Hostname: page-component-78c5997874-g7gxr Total loading time: 0 Render date: 2024-11-03T01:46:33.621Z Has data issue: false hasContentIssue false
  • English
  • Français

New Policy Elites and the Affordable Care Act: The Making of Long-Term Insiders

Published online by Cambridge University Press:  10 February 2022

WILLIAM GENIEYS ,
MOHAMMAD-SAÏD DARVICHE  and
BRENT EPPERSON
WILLIAM GENIEYS
Affiliation:
Science Po Paris, France
MOHAMMAD-SAÏD DARVICHE
Affiliation:
University of Montpellier, France
BRENT EPPERSON
Affiliation:
University of Montpellier, France
Get access Rights & Permissions [Opens in a new window]

Abstract

This paper examines the career trajectories of new health policy elites in the American federal government, identifying areas of expertise, partisan alignments, relationships to interest groups, and institutional constraints. We demonstrate that, in both the American and French cases, policy elites who have risen through prestigious educational institutions and undertaken extensive professionalization in government, have in fact developed comparable characteristics that blend broad knowledge of social, institutional, and partisan issues with technical skills. We argue that, benefiting from extensive experience in the back offices of power, deeply entrenched in the health policy sector, and promoting a programmatic reform agenda that reaffirms the regulatory powers of government, the new American health policy elites worked behind the scenes to draft and implement the final ACA legislation. Their ambitious, far-reaching reform effort succeeded where many advocates of comprehensive reform had failed, anchoring the political and institutional framework of the U.S. health care system.

Keywords

Affordable Care Act (ACA)U.S. health care policypolicy elitesDepartment of Health and Human ServicesClinton PlanHHS Strategic Plan
Type
Article
Information
Journal of Policy History , Volume 34 , Issue 1 , January 2022 , pp. 1 - 24
Copyright
© Cambridge University Press 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

NOTES

1. See for example, Oberlander, Jonathan, “Learning from Failure in Health Care Reform,” The New England Journal of Medicine 357, no. 17 (October 2007): 1677–79CrossRefGoogle ScholarPubMed; “Long-time Coming: Why Health Reform Finally Passed,” Health Affairs 29, no. 6 (June 2010): 1112–16; Lawrence R. Jacobs and Theda Skocpol, Health Care Reform and American Politics (New York: Oxford University Press, 2010); Jacob S. Hacker, “The Road to Somewhere: Why Health Reform Happened,” Perspectives on Politics 8, no. 3 (August 2010): 861–76; Paul Starr, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (New Haven, CT: Yale University Press, 2013); Eward Berkowitz, “Getting to the Affordable Care Act,” The Journal of Policy History 29, no. 4 (October 2017): 519–42.

2. Genieys, William, The New Custodians of the State: The Programmatic Elites in French Society (London: Routledge, 2010)Google Scholar; Patrick Hassenteufel, William Genieys, Marc Smyrl, and Javier Moreno, “Programmatic Actors and the Transformation of European Health Care States,” Journal of Health Politics, Policy and Law 35, no. 4 (August 2010): 517–38; William Genieys and Patrick Hassenteufel, “The Shaping of the New State Elites: Healthcare Policymaking in France since 1981,” Comparative Politics 47, no. 3 (April 2015): 280–95.

3. Hassenteufel, Patrick and Genieys, William, “The Programmatic Action Framework: An Empirical Assessment,” European Policy Analysis 7, no. S1 (February 2021): 28–47 CrossRefGoogle Scholar, https://doi.org/10.1002/epa2.1088.

4. Heclo, Hugh, “In a Search of Role: Amerca’s Higher Civil Services,” in Bureaucrats and Policy Making: A Comparative Overview, ed. Ezra N. Suleiman, (New York: Holmes & Meier, 1984), 12–13.Google Scholar

5. Heclo, Hugh, “Issues Networks and the Executive Establishment,” in The New American Political System, ed. King, Anthony (Washington DC, 1978), 98.Google Scholar

6. Genieys and Hassenteufel, “The Shaping of the New State Elites”; William Genieys and Jean Joana, “The Custodians of the State Policies Dealing with the Financial Crisis: A Comparison Between France and the US,” International Relations and Diplomacy 5, no. 6 (May 2017): 322–41.

7. Genieys, William, Gouverner à l’abri des regards. La réussite de l’Obamacare (Paris: Presses de Sciences Po, 2020).Google Scholar

8. Heclo, Hugh, A Government of Strangers. Executive Politics in Washington (Washington DC: The Brookings Institution, 1977).Google Scholar

9. Genieys, Gouverner à l’abri des regard.

10. This article is based on empirical data collected in the OPERA (Operationalizing Programmatic Elites Research in America) study, funded by the French Agence nationale de la recherche from 2008 to 2012 (ANR-08-BLAN-0032). The project focused on the transformation of the highest levels of U.S. governing structures, particularly in the health sector from 1988 to 2010. The project enabled the creation of a database of 152 detailed biographies and 191 anonymous and semidirective interviews. A second program, Programmatic Action in Times of Austerity: Elites Competition in the Health Sector Governance in the Health Sector in France, Germany, United Kingdom (England), and the US (ProAcTA) 2008–2018 (ANR-17-FRAL-0008-01/DGF BA 1912/3-1) is in progress. In this context, we carried out more than a dozen additional interviews (June 2018 to February 2019) in Washington DC with some key actors in the Patient Protection and Affordable Care Act reform to test the hypothesis developed in this article.

11. Oberlander, Johnathan, The Political Life of Medicare (Chicago: University of Chicago Press, 2003).Google Scholar

12. Genieys, Gouverner à l’abri des regard.

13. Putnam, Robert, “Elite Transformation in Industrial Advanced Societies: An Empirical Assessment of the Theory of Technocracy,” Comparative Political Studies 10, no. 3 (October 1977): 383–411.CrossRefGoogle Scholar

14. By “state elites” we mean the type of governmental elites who adopted the role of planners after the Second World War, situating their action at the intersection of the executive and legislative branches and the administration, developing policy styles that vary from state to state. Genieys, Gouverner à l’abri des regard, 42–46.

15. Pierson, Paul, Dismantling the Welfare State? Reagan, Thacher, and the Politics of Retrenchment (Cambridge: Cambridge University Press 1994).Google Scholar

16. Derthick, Martha, Policymaking for Social Security (Washington DC: The Brookings Institution, 1979).Google Scholar

17. Suleiman, Ezra, Dismantling the Democratic States (Princeton, NJ: Harvard University Press, 2003).Google Scholar

18. Genieys and Hassenteufel, “The Shaping of the New State Elites”; Genieys and Joana, “The Custodians of the State Policies Dealing with the Financial Crisis.”

19. Heclo, A Government of Strangers.

20. Brown, Lawrence, Politics and Health Care Organization: HMOs as Federal Policy (Washington DC: The Brookings Institution, 1983).Google Scholar

21. Brown, Lawrence, New Policies, New Politics: Government’s Response to Government Growth (Washington DC: The Brookings Institution, 1983).Google Scholar

22. Brown, Politics and Health Care Organization, 17.

23. Brown, Lawrence, “Technocratic Corporatism and Administrative Reform in Medicare,” Journal of Health Politics, Policy and Law 10, no. 3 (Fall 1985): 579–99.Google Scholar

24. Joseph Califano, interview by Edward Berkowitz, August 31, 1995, The Health Care Financing Administration Oral History, https://www.ssa.gov/history/CALIFANO2.html.

25. This centrist and largely bipartisan position allowed Altman to advise five successive presidential administrations. See Altman, Stuart and Shactman, David, Power Politics and Universal Health Care (Amherst, NY: Prometheus Books, 2011), 72.Google Scholar

26. Genieys, Gouverner à l’abri des regards, chaps. 2, 4, and 5.

27. OPERA Interview, Washington DC, October 26, 2011.

28. Ulrike Lepont, “Façonner les politiques aux marges de l’Etat: le rôle des experts dans les réformes de la protection maladie aux Etats-Unis (1970-2010)” (PhD diss. University of Montpellier, 2014).

29. Darviche, Mohammad-Saïd, Genieys, William, Hoeffler, Catherine, and Joana, Jean, “Des ‘long timers’ au sommet de l’État Américain: Les secteurs de la Défense et de la Santé (1988–2010),” Gouvernement et Action Publique 2, no. 1 (January 2013), 10–38.CrossRefGoogle Scholar

30. For a comprehensive view of the results of the sociographic analysis of the social background of Washington’s health policy elites, see Genieys, Gouverner à l’abri des regards, chap. 3.

31. Yates, Douglas Jr. “The Mission of Public Policy Programs: A Report on Recent Experience,” Policy Sciences 8, no. 3 (September 1977), 363–73.CrossRefGoogle Scholar

32. Allison, Graham, “Emergence of Schools of Public Policy: Reflections by a Founding Dean,” in The Oxford Handbook of Public Policy, ed. Moran, Michael, Rein, Martin, and Goodin, Robert G. (Oxford: Oxford University Press, 2006), 58–79.Google Scholar

33. Darviche et al., “Des ‘long timers’ au sommet de l’État Américain,” 15–18.

34. Genieys, Gouverner à l’abri des regards. At the origin of the program of the Ford Foundation there were eight schools, and today they are about 40 on American territory, which train more than 10,000 graduates per year. See James Pierson and Naomi Schaefer, “The Problem with Public Policy Schools,” The Washington Post, December 6, 2013.

35. Oberlander, The Public Life of Medicare.

36. Genieys, Gouverner à l’abri des regards, chaps. 4, 5.

37. Darviche et al., “Des ‘long timers’ au sommet de l’État Américain,” 22–26.

38. Lepont, Ulrike, “Out but In: The Reconfiguration of American Health Policy Expertise and the Advent of a ‘Peri-Administration’ (1970-2010),” Governance 34, no. 2 (March 2021): 435–56, https://doi.org/10.1111/gove.12518.CrossRefGoogle Scholar

39. OPERA Interview, Washington DC, May 28, 2010.

40. Ulrike Lepont, “Out but In.”

41. Genieys, Gouverner à l’abri des regards, chap. 8.

42. Ulrike Lepont, “Out but In.”

43. Joyce, Philip G., The Congressional Budget Office. Honest Numbers, Power and Policymaking (Washington DC: Georgetown University Press, 2011).Google Scholar

44. Genieys, Gouverner à l’abri des regards, chap. 8.

45. OPERA Interview, Washington DC, April 30, 2010.

46. Genieys, Gouverner à l’abri des regards, chap. 9.

47. OPERA Interview, Washington DC, April 28, 2010.

48. OPERA Interview, Washington DC, April 2, 2010.

49. ProAcTA Interview, Washington DC, June 21, 2018.

50. ProAcTA Interview, Washington DC, June 20, 2018.

51. ProAcTA Interview, Washington DC, June 19, 2018.

52. McDonough, John, Inside National Health Reform (Oakland: University of California Press, 2012).Google Scholar

53. Genieys, Gouverner à l’abri des regards, chap. 9.

54. OPERA Interview, Washington DC, April 28, 2010.

55. Nancy-Ann Min DeParle, interview with Edward Berkowitz, Washington DC, April 2, 2015, 60–61, https://www.nasi.org/research/2016/insights-top-oral-history-medicare-medicaid.

56. OPERA Interview, Washington DC, April 28, 2010, 5.

57. OPERA Interview, Washington DC, May 18, 2010.

58. For a different interpretation, see Donnelly, Kevin P. and , David A., Rochefort, , “The Lesson of ‘Lesson Drawing’: How the Obama Administration Attempted to Learn from Failure of the Clinton Plan,” The Journal of Policy History 24, no 2 (March 2012): 184–223.CrossRefGoogle Scholar

59. OPERA Interview, Washington DC, April 30, 2010.

60. OPERA Interview, Washington DC, May 24, 2010.

61. John McDonough, Inside National Health Reform.

62. Beaussier, Anne-Laure, “The Patient Protection and Affordable Care Act: The Victory of Unorthodox Lawmaking,” Journal of Health Politics, Policy and Law 37, no. 5 (October 2012): 743–78.CrossRefGoogle ScholarPubMed