When President Donald Trump needed a new pick for surgeon general last May, he turned to Health and Human Services Secretary Robert F. Kennedy Jr. for advice.

“Bobby really thought she was great,” Trump told reporters the day after choosing Casey Means, a close Kennedy ally and outsized voice in the Make America Healthy Again movement. “I don’t know her. I listened to the recommendation of Bobby.”

But nearly a year later, when Means’ candidacy stalled and Trump eventually selected Nicole Saphier to replace her, Kennedy played little role in the conversation.

Instead, Saphier came up as one of a host of options drawn up by White House officials, people familiar with the process said. The radiologist and Fox News contributor has no prior substantial relationship with Kennedy and a lengthy history of criticizing him and some of his policies.

It’s the latest sign that, after a year of letting Kennedy “go wild” on health care, as Trump promised ahead of the election, the president and his top aides are shortening the leash in the run-up to the midterms — and imposing tighter political constraints on the HHS secretary even at the risk of alienating the legion of followers he brought into the Republican Party.

The shifting dynamics have strained the White House’s relationship with MAHA voters who largely sided with him in the 2024 election. And they have raised fresh questions within Trump’s orbit about how far he must go to please a movement that some now doubt has lived up to its claim that it would be a major national political force within the GOP.

“I hate to say it, but I think they’re a little bit overrated,” said one Trump adviser. “To some extent, MAHA has always been a paper tiger.”

The White House in recent weeks chose candidates with more conventional health backgrounds to run the Centers for Disease Control and Prevention and serve as surgeon general, departing from Kennedy’s efforts at the beginning of his tenure to fill HHS’ top ranks with close allies and anti-establishment skeptics.

Trump aides have also reined in HHS’ controversial efforts to remake vaccine policies and overhaul medical research in favor of shifting to broader-appeal topics like lower drug prices and improving health insurance. In one damaging episode, Trump sided with major agricultural corporations over Kennedy and MAHA activists by seeking to accelerate domestic production of a controversial weedkiller.

That recalibration ahead of the midterms has raised fears among Kennedy’s close allies that he is being marginalized inside the administration, opening a fresh rift within the nascent MAGA-MAHA alliance.

On one side, some Trump aides and advisers have increasingly bristled over the demands from MAHA influencers on personnel and policy decisions. Those allies contend that MAHA has complicated efforts to fill key vacancies and make headway on issues critical to the midterm elections. They blame Kennedy and his allies in particular for advancing controversial vaccine policies that damaged the administration’s standing with some GOP lawmakers and proved broadly unpopular with the public.

Leaders of the MAHA movement, in turn, are vocally warning the White House that it risks losing an influential bloc of voters in November if it fails to prioritize their concerns. Their case got a boost last week, when House lawmakers scrapped a provision in a sweeping agricultural bill that would have effectively shielded pesticide makers from health-related lawsuits.

The alleged harms of pesticides have been a flashpoint with MAHA voters, one that prompted scores of people to rally before the Supreme Court last month. It’s also been a longtime priority for Means.

“This is a fast-growing, highly energized coalition of parents, farmers, and health advocates and we’re organizing in ways Washington isn’t used to,” said Vani Hari, a wellness influencer known for her “Food Babe” blog, who spoke at the anti-pesticide rally. “Ignoring that heading into the midterms is not just wrong, it’s politically shortsighted.”

The White House disputed suggestions that Kennedy was being sidelined, or that its commitment to MAHA priorities had diminished in any way.

“Making America Healthy Again has been a Day One priority for President Trump, and Secretary Kennedy continues to play a central role in the Trump administration’s whole-of-government effort to deliver on the President’s MAHA agenda,” spokesman Kush Desai said, pledging to “continue to deliver and tout MAHA victories for the American people.”

Still, it’s become an increasingly delicate balancing act. Trump last month hosted a contingent of MAHA influencers in the Oval Office aimed at easing tensions over his effort to boost the weedkiller glyphosate.

The gambit appeared to work; the MAHA group emerged from the White House feeling their grievances had been heard. But it also served to emphasize another thorny situation: Means’ stalled nomination for surgeon general. Means attended the meeting with the president and his advisers.

Alex Clark, a Turning Point USA podcaster and leading MAHA voice, directly pressed Trump about Means’ confirmation battle, Clark later told CNN, and the president responded enthusiastically. Kennedy hugged and thanked her afterward for raising the point, she said.

“She really is the spokesperson for MAHA,” Clark said of Means following the Oval meeting. “If she were to be in that position, I think that it would just really soothe a lot of this anxiety.”

Weeks later, Trump pulled Means’ nomination and replaced her with Saphier.

Clark has since blasted the decision, writing on X that Saphier’s selection is “a catastrophic mistake” and that “she gets an F when it comes to all things MAHA.” Hari also publicly opposed the move, arguing that the administration should leave the surgeon general position vacant if it can’t confirm Means.

And some theorize that MAHA voters may not just sit at home come November but could actively switch sides — noting that Democrats like Sen. Cory Booker of New Jersey supported the movement’s battle against pesticides.

“I think the right candidate, either a Democrat or Republican, could win MAHA voters with a message that they would want to hear,” said Barrett Marson, an Arizona GOP strategist.

Trump officials and others involved in the process said pulling Means’ nomination was less an abandonment than a pragmatic pivot that came after weeks of long-shot attempts to win her sufficient support.

“At some point, they had to make a decision,” said one person familiar with the process. “We’ve now burned a year and a half trying to get a surgeon general nominee confirmed.”

The White House has since sought to highlight Saphier’s own MAHA credentials, including her opposition to Covid-era vaccine mandates and a book that used the “Make America Healthy Again” moniker before it became a political movement.

“She’s very much in the MAHA mold,” said one White House official. “Philosophically, I don’t think there’s much daylight.”

There’s no guarantee that Saphier will get confirmed either. Trump transition advisers weighed her for surgeon general shortly after the 2024 election, according to a person familiar with the internal deliberations. She was dismissed at the time due to concerns about her lack of a US medical degree, the person said, as well as questions about whether her diagnostic radiology specialty had put her in direct-enough contact with patients.

Should Saphier survive the Senate gauntlet, she’ll likely face a tall test in winning over Kennedy’s MAHA allies both inside and outside the administration. Saphier criticized Kennedy several times over the last year, CNN has reported, accusing his vaccine policies of causing “chaos” and speculating over whether the administration was hiding measles cases. She also took public aim at Means, saying at one point she wished she were “a little bit less involved with MAHA.”

But six months out from the midterms, some in Trump’s orbit argued that her candidacy represents a key political test for the MAHA movement: Will it make the compromises necessary to become a stronger part of the GOP coalition — or remain a factional offshoot on the political fringe?

“She’s MAHA, but it’s like, sane MAHA,” the Trump adviser said of Saphier. “There’s a lot of stuff that MAHA supports, like cleaner food — that’s really popular stuff. But I also think that vaccines are very popular, and the White House has to take a good, strong, common-sense position on this stuff.”