There’s some nominees that have not gotten through committee for whatever reason, so that’s not anything new,” he added. “That’ll just be part of the process.”
A HELP Committee spokesperson added Thursday that Cassidy has voted for every Trump nominee and that the panel will “do its job to confirm qualified nominees and serve the American people.”
“Anyone who says otherwise doesn’t know what they’re talking about,” the spokesperson added.
The White House official said “Trump remains committed to nominating highly qualified individuals for a variety of posts that are aligned with the agenda the American people elected him to enact” and will continue to send nominees to the Senate, including to the HELP Committee.
Senate Majority Leader John Thune said in an interview he had not spoken to the White House about their plans for some of the major picks under HELP jurisdiction but he encouraged the administration to send nominees.
“I think it’s always better to have people in permanent positions rather than temporary,” Thune added.
Megan Messerly contributed to this report.
Rick Scott swears he’s not up to something.
Fresh speculation about the Florida Republican’s ambitions erupted again in recent days after he invited President Donald Trump to address the Senate at an especially sensitive moment — and without Majority Leader John Thune’s express approval. Then, he circulated a letter outlining how he thought the Senate GOP should be preparing for the November midterms.
But Scott insists those who see this as a prelude to a leadership challenge have it all wrong. Sitting in his Senate office less than 24 hours after hosting Trump, he told Blue Light News he’s perfectly happy running the conference’s conservative Steering Committee and predicted Thune would easily secure another term as leader.
“There won’t be a vote,” he said, adding that he’s “fine” with Thune continuing in the position.
“Here’s what I don’t get,” Scott continued, expressing exasperation with the palace intrigue. “Other people get to put out their position. If I put out mine, then I want to be leader?”
What has become eminently clear in recent weeks is that Scott — after a long career in business, two terms as governor and nearly eight years as senator — just isn’t a back-bench kind of guy.
He has lots of thoughts on how the Senate should be run and a willingness to express them, even if it puts him at odds with Thune’s vision. The leader, who trounced Scott in a 2024 conference election, has largely avoided holding doomed votes that would split Republicans and, like many GOP senators, would like nothing more than to get past the monthslong intraparty fight over the SAVE America Act, the elections bill pushed by Trump.
“One thing we can do up here is, we can take votes,” Scott said. “Even if they’re not going to pass, we each show people where we are versus the other side. And so, one thing that surprises me is, why don’t we take votes? … Let’s show people.”
Scott’s incarnation as a conservative thought leader is only his latest attempt to stay in the thick of the action in a body where obscurity can be hard to avoid. His stint running the GOP Senate campaign arm ahead of the 2022 midterms was controversial and ended with Democrats beating historical headwinds and slightly expanding their bare majority.
He annoyed colleagues with his policy of not intervening in contested Republican primaries and infuriated some of them by promulgating a policy agenda through his personal political operation that they hadn’t agreed to.
That did not deter Scott from challenging then-Minority Leader Mitch McConnell after the election that year, garnering only 10 votes of 47. He tried again after McConnell stepped down as leader two years later. Scott won 13 votes in a three-way race, but Thune ultimately prevailed.
Thune, unlike McConnell, doesn’t have an openly antagonistic relationship with Scott. He said in an interview that the Florida Republican has done a “great job” as Steering chair. It is in that role that Scott convenes the weekly Wednesday senators’ lunch and invited Trump to attend.
“He brings people in that help inform our conversations and discussions about some of the major policy issues,” Thune said. “I’m very supportive of what he’s doing.”
One Senate Republican who was granted anonymity to speak candidly said that Scott had earned “street cred” within the conference for how he’s run the Steering Committee. He has brought in Trump, Elon Musk and White House chief of staff Susie Wiles, among others, underscoring his connections with key luminaries in the contemporary GOP.
For now, the Steering position and his close ally’s return to the White House have given him renewed influence and a base of support outside of leadership, where multiple Republicans are viewed as potential contenders to succeed Thune if he decides to retire in 2028 or beyond.
Scott isn’t up for reelection until 2030, and he did not guarantee in the interview that he would stick around the Senate indefinitely.
“I’ve done this. I’ve tried different stuff,” he said. “So we’ll see.”
He had been the subject of past speculation about a presidential run but made clear in the interview he’s not interested in a Cabinet position because “I was 25 years old the last time I worked for somebody.” His future, he said, will revolve around the question, “Am I being productive?”
The GOP senator granted anonymity said he doesn’t think Scott will run for leader again in November but acknowledged that Scott is viewed as ambitious and that there’s “not a lot of ways to go up” in the Senate absent running for leader or president.
“Rick, appropriately, properly feels he’s got more to contribute,” the senator added. “I hope he feels a certain sense of satisfaction about his leadership on the Steering Committee because he really has made it great.”
For now, Scott’s sense of productivity has certainly been boosted by his dealings with and loyalty to Trump.
“President Trump works great with Senator Scott and has appreciated his efforts to advance the President’s America First agenda in the Senate — including urging a path forward for the SAVE America Act,” White House spokesperson Abigail Jackson said in a statement.
A person familiar with the administration’s thinking, granted anonymity to speak candidly, attested to Scott’s “deep relationships” across the administration, pointing to Wiles and Secretary of State Marco Rubio in addition to the president himself.
“Trump remembers the people who were with him” between his two presidential terms, the person said, adding that Trump “also respects ‘successful’ people and Rick may be the most successful business person in the Senate.”
Last week’s lunch invitation grew out of a conversation between Trump and Scott, though the meeting did not go as Scott had planned. Notes from Scott’s introduction obtained by Blue Light News show he wanted to spark a policy-driven conversation focused on three issues: the future of the Senate filibuster, passage of the SAVE America Act and preventing another government shutdown.
Instead, Trump came into the closed-door meeting “pissed” over a symbolic vote the previous day on the Iran war, Scott said, and quickly got into a back-and-forth with retiring Sen. Bill Cassidy (R-La.) on that issue. Trump proceeded to mostly air his grievances at senators rather than engage in any productive back-and-forth, attendees said.
Still, Scott said, “something positive” came out of the meeting because hours later Republicans defeated a different Iran war powers resolution. And he predicted there would be a “renewed emphasis” on the GOP elections bill that Trump views as his No. 1 priority.
He pointed to three potential paths forward for the SAVE America Act: attempting a “talking filibuster” that would force Democrats to hold the floor in order to block the bill, breaking the voting bill up into pieces or trying to include it in a party-line budget reconciliation bill, which would require precedent-breaking moves many GOP senators oppose.
Only the talking filibuster option, Scott believes, has a possible chance of success, and he urged Thune and his other colleagues to consider it.
“I think the right way is, let’s put it on the floor,” he said. “Maybe we should take all of August and do it. It is the most important thing to Americans, and it actually is important.”
Many of his colleagues don’t share his optimism, and it could be difficult to get enough senators interested in voting to even restart debate on the bill given the high level of frustration within the conference.
Asked about that frustration, Scott cut in: “[Then] don’t do it. Hey, I’m just saying, here’s how I look at life — I’m one senator.”
Alex Gangitano contributed to this report.
House Speaker Mike Johsnon said he plans to send President Donald Trump a bipartisan housing bill Monday, just days after the president abruptly canceled a signing ceremony for the legislation after Congress failed to pass his elections security act.
Speaking with Fox News’ “Sunday Morning Futures,” Johnson said the 21st Century ROAD To Housing Act is a Republican priority for lowering costs for Americans.
“I’m going to send the bill over to him on Monday, and it will become law,” the Louisiana Republican told host Maria Bartiromo. “I certainly want him to take the biggest, boldest marker that he has and do that big Trump signature proudly on that legislation because we’re delivering for the people, and that’s what he wants to do.”
The White House did not immediately respond to a request for comment on Johnson’s remarks.
The bill is the product of almost a year of back-and-forth between all four congressional corners and aims to increase affordability by boosting housing supply and home ownership. It passed both chambers of Congress with wide bipartisan support.
Trump was scheduled to sign the bill into law last week but canceled the ceremony “until such time as we pass the desperately needed SAVE AMERICA ACT, which I consider to be a National Emergency.”
Trump’s SAVE America Act would require voters to present a photo ID at the ballot box and effectively end mail-in voting. Trump has also said he would like the bill to include prohibitions on transgender athletes competing. But Republican leaders have repeatedly indicated the legislation does not have enough votes to pass.
Congressional leaders appeared taken aback by Trump’s signing cancellation, but Johnson on Sunday said he and the president have since met in the Oval Office to discuss the housing bill “in great detail.”
“We made a lot of promises to the voters, and we’re fulfilling those every single day of this Congress,” Johnson said. “This is a big part of that because this will increase the availability, the access to more housing, bring down cost, cut regulations, do the things we know are very important for that market. The president and I talked about that at length. Of course he wants to do those things.”
But if Trump does not sign the housing bill into law within the next few days, it would still become law unless he were to veto it. Congress also has the power to override a presidential veto.
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