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A Government of Insiders. The People who Made the Affordable Care Act Possible



William Genieys

Authors : William Genieys

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In A Government of Insiders, William Genieys traces the winding path from the failed health policy priorities of the Clinton administration to the passage of the Affordable Care Act (ACA). Genieys uncovers the pivotal role of a committed group of unelected governmental elites known as “long-term insiders” who meticulously developed policy ideas and political connections. During George W. Bush’s presidency, these insiders reconceptualized the foundations of a far-reaching health coverage reform both within and outside the public sector.
When President Obama took office, these insiders returned to positions of power and ensured that their reform vision took center stage. Genieys highlights how these people were instrumental in crafting and passing the ACA by integrating existing programs like Medicare and Medicaid, engaging market forces with an individual mandate and healthcare marketplaces, and addressing the crucial issue of cost containment.
By shedding light on the action of these unelected health coverage policy elites and their role as custodians of the public interest, Genieys challenges traditional assumptions about the influence of economic elites and reveals the positive role of unelected professionals in advancing the common good. A Government of Insiders is a groundbreaking exploration of the unseen forces behind major policy reform, providing a fresh perspective on the dynamics of power in American politics.




“Carefully researched and full of novel insight about the genesis of the Affordable Care Act, A Government of Insiders is a unique and highly compelling contribution to the analysis of policy elites. This fascinating book should be of interest to students of health care policy and, more generally, to scholars working on the role of experts in policy development, in the United States and beyond.”


—   Daniel Béland, McGill University


“A Government of Insiders should be required reading for all those who seek to improve access to health care in the United States. Like Alexis de Tocqueville, who taught us some important lessons about democracy that still ring true today, William Genieys has shed light on a technocratic policy elite (‘insiders’) whose expertise and political savoir faire have played a so-far less acknowledged role in the design and implementation of the Affordable Care Act. Like Tocqueville, Genieys examines the United States from an implicitly comparative perspective. Both observers provide a valuable view from outside, which is grounded in empiricism—more casual by Tocqueville, more formal, based on interviews and sociographic analysis, by Genieys—and equally insightful.”


—   Victor Rodwin, New York University


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