Vivek Ramaswamy is the less famous and less wealthy half of the duo of billionaires that President-elect Donald J. Trump has designated to slash government costs.

His better-known co-leader, Elon Musk, stands to benefit from the job in ways that are numerous and glaring. Mr. Musk’s companies have tremendous influence, billions of dollars in government contracts and ongoing battles with federal regulators.

Less attention has been paid to the potential conflicts that could stem from Mr. Ramaswamy’s complex web of financial interests, which span biotechnology, finance and other holdings.

At 39, he is one of the world’s youngest billionaires, having made his fortune in the pharmaceutical industry. As he reaches into the federal bureaucracy that shapes the fortunes of American companies, he could recommend spending cuts that ultimately make him and his investors richer.

Mr. Ramaswamy, who owns a stake currently valued at nearly $600 million in a biotechnology company he started, has called for changes at the Food and Drug Administration that would speed up drug approvals. He could help shape energy policy to promote fossil fuels, making it more attractive for investors to put their money into an oil-and-gas fund, provocatively called DRLL, offered by his investment firm.

And if he were to boost officials who embrace cryptocurrency, it may benefit his firm’s new Bitcoin business.

It is not yet known whether leaders of the so-called Department of Government Efficiency, or DOGE, which is not a governmental department but more of an outside advisory organization, will have to meet the same standard divestment requirements that many high-level federal appointees face.

Mr. Ramaswamy waded into controversy late last month when he blamed American culture for failing to produce enough workers suited for technical jobs. He also endorsed continuing to allow certain skilled immigrants into the U.S. labor market, a position shared by Mr. Musk and Mr. Trump but opposed by immigration hard-liners. The episode raised questions as to how long Mr. Ramaswamy will remain with the DOGE effort.

Mr. Ramaswamy, who two years ago stepped away from running his businesses, declined to say whether he plans to divest from any of his holdings.

With a stake valued at $150 million or more, he is the majority owner of his investment fund, Strive Enterprises, which he branded as a nemesis of liberal politics, and which is suddenly in line with the philosophies now ascendant in Washington. Several of Strive’s financial backers have close ties to the incoming Trump administration.

Investment funds like Strive generate revenue as a percentage of the money they manage. Luring new investors quickly raises the revenues of the firm. Mr. Ramaswamy’s elevated profile advising the Trump administration could help the firm bring in new clients.

Mr. Ramaswamy declined to be interviewed for this article. Strive’s current leadership, Mr. Musk and the Trump transition team also declined to comment.

Anson Frericks, a high school friend of Mr. Ramaswamy’s who co-founded Strive with him and is now a senior adviser at the firm, dismissed concerns about potential conflicts of interest for a firm offering investments in industries under federal regulation.

“We will always have to have a strict separation of church and state and comply with all the rules and regulations,” Mr. Frericks said.

Since being named to jointly lead DOGE, Mr. Ramaswamy had until recently been posting on Mr. Musk’s social media site X, hinting about where he may look to make changes in the government.

He called for slashing regulation, not just cutting government spending. He pointed to federal workers focused on diversity as potential targets for “mass firings.”

And he has been taking aim at the F.D.A. “My #1 issue with FDA is that it erects unnecessary barriers to innovation,” he wrote on X. He criticized the agency’s general requirement that drugmakers conduct two successful major studies to win approval rather than one.

Mr. Ramaswamy founded his biotechnology company, Roivant Sciences, in 2014, betting that he could find hidden gems whose potential had been overlooked by large drugmakers. The idea was to hunt for experimental medications languishing within large pharmaceutical companies, buy them for cheap and spin out a web of subsidiaries to bring them to market.

The venture is best known for a spectacular failure.

In 2015, Mr. Ramaswamy whipped up hype and investment around one of his finds, a potential treatment for Alzheimer’s disease being developed by one of his subsidiaries, Axovant. Two years later, a clinical trial showed that it did not work, erasing more than $1.3 billion in Axovant’s stock value in a single day.

Mr. Ramaswamy personally lost money on paper on the failure, but thanks to the savvy way he had structured his web of companies he and Roivant weathered the storm. Six products have won F.D.A. approval, and today Roivant has a market valuation of $8 billion.

Mr. Ramaswamy sold some of his Roivant stock to take a large payout in 2020, reporting nearly $175 million in capital gains on his tax return that year. But he is still one of the company’s largest shareholders.

If Mr. Ramaswamy recommends changes that speed up drug approvals through DOGE, that could be good news for Roivant, which is developing drugs that might come up for approval during Mr. Trump’s second term. The faster it can get medicines onto the market, the more valuable the company — and Mr. Ramaswamy’s stake in it — stands to become.

Fighting ‘woke’

In 2020, Mr. Ramaswamy started writing opinion pieces attacking the environmental, social and governance, or E.S.G., movement.

He found a perfect foil in the world’s biggest asset manager, BlackRock, and its chief executive, Laurence D. Fink. At the time, Mr. Fink was vocal about pushing companies to rethink their carbon footprints. Mr. Ramaswamy viewed that position as a breach of BlackRock’s duty to try to maximize returns for investors.

Mr. Ramaswamy was taking on a niche subject that was being debated in obscure journals and business school classrooms but one that was hardly front of mind for most investors.

In July 2020, Mr. Ramaswamy asked D.A. Wallach, a health care investor, to read a proposal for what would become his first book, “Woke, Inc.” Mr. Wallach said he was initially skeptical.

“Do average people really care about Larry Fink putting carbon emissions requests on the board of Exxon?” Mr. Wallach recalled wondering at the time. But Mr. Wallach later became a seed investor in Strive, persuaded by Mr. Ramaswamy over dinner at the upscale Polo Lounge at the Beverly Hills Hotel in Southern California.

In 2021, Mr. Ramaswamy stepped down as chief executive of Roivant. He fished around for a new business idea.

A classmate of Mr. Ramaswamy’s from an all-boys Catholic high school in Cincinnati, Mr. Frericks, had worked as an executive at Anheuser-Busch and shared Mr. Ramaswamy’s views about the E.S.G. movement.

Mr. Frericks said they knocked several ideas around: “Merit Airlines,” which would hire the top 5 percent of pilots, regardless of race, sex or background; “Pop Without Politics,” an alternative to Coca-Cola; and a “free-speech” version of Twitter, before Mr. Musk ran with the idea and bought the social media platform.

They ultimately landed on a different idea. They would start an investment firm near Columbus, Ohio, that would court an audience they believed had been neglected by Wall Street: everyday investors and public pension fund managers who were alienated by companies adopting liberal policies pushed by money managers like Mr. Fink.

Mr. Ramaswamy recruited financial backers who now have deep ties to the incoming Trump administration. Among them were Howard Lutnick, whom Mr. Trump has picked to be commerce secretary; the former investment firm of Vice President-elect JD Vance; and other large Republican donors and influential voices, including Doug Deason and the billionaire fund manager Bill Ackman.

Releasing the handcuffs

Strive’s first offering, in August 2022, was the energy fund DRLL.

In television appearances, Mr. Ramaswamy drummed up demand for the fund. He pitched viewers on an opportunity to be part of a renaissance in the American energy sector, which he said had been constrained for too long by “E.S.G. handcuffs.”

The reality was more complicated. Energy stock price growth has been sluggish for reasons that have nothing to do with diversity quotas and emissions caps. For years, U.S. producers spent big in pursuit of growth, costing investors billions and causing many to sour on the industry. Lower oil prices have further reduced the incentive to drill.

And what Mr. Ramaswamy was pitching was more commonplace than he made it sound.

DRLL was a basket of stocks known as an exchange-traded fund, or an E.T.F., an unglamorous investment vehicle that has grown popular among investors looking for less risk than betting on individual stocks. Mr. Ramaswamy’s E.T.F. was nearly identical to popular offerings from BlackRock and other providers, containing a standard mix of stocks like Exxon, Chevron and dozens of other oil and gas companies.

What Strive promised investors in DRLL was essentially a sustained pressure campaign. Strive would meet with chief executives, carefully vote on board seats and shareholder proposals and publicize its efforts, all with the aim of pushing energy companies to shun liberal policies.

“We wanted a seat at the table, to be able to vote on shareholder resolutions, to engage with management, write letters on our views,” Mr. Frericks said.

Mr. Ramaswamy sent an angry letter to Chevron, criticizing the company for how it responded to pressure from climate activists to cap emissions produced by its suppliers and consumers. (Chevron set goals related to how clean those emissions should be, but it didn’t limit them overall.)

In November 2022, Mr. Ramaswamy flew to Houston for a meeting with the Exxon chief executive, Darren Woods. When the oil giant subsequently appointed two Strive-approved board members, Strive declared victory.

As a presidential candidate in mid-2023, Mr. Ramaswamy reported that he had between $5 million and $25 million of his own money invested in DRLL.

From C.E.O. to candidate

Strive employees watched with intrigue, and sometimes tagged along, as Mr. Ramaswamy met with governors, other state officials and wealthy contacts. Often, it wasn’t clear whether the motivation was to seek an investment or perhaps to make connections that could fuel Mr. Ramaswamy’s bigger ambitions.

He set a busy pace, using private jets to crisscross the United States and traveling with a body guard. He hated staying in hotel rooms, so if he traveled he would nearly always fly home to sleep.

He met with heads of public pension funds in Republican-led states, urging them to move their money to Strive from providers like BlackRock.

But Strive’s pitch struggled to land with that audience. According to S&P Global’s Capital IQ database, only one public pension fund, in Texas, appears to have put money in a Strive E.T.F., and it quickly withdrew its position. One official at a public pension fund in a Republican-led state who met with a Strive representative said it was confusing how Strive was different from the competition, or how its mission would generate the best returns.

Employees at Strive were often surprised by the relative extravagance of Strive’s spending.

Before the firm was generating much revenue, many employees were issued a company credit card and had the impression that they could spend freely. The firm built out a new office, with room for some 100 employees, despite having a staff of about 35.

Mr. Ramaswamy was a regular presence in Strive’s office, often dressed in shorts and flip flops.

In December 2022, the firm held a holiday party in downtown Columbus at The Vault, a former bank repurposed as a lavish event space. In front of his delighted colleagues that evening, Mr. Ramaswamy performed a karaoke rendition of Eminem’s “Lose Yourself.”

Employees were given a pointed holiday gift: a copy of a book, “Fossil Future” by Alex Epstein, arguing for more oil, coal and natural gas consumption.

Two months later, Mr. Ramaswamy announced that he was running for president. He stepped down as chairman and chief executive of Strive. That summer, as a candidate on the campaign trail, he reprised his performance of “Lose Yourself” onstage at the Iowa State Fair.

A crypto arm

As Mr. Ramaswamy’s political profile has risen, the ideas he railed against have receded on Wall Street and in American life.

In 2023, Mr. Fink of BlackRock said that he would no longer use the term E.S.G. Last week, BlackRock pulled out of an international climate coalition supporting the goal of net zero greenhouse gas emissions by 2050, while Meta and Amazon ended internal diversity programs.

Mr. Ramaswamy has taken credit for the change of heart. “Strive’s success, I think, was probably the single greatest factor in the United States of America that turned E.S.G. from the dogma,” he said.

Today, Strive manages over $2 billion in assets, a strong start for a new player in the market, but a drop in the bucket compared with the largest money managers. BlackRock, by comparison, manages $11.6 trillion in assets.

“Strive did better than we thought it would,” said Eric Balchunas, a Bloomberg analyst who tracks E.T.F.s.

But the growth of Strive, which in some cases charges higher fees than its competitors for its E.T.F.s, has been constrained by a mundane reality: Many E.T.F. investors are just looking for low fees and the ability to swiftly and easily make transactions. Politics isn’t a factor.

“Most of them don’t care,” Mr. Balchunas said. “People just want cheap access to stocks.”

After years in the unglamorous world of traditional E.T.F.s, Strive has been expanding into a more buzzy world of finance after raising $30 million in new funding from a group of backers including Cantor Fitzgerald, the financial services firm led by Mr. Lutnick.

Late last year, Strive poached the leadership team of a firm in Dallas that managed money for wealthy families and individuals, providing Strive a new arm, and a new headquarters, in Texas.

The move got Strive into cryptocurrency, which helped finance Mr. Trump’s campaign but has faced regulatory headwinds in Washington. The firm’s website now points to its “focus as a transformative Bitcoin-company.”

It also opened up a new potential area for conflict in Mr. Ramaswamy’s role at DOGE: the potential power to alter the approach of agencies that regulate the financial sector.

Soon after being diagnosed with metastatic breast cancer, Virginia King sat in an outpatient clinic in Santa Fe, N.M, while a nurse injected her with a powerful drug to slow damage to her spine, where the disease had spread.

Even though the drug had a list price of about $2,700, the hospital that owned the cancer center billed Mrs. King’s insurance company $22,700. Her insurer paid $10,000, but the hospital wanted more.

She got a bill for over $2,500 — “more than half my take-home salary for a month,” said Mrs. King, 65.

She had unknowingly sought care from a hospital that participates in a federal program allowing it to buy drugs at a steep discount and charge patients and insurers a higher amount, keeping the difference.

The intention behind the program was for a small number of safety-net providers to have access to affordable drugs and be able to expand their care for needy patients. But instead, the program has exploded: Now, more than half of nonprofit hospitals in the United States take part. While some providers say it has helped keep their doors open, others — especially large nonprofit health systems — have been accused of maximizing payouts and swallowing the profits.

The program’s escalation has driven up health care costs for employers, patients and taxpayers, studies show.

In 2023, for instance, New York changed the way it administers drug benefits for Medicaid patients, in part because the state had discovered the cost of the federal program had increased by more than 200 percent over three years, said Amir Bassiri, the state’s Medicaid director.

“The numbers and the growth were staggering,” he said. “We all bear the cost.”

Along the way, one little-known middleman has been cashing in, The New York Times found.

The company, Apexus, has worked behind the scenes to supercharge the program, according to interviews with current and former employees and emails, internal reports and other documents.

Twenty years ago, the federal government chose Apexus to manage what was then a small program, negotiating with drug distributors and manufacturers to secure better prices and access to medications. But Apexus is allowed to collect a fee for almost every drug sold under the program, giving the company an incentive to help hospitals and clinics capture as many prescriptions as possible:

• Its “purchasing optimization team” shows hospitals how they can make more money by buying different drugs.

• A certification program and an Apexus-run “university” trains providers in boosting earnings.

• Apexus employees give advice that broadly interprets the rules of the program so hospitals can claim additional patients and drugs.

Apexus was on track to double its revenue from 2018 to 2022, projecting $227 million that year, according to a 2022 internal memo written for the directors of Apexus’ parent corporation and reviewed by The Times. The company costs relatively little to operate and has enjoyed profit margins above 80 percent, according to that memo and three former employees.

In a statement, Apexus said it simply executed its government contract and did not contribute to the growth of the program, called the 340B Drug Pricing Program. “The drivers of growth are multifaceted,” the statement said.

But in the 2022 memo, the president of Apexus, Chris Hatwig, posed a question: “Are there other areas for program expansion within 340B that we are not thinking about?”

Government officials have told Apexus to focus solely on administering the program and not to influence drug purchases. But Apexus leaders have sometimes ignored that request, according to two complaints filed with a government watchdog and six current and former employees, speaking on the condition of anonymity because they feared professional or legal retribution.

In its statement, Apexus said it was “fully transparent” with the Department of Health and Human Services and had never breached its contractual obligations.

The Health Resources and Services Administration, an agency within H.H.S. that oversees the program, declined to answer detailed questions from The Times. But in a statement, a spokeswoman said the agency “conducts rigorous oversight of all contracts,” and “to our knowledge, Apexus has not violated” its contract. Regulators and leaders of the company meet frequently to discuss the company’s work and prevent conflicts of interest, the spokeswoman said.

The growth of 340B has drawn criticism for years from Congress, drugmakers and employers, who say it has added to ballooning health care costs. But the role of Apexus has largely gone unexamined.

“They’ve got a license to hunt,” said Marsha Simon, who as a staff member of a congressional committee helped write the bill that authorized the program.

$66 Billion in Sales

Established in 1992, the 340B program essentially requires pharmaceutical manufacturers to offer discounts on outpatient drugs to hospitals and clinics that treat a greater share of low-income and uninsured patients.

The hospitals then can charge insurers and patients the standard price and keep the profits. Although the money is supposed to encourage care for impoverished patients, there are few rules to enforce that.

Patients rarely know they are part of this system. Their prescriptions can be counted as 340B when they get outpatient treatment at a hospital or clinic that qualifies for the program, regardless of the patients’ own income or insurance status. The provider can continue to make money off the patients’ future outpatient prescriptions, even if they get them somewhere else.

Apexus has had contracts to handle the program since the early 2000s. The government does not pay Apexus — instead, drugmakers and distributors pay the company a small percentage of sales.

Based in Irving, Texas, it is a subsidiary of Vizient, a private business owned by hospitals that negotiates a range of health care discounts. Apexus was established as a small nonprofit in 2007 but became a for-profit company in 2014.

Around the same time, 340B began to explode for a number of reasons. More hospitals qualified for the program after the Affordable Care Act expanded the number of people on Medicaid. Other health care systems qualified after acquiring hospitals and clinics in poor areas. Some, already eligible for 340B, bought up practices that used high-margin drugs, like oncology clinics. And a government rule change meant hospitals could make money from prescriptions filled at a greater number of pharmacies.

A decade ago, sales of 340B drugs were $12 billion. In 2023, they reached a high of $66 billion.

Fighting the program’s growth has become a top priority for drugmakers, as well as some employers and insurers.

In North Carolina, prescription drug spending for state employees jumped almost 50 percent from 2018 to 2022. A report in May from the state treasurer’s office found that 340B was partly to blame: Hospitals that participated in the program billed the state health plan far more than hospitals that did not — almost 85 percent more for certain cancer drugs. In one example, hospitals bought a drug commonly used to treat melanoma for an average of $8,000 but billed the state $21,512.

In some cases, costs are passed along to patients.

Mrs. King, the cancer patient in New Mexico, refused to pay her $2,500 bill, and the hospital, Christus St. Vincent, sent it to collections in July.

After The Times asked about the bill last month, a spokeswoman for Christus St. Vincent said the charge was “a misunderstanding and has been resolved,” adding that the drug program helped the hospital provide charity care and reinvest in cancer treatment and primary care.

Mrs. King switched to a free-standing oncology clinic that does not qualify for the federal drug program. That clinic billed her insurance $8,000 for the injection, about a third of what Christus St. Vincent had charged. Her responsibility was nothing.

An Ever-Growing Portfolio

Ms. Simon, who helped draft the legislation creating 340B, said the government chose an outside contractor like Apexus in order to negotiate with distributors and drugmakers on behalf of small hospitals and clinics without a lot of buying power.

But regulators and Apexus have expanded that role, allowing the company to build a highly profitable business off the program and the loosely written statute that authorized it. The company has been “aggressive” in helping health care facilities maximize their revenue from the program, said Shawn Gremminger, chief executive of the National Alliance of Healthcare Purchaser Coalitions, which represents employers who buy health insurance for more than 45 million people in the United States.

“This is a government contractor, and the goal of the government should not be, ‘How do we make more money for 340B providers?’” said Mr. Gremminger, whose organization has pushed for the program to be overhauled.

Over the past two decades, Apexus has adapted its business model to harness 340B’s tremendous growth. A 2022 PowerPoint presentation obtained by The Times showed that Apexus employees received bonuses if the company increased its revenue each year.

With exclusive access to sales data, Apexus’ “purchasing optimization team” will analyze a hospital system’s drug-buying habits and compare them with those of their competitors, according to four current and former employees. In some cases, Apexus will suggest that a hospital buy more 340B drugs or tweak its inventory in ways that can churn more cash.

Apexus declined to answer detailed questions about its optimization team, but said in a statement that the company “only provides technical assistance” in keeping with regulations.

Apexus also holds “340B University” events to help providers and others in the health care industry understand the program, and it fields questions through a national call center. But the rules governing the program are ambiguous, and Apexus offers broad interpretations, according to four current and former employees.

For instance, one of the thorniest issues is which patients can be claimed by hospitals for discounted drugs. The further a hospital casts its net, the more patients and drugs it can include under the program, and the more money it can make. Apexus has advised hospitals that they can mine records as far back as 36 months for eligible patients they may have missed, two of those employees said.

Similarly, Apexus employees have showed hospitals how to maximize the number of pharmacies they work with, boosting the number of prescriptions that can qualify for discounts, those employees said.

In its statement, Apexus said those examples were inaccurate but would not say how. It added that the company encouraged “conservative and responsible stewardship” of the 340B program, and that all information it provided was approved by regulators.

A spokeswoman for H.R.S.A. said it reviewed materials prepared by Apexus but declined to comment on that specific advice.

The company has developed other ventures that have brought in revenue:

• About eight years ago, Apexus began selling a $750 course for people to become “certified experts” in 340B.

• It started a business to give hospitals better access to specialty drugs — for conditions like cancer, H.I.V. and autoimmune diseases — which are major drivers of 340B’s growth. That company, Acentrus, helped hospitals and clinics provide data to manufacturers in exchange for deeper discounts and access to those drugs. It was sold last year.

• The company charges 3 percent in fees for a line of generic drugs that are managed and provided by drug distributors, according to former employees. Apexus simply provides access to the health systems.

For the last decade, Apexus has earned millions of dollars on drug purchases made outside the 340B program: Because not all outpatient drugs qualify for 340B discounts, hospitals must stock their pharmacies with medication purchased through different channels. Apexus acts as a middleman, making fees off those transactions.

That has frustrated drugmakers and competitors. In 2021, the drug manufacturer Baxter wanted to sell non-340B drugs to hospitals without going through Apexus, according to emails obtained under public-records laws. But government regulators would not allow it, a spokeswoman for Baxter said.

In early November, Premier, the main competitor to Apexus’s parent company, Vizient, sued the federal government over these sales. The setup, the suit argued, forces hospitals to pay higher prices for those non-340B drugs and drives revenue to drug manufacturers and Apexus.

In its statement, Apexus said its federal contract did not preclude it from developing other businesses, as long as they were not in conflict with the terms of the agreement.

Regulators were aware of these ventures, the company said, noting that its specialty drug business, Acentrus, was in “no way associated with” the 340B program. The 2022 company memo, however, said Acentrus “resulted in an additional $20 million” in revenue within the 340B program.

H.R.S.A. declined to comment on the scope of its authority over Apexus and whether it knew about all the company’s revenue-generating arms.

Criticized, but Pushing Ahead

About six years ago, Krista Pedley, then the director of the H.H.S. office in charge of 340B, reprimanded Apexus leaders in a Skype meeting, saying it was acting more like a sales-driven business than a program administrator. She reminded them that Apexus’ role was not to help 340B grow, according to five former or current employees familiar with the meeting.

For about a month afterward, regulators reviewed any communication Apexus had with health care facilities to make sure the company didn’t overstep, the employees said.

But that did not seem to dampen the company’s pursuits. (In an email, Ms. Pedley said she did not recall that meeting, and noted that her former office met regularly with Apexus.)

In 2021, an unnamed Apexus employee filed a complaint with H.H.S.’s Office of Inspector General, an internal watchdog, saying the company was “always trying to grow the program.” The company, the employee wrote, had hired “sales-type” staff to influence hospitals’ drug-purchasing decisions.

The complaint said that regulators did not understand Apexus’ business, and that employees had been told by company leaders to describe its work as “education.”

Another anonymous complaint, filed in 2022, echoed the allegation that Apexus had hired staff to help shape hospitals’ purchasing decisions, and said it was using “data in ways to drive revenue for itself, without asking (or asking and disregarding) the government’s opinion.”

Apexus declined to answer specific questions about the meeting with Ms. Pedley, but said The Times’s account was a “mischaracterization of our day-to-day, collaborative discussions” with the agency.

Apexus rejected the allegations in the anonymous complaints and said it had been unaware of them until The Times provided it with copies. The spokeswoman for H.R.S.A. said that it, too, had been unaware of the complaints.

In interviews, four current and former employees said that for years, Mr. Hatwig, Apexus’ president, acknowledged that regulators did not want the company to develop sales-focused arms of the business but encouraged his staff to do so anyway, saying that the government would not know.

Apexus denied that, saying that “everyone at Apexus understands the expectation that they conduct themselves and perform their work in an ethical and compliant manner.”

Julie Tate and Carson Kessler contributed research.