A Government of Insiders: The People Who Made the Affordable Care Act Possible

Book Title: A Government of Insiders: The People Who Made the Affordable Care Act Possible

Author: William Genieys

Translator: Melanie Mauthner

Publication Details: John Hopkins University Press, 2024, 406 pp., $41.95 paperback

Embark on a behind-the-scenes, guided tour of the characters and events that led up to the approval of the Patient Protection and Affordable Care Act, otherwise known as Obamacare. In A Government of Insiders, translated to English from French, William Genieys discusses the influence of unelected “political elites . . . long-term insiders” (p. 4), those who held positions in Congress and the executive branch of government, on the development of health care reform. He traces the evolution of “the key role of unelected governmental elites in the failure and ultimate success” (p. 1) of the Affordable Care Act, starting with the National Health Insurance project and ending with the Obama administration. On this trip, the reader is shown how these insiders “in the back offices of government, act[ing] as policy-formation professionals” (p. 17) are the architects of our current health care system reform process. Using the results of two research projects funded by the French National Research Agency—Operationalizing Programmatic Elite Research in America and Programmatic Action in Times of Austerity: Elites’ Competition and Health Sector Governance in France, Germany, the UK and the US—Genieys provides a perspective on the people in the background shaping the policies that elected legislators approve. He ties in his knowledge of European governmental and policy structure, using it to compare, contrast, and explain the history of United States health care policy reform.

This book is divided into three sections that integrate with one another. Part I is a sociohistorical analysis that describes the historical and cultural context for the development of the Affordable Care Act. It starts with a brief history of the political forces behind social insurance, moving to Medicare, and finally Medicaid. Part II is a sociographic study of 944 policy elites who worked in the Clinton, Bush, and Obama administrations. This analysis is conducted by examining their educational background and political career trajectory. In this section, three types of political elites are identified: migrants, translators, and experts. Institutional migrants and technocratic translators are later labeled as insiders, and policy and issue experts labeled as strangers. Part III is a discussion of how changes in the background of a smaller subset of 151 policy elites—the insiders—and their approach to health care policy influenced the eventual crafting of the Affordable Care Act. The reader is shown how these political insiders shaped the policy and reform-making process through the mistakes and failure of reform during the Clinton administration, the quieter bipartisan discussions held during the Bush administration, and the confident capitalization on lessons learned for successful reform during the Obama administration.

While this book covers this topic with a research-minded approach, it is a difficult read for the political and economic policy novice. Without prior knowledge of terminology, understanding who are the political insiders that Genieys is describing takes a while. Having familiarity with the prior health care reform attempts and health care task forces is necessary to more easily follow the quick journey through health care history that is presented in this book. Fortunately, some tables and lists are offered to help the reader organize the amount of information that is presented on the policy elites.

Faculty could reference this book when discussing health care insurance and reform, highlighting the role of teamwork and encouraging medical students, residents, and colleagues to network with the unelected governmental officials who craft health care policy. This book brings to the forefront how health care policy is crafted by those with economic, public health, and judicial degrees and training, but not by the health care professionals who are on the front lines. The author underscores how a team approach to a topic with a united, cohesive vision, as well as the flexibility to listen to opposing views, ends with a goal achieved. Overall, this book shines an interesting light on the history of the unseen processes both supporting and challenging United States health care reform efforts.