Home>Shaping Policy with Insiders: The Case of Obamacare Reform
7 April 2026
Shaping Policy with Insiders: The Case of Obamacare Reform
In March 2010, the U.S. healthcare system reform, known as Obamacare, was enacted. Contrary to explanations based on path dependence or those emphasising the role of powerful sectoral interest groups, William Genieys attributes the success of this reform to the discreet, behind-the-scenes actions of policy elites with unique career paths: long-term insiders. Analysing the implementation of « Governement of insiders » provides a better understanding of the processes at work in public reforms. William Genieys is the director of the Executive Master of Public Administration at Sciences Po Executive Education and the author of A Government of Insiders (Johns Hopkins University Press, 2024) (*).
« A Government of insiders »: elites in the shadows of power
William Genieys has used a comparative approach in his research to shed new light on the role of unelected elites in democratic governance. Behind the scenes, these governemental insiders can have a strong influence on the shaping of public policy : « They control the agendas of top leaders, such as the French prime minister or the US president, contribute ideas and seek to address specific issues through reforms », he explains.
In the United States: the singular political socialization of long-term insiders
To understand the success of Obamacare—the reform of the U.S. healthcare system under President Barack Obama—William Genieys examined a specific group of people: insiders. These individuals were close to the Democratic Party and active in both the Clinton presidential administrations and numerous congressional committees. They fit the sociological profile of long-term insiders. Genieys and his team—comprising Anne-Laure Beaussier (CSO) and Urlike Lepont (CEE)—conducted interviews with many of these insiders.
What sets them apart is that they have anchored their actions and thinking in the long term within the realm of government affairs. In fact, they were active in the bakc offices of power under the Clinton administration (1993–2001). They distanced themselves from the government during the Republican Bush administration (2001–2009) but continued to influence the future reform of the U.S. healthcare system through various institutions, such as public health schools in the Washington, D.C., area and think tanks.
When Barack Obama took office, these unelected elites regained their full influence over public policy. They drew on two valuable assets: "their in-depth knowledge of health insurance issues and their considerable expertise in governance, thanks to their experience", notes William Genieys.
Obamacare: The Strategic Choice for a Consensual Far-Reaching Reform
During the Clinton administration, long-term insiders failed in their attempt to reform the health insurance system. For these Clinton administration veterans, the failure was linked to internal divisions and programmatic conflicts among the Democratic health policy elite. To prevent such divisions, t"he long-term insiders proposed a consensus-based reform under Barack Obama that would satisfy the greatest number of people", explains William Genieys. Being pragmatic, they did not want the new health insurance reform to be as comprehensive as it had been in the 1990s. Nevertheless, Obamacare will be a far-reaching reform aimed at expanding health insurance coverage to 22 million people…
News Perspectives on Public Administration
William Genieys’s work on insiders sheds light on the mechanisms that enable public reforms to succeed. His work focuses particularly on the actors involved in the decision-making process. His work highlights the role of unelected elites in our democracies, revealing their significant influence over government operations and political decision-making. Their proximity to power is a key factor in ensuring successful implementation of reforms.
William Genieys’s study shows that to properly identify their role, these insiders must be characterized precisely, paying particular attention to their professional backgrounds (e.g., length of service and movement between the public and private sectors) and career trajectories in relation to developing expertise in public policy.
In the United States, this underscores the importance of a particular category of insiders: those who take a long-term approach within a given public policy sector. However, the influence they wield also calls into question the prominence of other, more short-term-oriented actors—what the expert on American institutions, Hugh Heclo, termed "birds of passage"—in government leadership. Heclo coined the term "A Government of Strangers" to describe this phenomenon. This raises questions about the impact of interest groups on reform processes.
This research helps advance our understanding of decision-making dynamics in contemporary democracies. Analyzing elites, their career paths, and their expertise is central to the Executive Master of Public Administration (EMPA) program at Sciences Po Executive Education, which is directed by William Genieys.
(*) In 2025, the book won two awards: the Best Book Award from the International Public Policy Association (IPPA) and the Louis Brownlow Book Award from the National Academy of Public Administration in the United States