1Research into the sociology of the state has long emphasized the weakness of the American state in comparison with those of continental Europe. [1] Drawing on the Weberian definition of the state, such research postulates that the absence of a stable senior civil service to manage federal administration prevents the autonomization of the state and its differentiation from the rest of society, and thus limits its “state capacity”. From the very different analytical framework of public policy, Hugh Heclo’s “government of strangers” theory converges with this interpretation: in Heclo’s view, the lack of understanding of administrative operations and the historical nature of public policies shown by the “birds of passage” nominated to manage the US administration with each new presidential mandate inhibits the capacity of the administration to ensure the development, implementation, and the continuity of public policy, in comparison with European administrations. [2] The marked trend since the 1970s toward the externalization of expertise, and the entrusting of its production to non-governmental organizations, has further reinforced this idea of the dependency and weakness of the federal administration. [3]
2So how can we make sense of the paradox of a supposedly weak state whose “effects” in terms of regulation, standardization, and control of the population are at the same time so powerful? [4] From the early 1980s onwards, the weakness of the American state has been widely contested by studies that, through historical analysis over a relatively long period, have in fact revealed the effectiveness of the federal state to intervene and regulate sectors as diverse as health security, [5] agriculture, [6] social policy, [7] and racial policy. [8] By demonstrating the capacity of the federal administration to impose its authority in these different sectors, such studies have redrawn the boundaries of the debate about the American state: the question is no longer why it is “weak”, but why it is so different from European states and how to characterize it. [9]
3However, in recent years, these studies have in their turn been subject to criticism. Some researchers have contested their theoretical approach, which remains attached to a Weberian analysis “defining the state by the existence of a formal administrative power that is coercive and located within public administrations”. [10] Might the particularity and the force of the American state not derive in fact from its connections and interdependencies with the rest of society? Proceeding from the idea that “the American state was constructed not via the exclusion of other social and political structures, but in conjunction with a collection of partners belonging to the political system as well as to civil society”, [11] they have called for a reconceptualization of the American state through a multi-dimensional model of understanding, which involves envisaging its links to society not as a hindrance to its capacity to act, but as potential resources. [12] This position thus invites us to look beyond the central bureaucratic apparatus and to reconsider the role of institutions such as the federated states and local communities, as well as the “‘private’ organizations that are not conventionally considered to be part of the state at all”. [13]
4The present article aims to contribute to this debate by revealing a category of actors in the sector of healthcare policy regularly consulted for their expertise; a category evolving outside of the US federal state in non-governmental expert organizations. I will argue that these actors constitute a pool of resources comparable in many ways to that of specialized senior civil servants, from which US political decision makers can draw when they are seeking advisors for developing proposals for reform, or competent and “loyal” executives for managerial posts within the administration.
5This hypothesis has previously been proposed by Hugh Heclo himself, shortly after the publication of The Government of Strangers. [14] In his classic 1978 article on “issues networks”, Heclo signaled the growing importance in Washington of individuals whom he described as “policy professionals”, “policy specialists”, or “policy activists”. These individuals are characterized by their specialization in a particular sector of public policy, in which they have acquired a considerable level of knowledge, and predominantly work for private or semiprivate organizations. [15] Heclo shows that this profile type now largely dominates the appointees named to advise politicians or to middle management positions within the federal administration, to the detriment of political party activists. In his view, its emergence is the result of the expansion of the jurisdiction of the federal state and the strategy adopted by successive governments to externalize the implementation of these new policies (the rise of intermediary, non-governmental organizations). [16] Heclo uses the term “proto-administration” to describe these networks of actors who know one another and in which reputation plays a key role. This idea – the crux of our interest – is revisited in a chapter published in 1984, in a work comparing the higher echelons of the civil service in western countries. [17] In this chapter, Heclo develops the concept of an “informal higher civil service” formed of these same “policy specialists” but labels them with the more specific term “public careerists” in order to emphasize their unique pathways as “in and outers” circulating between nongovernmental organization networks and the administration, and whose long experience in Washington has enabled them to accumulate a keen understanding not only of a sector of public policy, but also how the administrative and political system works. [18] Without them, according to Heclo, “it would be difficult to imagine how the work of government could go on”. [19] This requires “loosening our concept of the higher civil service so as to include indeliberately organized, loosely woven career lines”. [20]
6This hypothesis, presented in the form of a research program, has not, to our knowledge, been subsequently fully pursued. Studies from the field of public policy have considered specialized actors, generally in order to include them in broader public policy networks (such as policy communities, issue networks, and advocacy coalitions) [21] or in order to highlight the individual role of some as public policy entrepreneurs. [22] But these actors have rarely been the object of a focused analysis that allows their potentially unique characteristics to emerge and that considers their collective role in the development of US public policy. Studies have been carried out on the organizations in which these actors evolve, and in particular on think tanks, which have received growing attention. [23] But these studies are most often situated at a macro level and take little interest in actors and their interactions with the political or administrative world. Furthermore, the use of institutional category (the think tank) as a starting point, rather than the sector of public policy, limits the sample of policy specialists (or public careerists) to which these studies can give access. In both cases, the connection between the sociology of the administration and the sociology of the state has not been further pursued. This is likely explained in part by the choice of subject and by institutional compartmentalization. But it is also probably linked to the difficulty of understanding these actors, who are dispersed across multiple institutions and who do not form an easily identifiable group.
7This article is based on research that first aimed to identify the experts who are most consulted by US decision makers on questions of healthcare policy, i.e. the actors to whom US decision makers turn for their expertise to advise them on healthcare policy issues, develop programs and instruments of reform, and to hold executive positions within the administration (cf. box outlining methodology). [24] From the late 1930s to the 1960s, this type of role was primarily carried out by doctors (among the Republicans) and by senior civil servants from the Social Security Administration (among the Democrats). [25] My earlier research has revealed that this situation began to change in the 1970s. [26] From then on, the vast majority of such individuals have belonged to the category of “policy specialists” described by Hugh Heclo and John Kingdon: individuals who dedicate their career to a particular area of public policy, and are affiliated to non-governmental expert organizations. The emergence of these actors, who describe themselves as “health policy analysts”, is thus closely linked to the development of policy analysis as an established form of expert knowledge that claims autonomy from academic knowledge and that has given rise to the particular professional status of “policy analyst”. [27]
8The aim of this article is to describe which of these health policy analysts were the most frequently consulted between the 1970s and the 2000s, and to show how, during this period, these actors constituted for US decision makers a pool of health policy specialists with a long-term investment in providing critique and advice regarding public policies. I will thus show how an organized and relatively homogeneous space of expertise – available to decision makers and with relatively strong control over access to strategic positions of expertise on healthcare policy – has developed outside the state. Due to similarities with some of the key features of European higher civil services, I propose to describe this space as a “peri-administration”.
9I will first outline the professional affiliations of the most consulted experts with organizations that encourage specialization in a particular sector of public policy. Secondly, I will show how the technical skills thus acquired are doubly honed through their adaptation to political constraints and a great familiarity with Washington and its ways of working. Finally, the third section will examine the connections between these actors, revealing the existence of a network that, although informal, is characterized by a high level of interaction and co-option.
Methodology for identifying the most consulted experts and for a qualitative study
- regular consultation by politicians, which places the individual in a “situation of expertise” that confers upon them the status of expert; [29]
- intellectual development of proposals for relatively formalized programs or instruments of public policy, i.e. the production of specific knowledge directed toward action. [30]
– Consultation as an expert by the executive or legislative power, identified through one of the following situations: participation in congressional hearings, nomination to the main expert commissions of the government and of the Congress on healthcare policy (PPRC, ProPAC, MedPAC, CBO Health Advisory Panel, National Advisory Council for Healthcare Policy Research and Evaluation at the Agency for Healthcare Research and Quality), nomination to positions within the federal administration or Congress (political appointment).
– Production of gray literature aiming to develop instruments and programs of reform in the field of healthcare policy, identified by drawing up a list of authors publishing in the two main specialist journals of expertise (Health Affairs and the “Perspectives” section of the New England Journal of Medicine). These journals were chosen on the reputational basis established during exploratory interviews. Their target audience, beyond that of the rest of the expert community, is decision makers in the medical and political milieu, rather than the university milieu.
From this basis, I isolated those individuals with strong evidence of consultation and publication. I restricted myself to the following criteria: to have published at least eight times in the journals considered AND to have held at least two “political” positions. [31]
Diagram summarizing the methodology for identifying the most consulted experts
Diagram summarizing the methodology for identifying the most consulted experts
A specialist career outside the administration
10One of the remarkable features that characterizes those whom I identified as the most consulted experts on issues of healthcare policy by US political decision makers since the 1970s is their professional affiliation – throughout their entire career or nearly so – to three types of organization: universities, think tanks, and foundations. The strong development of these institutions over the last four decades has in effect made it possible to “have a career” as an expert (or, in the American term, as a policy analyst). It has also encouraged super-specialization in a particular sector of public policy. The consequence has been the development of a specific professional status, that of policy analyst, specified according to the sector as economic, education, agricultural, or, in this case, health policy analyst. The analysis of the most consulted experts thus reveals the specific way in which public expertise has developed in the US since the 1970s.
Affiliation with non-governmental expert organizations
11According to my research, as of 2010, thirty-two of the seventy-three experts studied worked in a university, eighteen in a think tank, and eleven in a foundation. In contrast, only three worked in a consulting firm, two in an interest group, two in a company, and only one in the administration. One final isolated case was an individual working in the editorial team of the most-read specialized journal of expertise in Washington, Health Affairs. This snapshot is confirmed by reviewing the set of career pathways, which, for the vast majority, were pursued almost exclusively within the first three types of organization mentioned. In fact, as of 2010, only eight of the experts had spent more than five years of their career in the lucrative private sector [33] (of which five more than twenty years) and only four had spent more than ten years in the public administration. Figure 2 presents several examples of career pathways that show the importance of these three kinds of organization – universities, think tanks, and foundations – in the career of the most consulted experts.
12The three categories of organization in which the most consulted experts are concentrated are generally considered to be relatively distinct in the system of knowledge production. Firstly, universities and think tanks are differentiated in terms of their independence from political demand: while the former is situated in an academic space with its own rules and agendas, the latter, situated more directly in the space of expertise, is thought to be more constrained by the political space (although it does have a certain degree of independence, notably financial). [34] The specificity of foundations appears to lie in not directly producing knowledge but instead financing other structures that do so – specifically, universities and think tanks. This study seems however to blur these categories, since the foundations in which these experts work, such as the Commonwealth Fund or the Kaiser Family Foundation, have in fact developed internal teams of experts tasked with producing and disseminating expertise on the same model as think tanks. Universities also appear to be much less of a distinct space than think tanks or foundations. This derives in large part from the fact that the most consulted experts are very rarely affiliated with traditional academic departments, but with dedicated health services research centers, primarily linked to schools of business, law, medicine, or public policy. As highlighted by one of the few researchers who has written about this kind of structure, these centers resemble universities but are much closer to private non-profit expert organizations, such as think tanks, than university social science departments. [35] In effect, their main objective is to produce policy analysis, i.e. knowledge directly relating to public policy. This is evident in the requirements and promotion criteria for their staff which, according to the experts interviewed, are very different, notably with regard to publication:
– What is the difference for a health economist between being in academia or in a school of public policy?
“The expectations in terms of publishing are not the same. In academia, if you want to be a well-recognized professor, I assume you must publish in reviews like The American Economics Review, things like that. In other schools, you can but it is not expected. What is expected is to publish in Health Affairs, The New England Journal of Medicine, things like that.” [36]
Examples of expert career pathways
Examples of expert career pathways
14A review of the experts’ CVs confirms this statement from a health economist, who was himself affiliated to a school of public health. Regardless of the professional institution to which they belong, the most consulted experts publish a great deal (most of the CVs list over a hundred publications), but in journals or with publishers within the field of expertise rather than the academic field. In addition, they greatly promote their experience as experts, systematically placing this information above their publication list in their CVs. Furthermore, centers affiliated to universities are financed in the same way as think tanks, i.e. via government contracts and private foundations, the salary of researchers depending in whole or in part on the funds thus raised. [37]
15In fact, beyond the teaching obligation for experts affiliated to university centers, I have observed no significant differences between the three types of organization identified – universities, foundations, and think tanks – when it comes to the work carried out by the experts studied, as well as the constraints and demands with which they are faced. In all three cases, what is required is proximity to current legislative affairs and the decision makers involved, and to respond effectively to political demand. In recent years a number of studies have focused on think tanks, seeking to highlight the particularity of these institutions, but struggling to give them a precise definition. [38] In contrast, this study – which is based on actors rather than institutions of expertise – shows the hazy nature of the boundaries between organizations that are generally considered as separate and which can in my opinion be regrouped into a common category of non-governmental non-profit centers of expertise. Their common denominator is that they are situated in the sector of policy analysis and thus they create policy analyst positions, rather than academic positions.
16These devolved structures of expertise seem well-adapted for the careers of those who wish to become experts frequently consulted by politicians. At a remove from academia, they enable such individuals to be completely dedicated to the work of expertise while offering them a register of legitimacy more effective than consulting firms or interest groups, since they can claim greater independence from their funding sources. Compared to the civil service, these private organizations offer not only better remuneration, but also greater visibility and greater freedom of expression, enabling their experts to take a public stand on issues and, in the end, have easier access to influential positions.
17The fact that these organizations now house the majority of the most consulted experts on healthcare policy reflects their substantial development since the 1970s. Research into think tanks indicates a fourfold increase in their number during this period, [39] and such growth has been particularly marked in the health sector where, for reasons specific to this area, the funding opportunities for non-governmental centers of expertise have been especially abundant, particularly since the late 1980s. “Getting funding for healthcare was quite easy and probably easier than for most other areas. There were plenty of potential sources”, [40] I was told by the president of a healthcare policy think tank that was founded at the beginning of the 1980s. This situation can be explained by the combination of several factors: firstly, the part played by health in the American economy (17% of GDP in 2010) and the extreme politicization of the subject due to the growing difficulty of accessing healthcare, which has made it a particularly visible public problem that interests both public and private funders of expertise. Secondly, the numerous conversions of hospitals and mutuals from non-profit to for-profit organizations have been accompanied, for legal reasons, by the creation of multiple foundations investing in health. [41] The continued growth of the sector also makes it a significant job creator, which explains the explosion in the number of university centers specializing in health, which have invested in the training niche of health management (encompassing hospitals, industry, and administration). [42]
18The USA is therefore home to a profusion of non-governmental non-profit centers of health policy expertise, which provides experts with numerous opportunities. This is demonstrated by the diversity of organizations to which experts are affiliated: as of 2010, the 73 individuals identified were scattered among 49 different organizations. These organizations form a network of institutions whose establishment has ensured expert positions and secured their professional paths. In the sector of healthcare policy, this constitutes an infrastructure that enables career longevity and stability, and thus the institutionalization of a space of expertise outside the administration.
Specialization in healthcare policy
19By offering the experts they employ the potential for long careers, these expert organizations also encourage specialization in one sector of public policy. In fact, whether they are think tanks, foundations, or university centers, they are strongly structured around public policy sectors: many are entirely focused on a single sector and those that are more generalist are divided into departments that follow a sectorial division (health, defense, education, etc.). As demonstrated by the examples in Figure 2, one of the features that distinguishes the most consulted experts is the longevity of their career as experts in healthcare policy. Thus, as of 2010, over three quarters had specialized in this sector for over twenty years, of which the vast majority had been in the field between 30 and 49 years (Table 1). It should be noted that although not all were at the height of their careers in 2010, they were all still active. Even the oldest, who had begun their careers in the 1960s or early 1970s, still held Senior Fellow or Professor positions in leading institutions like the Brookings Institution or the University of Princeton, and were still regularly publishing articles and memos, and interacting with decision makers, for example at congressional hearings. Some were even among the most influential experts involved in the Affordable Care Act reform. Between 2008 and 2009 Karen Davis, for example (72 years old in 2010), a political appointee to the Ministry of Health under Jimmy Carter, gave three statements to Congress regarding reports from the Commonwealth Fund – among the most cited of the Democrat documents – which she oversaw as president of this foundation.
Length of specialization of the most consulted experts in the health sector (in 2010)
| Length of specialization in the health sector (years) | Number of individuals (/73) |
|---|---|
| 13-19 | 7 |
| 20-29 | 11 |
| 30-39 | 29 |
| 40-49 | 18 |
| 50-54 | 2 |
| ? | 6 |
Length of specialization of the most consulted experts in the health sector (in 2010)
20The longevity of specialization can be explained firstly by very early entry into the sector, and secondly by maintaining the same course until retirement, which itself tends to be very late. [43] The majority of the individuals studied had in fact specialized in the health sector since their studies or since their first professional experience (Tables 2 and 3). Where this was not the case, specialization was the result of professional circumstance and opportunity and had generally occurred quickly after graduation, during first employment in the administration, at the federal or federated state level.
Area of focus for the most consulted experts during their studies
| Area studied | Number of individuals (/73) |
|---|---|
| Health | 53 |
| Social policy | 7 |
| Public finances | 6 |
| Job market | 2 |
| Other | 4 |
| ? | 1 |
Area of focus for the most consulted experts during their studies
Interval between completion of studies and specialization in the health sector
| Interval between completion of studies and specialization in the health sector (years) | Number of individuals (/73) |
|---|---|
| 0 | 53 |
| 1-2 | 9 |
| 3-5 | 3 |
| 6-9 | 3 |
| 10-19 | 2 |
| > | 1 |
| ? | 1 |
Interval between completion of studies and specialization in the health sector
21In addition, this specialization is exclusive: overlap with another specialization was the exception (three individuals, in public finances) and this second specialization was minor compared to health. It also seems definitive: I did not note any interdisciplinary moves into other sectors.
22As a result of this early and continued specialization, the experts studied – who define themselves as “health policy analysts” – have acquired technical skills in healthcare policy. They have closely followed different reform projects from the beginning of their career. They understand the big picture of such reforms, but also master the detail of the instruments envisaged and the way in which these have been constructed. They are also mindful of the background to how such instruments have been received and have an idea of the reasons for past successes and failures. The most consulted experts have not carried out first-hand empirical research for a long time – if they ever did. However, a detailed vision of this history of policies is essential to them in navigating their way through the multitude of projects discussed and in developing their own proposals. There have been many reform projects since the 1970s, but their outlines have varied very little, innovation focusing more often on marginal modifications of instruments and their reorganization than on radical transformations. [44] An inside-out understanding of these programs is therefore required in order to appreciate their variations and nuances.
A long experience of American policy
23Working on the development of reform programs and instruments, the experts regularly consulted by decision makers are not however characterized only by a technical understanding of healthcare policy acquired through long-standing specialization. They are also distinguished by a willingness to take into account the political context in order to propose “workable” solutions, which lies at the heart of the concept of “policy analysis” to which they relate. [45] This skill derives in particular from the long experience of Washington’s political intricacies that characterizes the most consulted experts as a whole.
The profession of “policy analyst”: acceptance of the political dimension
24The actors studied are far removed from the figure of the expert who relies on the objectivity of scientific knowledge in order to justify the neutrality of a position and establish legitimacy. [46] On the contrary, all recognize and accept the political dimension of their activity, situated as it is on the border between policy and politics. This is even, in their view, what distinguishes the profession of policy analyst. [47] This political dimension is expressed in two ways. Firstly, these experts consider that their job is to propose plans for reform that are not only technically consistent, but also, and above all, politically “workable”. [48] It is by this yardstick that ideas are developed, discussed, and judged in expert forums. A proposal that does not meet this requirement is banished to the margins of the space of expertise, beyond the central forums that provide access to the world of politics. Hence, during the period of study, my attention was frequently drawn to the strategies of compromise and adaptation on the part of experts who wanted to stay “in the game” in order to fit with political demand and the politically “workable”. One expert, who began his career at the beginning of the 1990s, described for example the difference between his personal opinion and what could be realistically defended:
“This is a funny way to say it. Personally, I think I have moved to the left (since 1993) but publicly I have become more aware of how it is important to try to find the middle. That is how I feel. I am more clear on what I think is the best way to be but it is very clear that we won’t get it by saying: ‘it is the best way’”. [49]
26Workability is judged by electoral results, by the state of power relations between the different currents within parties, the events that are currently making the news, and the supposed state of public opinion, as evaluated by polls. The evaluation also takes into account the position of interest groups, which are recognized as a strong blocking power: if a recommendation does not receive the support of at least some of the main interest groups involved, the view in Washington is that it has no chance of being adopted. Thus, maintaining good relations with interest group representatives – attending events they have organized, serving on company boards of directors, or being involved in “mixed” working groups – is, to some extent, a source of credibility for experts.
27The experts I met also accept the political dimension of their activity by positioning themselves on the partisan spectrum and being publicly associated with one camp rather than another. Considering the space in which she works, one of the interviewees thus declared:
“Hmm… You know John Kingdon, when he spoke about experts… I have always thought that he missed that experts also have political values and identification. So their analyses reflect the values of the society and public debate.” [50]
29The position of the experts we met was generally therefore to claim the objectivity of their data, but also to recognize that their recommendations were founded on values closer to one or other of the two political parties. [51] Only a few of the interviewees complained of excessive politicization in recent years. In many ways, the function of policy experts can be seen as shoring up the positions of the politicians to whom they feel closest by lending them arguments. According to the typology of situations of expertise established by Claudio Radaelli, this attitude corresponds to a situation of high politicization and high visibility of the relevant subject, the typical situation of political use of expertise where each party uses the arguments of experts on whom they can rely in order to justify their positions. [52] What makes this case unusual is that the experts recognize this situation and do not seek to deny it. Furthermore, expert organizations that seek to avoid a strong partisan affiliation, like the Brookings Institution or other forums, no longer claim the neutrality and objectivity of their research. As Donald Critchlow noted at the beginning of the 1990s, this ideal has been replaced by the foregrounding of the “bipartisan” nature of the research and events funded, which appears to have become, in a context of extreme politicization and polarization, a new source of respectability and legitimacy for their activity. [53]
30In contrast to expectations, this pronounced politicization of expertise is not an obstacle to its success. It even appears to be a source of funding since, as Yves Dezalay and Bryant Garth have highlighted in relation to US charitable foundations, “the existence of political adversaries represents, for each camp, the best ‘marketing’ argument for their respective clientele and sponsors”. [54] In other words, it stimulates decision maker demand for data, advice and programs, and thus generates activity for expert actors.
Actors familiar with Washington and its institutions
31The capacity of the most consulted experts to assimilate this political dimension and to play the game rests in particular on another trait that characterizes them: their lengthy experience of Washington and the US political institutions in which they have all spent time during their career. This stems mostly from having worked within the federal administration, in which the vast majority of the most consulted experts (53 of 73) have occupied a full-time position at least once in their career (for examples, cf. Figure 2). I note that regular consultation with political decision makers always occurs after this first experience, which appears to be a determining moment in the path toward becoming a highly-consulted expert. As shown in the following table, this experience usually takes place relatively early in an expert’s career, in the two years following graduation from their final degree, or sometimes even before their doctorate.
Occurrence of the first full-time federal government positions in the careers of the most consulted experts
| Number of years between final degree and first position in the federal government | Number of individuals (/73) |
|---|---|
| ≤ 2 years | 33 |
| 3-5 years | 6 |
| 6-9 years | 4 |
| ≥ 10 years | 10 |
| Not applicable | 20 |
Occurrence of the first full-time federal government positions in the careers of the most consulted experts
32In accordance with the specialization that characterizes these actors, nearly all the positions occupied specifically concern health policy issues (and although it is not necessarily clear from the job titles in Table 5, this is also the case at the White House or in Congress). The relevant federal institutions are more generally in the executive rather than legislative branch but all are, on the whole, markedly political institutions, which indicates the importance of this dimension in the governmental experience of the most consulted experts. [55]
Federal institutions in which the most consulted experts have worked*
| Institutions within the federal government | Number of individuals | ||
|---|---|---|---|
| White House (Executive Office of the President) | Domestic Policy Council | 8 | 22 |
| Council of Economic Advisors | 6 | ||
| Office of Management and Budget (OMB) | 4 | ||
| National Economic Council | 3 | ||
| Office of Planning and Evaluation | 10 | ||
| Department of Health and Human Services* | Center for Medicare and Medicaid | 7 | 33 |
| Services (CMS)** | |||
| Office of the Secretary | 6 | ||
| Agency for Healthcare Policy and Research*** | 6 | ||
| Public Health Service | 4 | ||
| National Institute of Health | 1 | ||
| National Health Service Corps | 1 | ||
| Other | 3 | ||
| Congress | Congressional Budget Office (CBO) | 6 | 7 |
| Representative’s Office | 1 | ||
| Other | Treasury Department | 2 | 4 |
| Department of Defense | 2 | ||
Federal institutions in which the most consulted experts have worked*
*: DHHS = DHEW prior to 1979; CMS = HCFA prior to 2001 (created in 1977); Agency for Healthcare Research and Quality = Agency for Healthcare Policy and Research (1989-1996) = National Center for Health Services Research (1968-1989).33Although it is very common, this experience is, on the other hand, short-term: only four individuals of the 53 had stayed more than ten years and over two thirds had stayed less than five years. It might even be thought that remaining within the administration appears to be a handicap for those who wish to forge a career as a prominent expert. In addition, as shown in Table 6, this passage to government is not usually repeated: less than half (nineteen) returned for a second stint and only four for a third time (no-one more than three). [56] This is an important point, as it complicates the widespread vision of the “revolving door” as a constant back-and-forth between the government and private organizations: what is important is perhaps less the number of positions than their existence at all, even if there are few of them.
Number of full-time positions held in a federal institution during the course of career
| Number of returns to the federal government | Number of individuals (/73) |
|---|---|
| 0 | 20 |
| 1 | 26 |
| 2 | 19 |
| 3 | 04 |
| > 3 | 0 |
Number of full-time positions held in a federal institution during the course of career
34The very short duration of experience in federal institutions may seem paradoxical compared to the importance that I assign to this in the career of the most consulted experts. However, the interviewees revealed that this experience is crucial because it sets in motion two processes that are essential to becoming a highly-consulted expert: firstly, building a network and developing a “relational fabric” [57] by getting to know sponsors and other experts already well connected in the world of politics (cf. the third section of this article); and secondly, assessing the expectations of political decision makers and the administration in terms of expertise. This was further explained by one expert whose first experience of government took place under Nixon:
“You really need to work very closely to government to understand how elected representatives or political appointees make decisions. If you’re serving in government you learn to know why the economic side of things is or is not important for the President, Congress or a cabinet secretary. Experiences give you an understanding of who plays and who doesn’t play the game. Other issues are important: the way evidence is presented in the government is very different from how it is in universities. I briefed the vice-president but I never saw the model presented once. I have never met a president or cabinet secretary who does calculate.” [58]
36The political skills thus acquired consist of knowing both who to address in the complex interplay of political institutions and how to formulate a discourse that resonates with the way that political decision makers reason and consider problems.
37Experience of federal institutions is not however limited to holding a full-time position within them, but occurs throughout the careers of the experts studied, via consultation processes. This happens primarily through regular nominations to expert commissions. Three quarters of the experts had been a member at least once (and two thirds more than once) of a committee, advisory group, or expert panel within the executive branch or in Congress. Congressional hearings provide other occasions for the most consulted experts to familiarize themselves with the arcane workings of the Hill.
38In addition to these relatively formal positions, experts may hold the unofficial status of consultant to an elected political representative (a secretary, representative, or senator) or to a campaign, which provides another way for experts to have a window onto the workings of American political institutions. These positions, which are not accompanied by employment contracts, are very common throughout expert careers.
39Above all, we should not overlook the interaction – routine and sometimes daily – which takes place at social occasions in the capital. Although informal, these are key opportunities for experts: seminars, conferences, meetings, dinners, and drinks, to which politicians are invited and where a significant amount of information circulates. As one expert from the RAND Corporation think tank testified, these interactions are key to remaining connected with the world of politics:
“Social events are very important.”
– For instance, what kind of social events?
“Just being in places where you can talk informally about what you have done. That can be a cocktail party or a dinner, or a meeting, or a lunch.” [59]
41According to this same expert, who lives in California, this explains the importance of living in close proximity to Washington:
“It is harder to be connected when you live on the West Coast because it takes six hours to fly to Washington, almost like traveling from Washington to Paris. For that reason, people don’t do it as often and people tend to go home immediately after the formal meeting and miss the social events.” [60]
43In fact, as the following table shows, only eight of the experts live on the West Coast. [61] The need for regular interaction with American political institutions thus requires those who want to be regularly consulted to be geographically close to the capital. [62]
Where the most consulted experts lived in 2012
| Home location | Number of individuals (/73) |
|---|---|
| Washington DC | 33 |
| Boston | 14 |
| New York | 5 |
| Other (East Coast) | 12 |
| West Coast | 8 |
| ? | 1 |
Where the most consulted experts lived in 2012
44The skills of the most consulted experts are thus far from just a technical knowledge of the programs and instruments relevant to health coverage policies. They include an understanding of the political issues that surround the production and circulation of expertise, so that they know both whom to approach with their ideas and how to formulate them so that they have some kind of impact. These skills, which are expected of every policy analyst, but which are particularly developed among those whom I have studied due to the particular positions that they hold, are acquired through sustained frequentation of Washington over several decades, which gives these actors time to familiarize themselves with the formal and informal rules that apply to American political life.
The closed community of the most consulted experts
45From the first two sections of this article, we can conclude that, in contrast to what might be assumed at first glance, the dispersion of the most consulted experts across multiple organizations of expertise outside the government does not prevent them from continuing to follow the areas of policy in which they specialize over the long-term, nor from acquiring the political skills to evaluate the workability of their proposals. In this final section, I aim to show that such institutional dispersion does not imply a greater diversity of profiles, nor the isolation of experts from one another. In fact, I have found there to be a strong social homogeneity among the most consulted experts, which encompasses their educational background and the kind of knowledge that they contribute. Far from being “free spirits”, these experts form a network of actors who recognize one another as such and who support one another by providing mutual services, which may well contribute to this homogeneity of profiles. These experts are not therefore merely “in the service” of politics. They form a group that has a certain level of control over its boundaries and has thus acquired a certain degree of autonomy. [63]
Homogeneity of profiles and skills
46The institutional dispersion of the most consulted experts has not resulted in heterogeneity of profiles. Their social properties correspond to what is generally observed among the American elites: [64] the experts studied, who include only two non-whites (including one black person) and nineteen women, are primarily white men from the upper middle classes, with a level of education well above the national average. [65] In fact, when it comes to education, the most consulted experts are particularly distinguished: all have at least a Master’s degree (which is the case for only 7% of Americans) and 66 have a doctorate (including medical M.D.s and legal J.D.s), most obtained from a selective, if not prestigious, institution (nineteen of the experts studied at one of the “Big Three” – Harvard, Yale, Princeton – and 26 at highly regarded private institutions, seventeen at public state universities, and six at other lower-ranking universities). [66] This level of education is akin to that of the university elite but is well above the average level for the American elite, including those in the administration.
47To these different commonalities is added another more distinctive feature: the homogeneity of the disciplines in which they are trained, largely dominated by economics, and more specifically by neoclassical microeconomics. Thus, as shown in Table 8, almost half of the most consulted experts have a doctorate in economics. Due to their very early specialization in health (as discussed above), these are health economists, a sub-discipline that began developing in the United States in the 1960s and which involves applying the principles of neoclassical microeconomics to the field of health. [67] This strong presence of economists may initially seem counterbalanced by the not inconsiderable number of doctors. It is nevertheless remarkable how few of these doctors are doctors only of medicine (M.D.). Two thirds have an additional Master’s degree, during which they received training in health economics, either directly through an economics course (M.B.A.) or through a Master’s in Health Policy and Management (M.H.P.M.). The theoretical basis of this latter sub-discipline – which has developed since the 1980s in the schools of public health and in which some of the youngest individuals I studied have a doctorate – draws primarily on epidemiology, health economics, and management. Similarly, public policy courses are generally very different from a background in political science; the former are multidisciplinary courses in which the science of economics plays a major role. [68] This domination by the discipline of economics is noted by the experts themselves, and in particular those who are exceptions to the rule, like this political scientist:
– As a political scientist, do you feel a difference from economists for instance? Do you think that training matters?
“Yes. I spent my whole career with economists. I think they are the most influential in the policy debate. They have plenty of authority. Simulations and numbers estimates frequently drive conversations. And I think that the capacity to bring numbers to bear is much more the domain of economists.”
– Did you sometimes feel frustrated?
“No, I was with them. It did not affect me. I learned their language.” [69]
Educational background of the most consulted experts
| Discipline | Number of individuals (/73) | |
|---|---|---|
| Economics | 34 | |
| Medicine | 14 | |
| On its own | 5 | |
| + Master of Health Policy and Management (M.H.P.M.) | 3 | |
| + Master of Business Administration (M.B.A.) | 2 | |
| + M.B.A. and M.H.P.M. | 2 | |
| + History | 1 | |
| Political science | ||
| Law | 5 | |
| Health policy and management | 4 | |
| Public policy | 4 | |
| Sociology | 1 | |
| Journalism | 1 | |
Educational background of the most consulted experts
49As Steven Rhoads has noted, this demonstrates the degree to which economics, and in particular microeconomics, has become the lingua franca of policy analysis in the United States, to the extent that mastery of this field is necessary in order to penetrate influential circles. [70]
50It is therefore again of note that the variety of educational institutions – I count 33 different universities (for the highest diploma) – has not led to a great diversity of profiles, training pathways, and knowledge. What is striking in contrast is their homogeneity, in particular regarding the knowledge shared, largely dominated by health economics, which forms a common matrix of knowledge for the most consulted experts.
51This homogeneity of knowledge does not mean that all the most consulted experts have the same ideas on policy. Health economics recognizes fault lines in the market in this sector, and leaves space for discussion of the degree to which markets should be regulated and individuals held responsible, two major and divisive issues in American political debate. Due to their positions on these two issues, as we have seen, experts sometimes engage in profound disagreements among themselves and are positioned differently on the partisan spectrum. However, certain fundamental assumptions, which have major consequences on how healthcare policy is understood, are shared by all: the scarcity of resources, which makes the issue of access to services dependent on its cost; and the economic rationality of individuals, whose behavior may in consequence be modified by financial incentives. Although I do not have space in this article to develop this angle, it is important to note that, because the most consulted experts are those in strategic positions of expertise and frequently draw up the first drafts of reform, their homogeneity in the area of knowledge reduces the alternatives available to decision makers. [71]
A network of acquaintances
52Nor does the institutional dispersion of the experts studied mean that they are isolated from one another. During interviews numerous references were made to the fact that they know one another very well. As one interviewee described: “It is a very small community. We know each other, or we know of each other or about each other” [72], or, as another put it: “As I said, there is just one group of people in this field, we’re just talking to each other […] So it’s a society. That is stable” [73]. Another interviewee even described the field as “It’s kind of a family!”. [74]
53This finding was even more striking because the list of most consulted experts had been produced upstream of the interviews, without resorting to the “snowball method” (cf. methodology box).
54This high level of acquaintance results firstly from the fact that the experts regularly consulted on healthcare policy in Washington are few in number, and circulate in the same sites where expertise is produced and disseminated, and thus have multiple opportunities to socialize and collaborate on the production of opinions and reports. Among these sites are the different expert arenas created at the behest of the political sphere: governmental expert commissions (executive and legislative branches), congressional hearings, campaign teams, and political appointee positions in the administration. These arenas are important because they foster familiarity with the world of politics and serve as places for experts to meet and exchange ideas.
55The most consulted experts also encounter one another in non-governmental expert organizations. These organizations establish expert commissions and working groups seeking to produce opinions and reports that they subsequently publicize. They also organize seminars and conferences aimed at the world of politics and the media, for which they engage the services of “prominent health policy experts”. The goal for these organizations is always to bring together experts who are already visible and well-connected in the world of politics in order to increase the chances of the event or the documents produced being widely circulated. They thus contribute to maintaining the status and the network of the “most consulted experts”, one feature of which is involvement in these multiple forums.
The multiplicity of expert forums on healthcare policy in Washington (2000s)
The multiplicity of expert forums on healthcare policy in Washington (2000s)
56The relationships built upon frequentation of these expert forums do not remain simply those of acquaintanceship. As testified by the use made by the experts studied of the terms “group”, “community”, “family”, “society”, and “network”, they themselves feel that they belong to the same actor network, which some distinguish by a common experience of government and expertise in the service of politicians:
“If you served, you met all these people. They hadn’t served their whole career. But your common ground was that you had served at some point and you understood the reality of government decision-making. The ones who saw Nixon in office, they’ll remember it for the rest of their life! You are part of a group who knew that their experiences were different. All these people form a network.” [75]
58Like all networks, even informal ones, this one is self-perpetuating: the most consulted experts call upon and recommend other highly consulted experts when they have the opportunity. One expert from the Brookings Institution, for example, referred to the invitation that he had received that same morning to participate in a conference:
“Let me give you an example. This morning I’ve just got an email. That was a man who worked in the Office of Management and Budget, Ezekiel Emmanuel. You heard of Rahm Emmanuel? He’s his brother. He went to the University of Pennsylvania. He’s a liberal but he and people at Heritage foundation, which is very conservative, are going to organize a meeting for December. So he wrote me and asked me: ‘Would you be interested in attending such a meeting?’ I am sure there will be 30 or 40 people there, most of whom I know.” [76]
60Co-option is also involved in nominations to positions of expertise in commissions, hearings, political campaign teams, or political appointee positions, which, according to the interviews I conducted, happens in the vast majority of cases on recommendation from another expert. Integration into this circle is thus essential to the career of an expert, because they rely on this network of acquaintances to contact them and appoint them to a “situation of expertise”. The network thus acts as a catalyst for opportunities. Somewhat surprisingly, according to the interviewees, it seems that achieving inclusion in this network is even more important to the career of an expert than making connections with political decision makers.
– Do you think that you became closer to policymakers after this experience [in government]?
“I kept in touch with some policymakers but I was also talking more about policy issues with other researchers. I was getting to know other people doing policy research around Washington better. And that’s very important.” [77]
– Have you built stable relationships with any politicians or staffers during your career?
“No. As I said there is just one group of people in this field, we’re just talking to each other. But I have no stable relationship with a person in office.” [78]
– Did you meet people important for the rest of your career [during your experience in government]?
“I am quite familiar with European literature and everything. Your question seems to refer to something that exists in some European governments where there are very elite networks of public servants who meet when they’re young and who have contacts with high level people in the parties and the government. That influences their role forever and 20 years later you can discover who they were. It actually doesn’t work like that here. The contacts you make are a small number of academics, really interested in how the government makes decisions and how it works in order to affect that. But we don’t necessarily have contact with political leaders for our whole career.” [79]
62This relatively weak influence of political decision makers on the nomination of experts has already been noted by Hugh Heclo with reference to political appointee positions. Heclo noted that so many positions are offered that it is impossible for elected politicians to check every nomination. [80] Below the top positions, when it comes to the myriad of intermediary posts on which the actors I studied set their sights, nominations are therefore made between the members of the network of already highly consulted experts, who co-opt one another. This is true to an even greater extent for nominations to expert commissions.
63Consequently, the group of the most consulted experts have significant margins of maneuver in controlling the entrance (and sometimes the exit) to these so-called intermediary posts. And yet such positions are no less strategic from the point of view of expertise since it is in these positions that politicians find the “policy specialists” they need when they are looking to develop a reform.
64Co-option among the most consulted experts is therefore a key element in explaining the homogeneity of profiles and knowledge of those with access to the circles closest to political power.
65* * *
66Research into the American state often insists upon the exceptional nature of the country’s lack of a stable higher civil service. The United States is thought to lack a category of actors – senior civil servants – that politicians from the majority of other western democracies can access when recruiting executives for management positions in the administration, or advisers to join their close teams. [81] This is often seen as a point of weakness for the American state, because the close technical understanding of policies that senior civil servants have developed over a long period of time, as well as of the administration and the political issues with which their interaction with officials has familiarized them, makes them useful and soughtafter resources in the process of policy development and/or implementation. [82]
67Although American politicians do not have available a stable pool of senior civil servants, my research has provided evidence that, in the area of healthcare policy, they can draw upon actors scattered in a nebula of non-governmental expert institutions, mostly situated in Washington or affiliated to one of the big East Coast universities. Their professional affiliation to non-governmental expert institutions makes these actors, who define themselves as policy analysts, just as prepared and available to respond to the needs of politicians as the French civil servants seeking to “make a career” [83], since multiplying “situations of expertise” close to decision makers is the objective assigned to them by their employer, and is what ensures recognition by their professional milieu.
68These actors also possess the dual competence – both technical (policy) and political (politics) – that is attributed to senior civil servants, [84] but which is also at the heart of “policy analysis”. Specialists from the beginning of their career in the same field of public policy – healthcare policy – they master the detail of the programs and instruments discussed over several decades. [85] At the same time, in situating themselves exclusively in the field of expertise (i.e. as an expert in knowledge relating to policy), they are particularly conscious of the need to consider and adapt to what they perceive to be the environment and the political constraints for developing their proposals.
69In this, they can draw on their long experience of the federal institutions and political life in Washington. Their acceptance of the rules of politics goes hand in hand with a recognition that political values are integrated into the production of expert knowledge. Since these values will correspond more to one political party than another, they do not hesitate to admit an affiliation or a party loyalty – even if none of them are card-carrying members. In many ways this politicization brings them closer to the figure of the “political bureaucrat” described by Renate Mayntz and Hans Ulrich Derlien with reference to German senior civil servants. It can be read in the light of the concept of “functional politicization” developed by Mayntz and Derlien, political skills being considered by the actors themselves as a necessary condition for holding senior positions in the administration or as political advisors. [86]
70The final part of this article has also shown how these actors, although scattered, are not isolated from one another. They form a group that, while informal, recognizes itself as such, maintains relationships between its members, and has relative control over access to strategic positions of expertise, these being most often obtained through the recommendation of one of the members of the group. This phenomenon of co-option partly explains the relative homogeneity of the profiles of the most consulted experts, both from the point of view of their sociological characteristics and the educational background and knowledge they channel (which is dominated by microeconomics). These actors thus enjoy a certain degree of autonomy – or at least a degree of latitude – from political decision makers which is similar – although doubtless to a lesser degree and in a far less institutionalized manner – to the autonomy that certain senior civil servants seek to attain. [87]
71This relative autonomy of an established group – even in a very informal manner – has major consequences for public policy, since it tends to reduce the alternatives available to decision makers. Dominated by microeconomic thinking, what the recommendations of the most consulted experts have in common is that they link the issue of access to care to that of its cost and emphasize the mechanisms of competition and economic incentives as a way to reduce that cost. It is interesting to note here that dispersion of the production of expertise across multiple non-governmental institutions does not necessarily render expertise more plural and diversified in terms of the content of the knowledge and recommendations circulated. This article has only gestured toward the implications for American healthcare policy, which constitutes a second component of the analysis presented here, and which is developed in another publication. [88]
72Given the different elements described here – availability and continuity over time, dual technical and political competence, and the relative homogeneity of the group – which are characteristic of senior civil servants and which, in this study, are attributed to actors who circulate within non-governmental organizations of expertise, I propose using the term “peri-administration” to describe this latter group. In using this term, I do not seek to affirm some kind of natural identity between the two types of organization, but simply to indicate their convergence and similarities on key points. Heclo has used the term “proto-administration” to highlight one aspect which particularly concerns him: the recruitment of this personnel by co-option rather than by formalized and impersonal rules, thus opening the way to clientelism. Although this raises an important issue, I prefer the term “peri-administration” because it is both less restrictive and less normative (in the sense that it does not suppose a “normal” historical development of the administration) and therefore more open to different interpretations of the phenomenon observed.
73When applied to the Affordable Care Act reform of 2010, the presence of this peri-administration allows us to understand a phenomenon that was noted by numerous commentators and considered to be a factor in the reform’s passage: the presence in Democrat candidate campaign teams and then in the new Obama administration of numerous health policy specialists who, although having long left the administration, had been involved in the reform project of the Clinton administration in 1993 and who were consequently able to pass on the experience they had acquired seventeen years earlier. [89] These shadow actors, who are unknown to the general public but who have been precious resources for the Democrats, are precisely those who figure in the group of the most consulted experts studied here (for the period of the late 2000s and the Democrat group). This suggests that some of the resources involved in the “state capacity” of the United States are not necessarily found directly in its administration but in private organizations that form a close “periphery”. This is supported by recent reflections on the American state that, in reconsidering the classic frameworks of interpretation proposed by the Weberian model, seek to reconceptualize how we comprehend the state by proposing a multidimensional understanding that goes beyond the central administrative apparatus. [90]
74Generalizing these conclusions from the case of healthcare policy would require a comparative study with other areas of public policy. It is probable that the ease of financing nongovernmental expert organizations specializing in health issues makes it a sector where the infrastructure of expertise outside the federal administration is particularly developed. Nevertheless, it is far from certain that healthcare policy is an exception. This conclusion supports the more general observations made by Hugh Heclo. In addition, recent or ongoing research into other – albeit sovereign – areas such as the fight against terrorism or national defense [91] shows the importance of expert networks outside administrative enclosures. Further research in this area is certainly warranted.
Notes
-
[1]
Bertrand Badie and Pierre Birnbaum, Sociologie de l’État (Paris: Hachette, 1982); Pierre Birnbaum, “Défense de l’État ‘fort’. Réflexions sur la place du religieux en France et aux États-Unis”, Revue française de sociologie, 52(3), 2011, 559-78; Samuel P. Huntington, Political Order in Changing Societies (New Haven: Yale University Press, 1968); J. P. Nettl, “The state as a conceptual variable”, World Politics, 20(4), 1968, 559-92.
-
[2]
Hugh Heclo, A Government of Strangers: Executive Politics in Washington (Washington: Brookings Institution Press, 1977).
-
[3]
James A. Smith, The Idea Brokers: Think Tanks and the Rise of the New Policy Elite (New York: The Free Press, 1991).
-
[4]
Peter B. Evans, Dietrich Rueschemeyer and Theda Skocpol, Bringing the State Back In (Cambridge: Cambridge University Press, 1985); William J. Novak, “The myth of the ‘weak’ American state”, American Historical Review, 113(3), 2008, 552-72; Stephen Skowronek, Building a New American State: The Expansion of National Administrative Capacities, 1877-1920 (Cambridge: Cambridge University Press, 1982).
-
[5]
Daniel P. Carpenter, Reputation and Power: Organizational Image and Pharmaceutical Regulation at the FDA (Princeton: Princeton University Press, 2010).
-
[6]
Daniel P. Carpenter, The Forging of Bureaucratic Autonomy: Reputations, Networks, and Policy Innovation in Executive Agencies, 1862-1928 (Princeton: Princeton University Press, 2001).
-
[7]
Theda Skocpol, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Cambridge: Belknap Press of Harvard University Press, 1992).
-
[8]
Robert C. Lieberman, “Weak state, strong policy: paradoxes of race policy in the United States, Great Britain, and France”, Studies in American Political Development, 16(2), 2002, 138-62.
-
[9]
Desmond King and Robert C. Lieberman, “The political crisis of the American state: the unsustainable state in a time of unraveling” in Lawrence Jacobs and Desmond King (eds), The Unsustainable American State (New York: Oxford University Press, 2009), 3-33. For an overview of these studies from the schools of American political development and policy history, cf. Desmond King and Patrick Le Galès, “Sociologie de l’État en recomposition”, Revue française de sociologie, 52(3), 2011, 453-80; Sarah Gensburger, “Contributions historiennes au renouveau de la sociologie de l’État: regards croisés franco-américains”, Revue française de sociologie, 52(3), 2011, 579-602.
-
[10]
Desmond King and Robert C. Lieberman, “L’État aux États-Unis: nouvelles perspectives de politique comparée. Pour en finir avec le mythe de l’État ‘faible’”, Revue française de sociologie, 52(3), 2011, 481-507.
-
[11]
King and Lieberman, “L’État aux États-Unis”.
-
[12]
Desmond King and Robert C. Lieberman, “American state building: the theoretical challenge” in Lawrence Jacobs and Desmond King (eds), The Unsustainable American State (New York: Oxford University Press, 2009), 299-322.
-
[13]
King and Lieberman, “American state building”, 299-300.
-
[14]
Heclo, Government of Strangers.
-
[15]
Hugh Heclo, “Issue networks and the executive establishment” in Anthony King (ed.), The New American Political System (Washington: American Enterprise Institute, 1978), 87-124.
-
[16]
Heclo, “Issue networks”.
-
[17]
Ezra N. Suleiman (ed.), Bureaucrats and Policy Making: A Comparative Overview (New York: Holmes & Meier, 1984).
-
[18]
Hugh Heclo, “In search of a role: America’s higher civil service” in Suleiman, Bureaucrats and Policy Making, 8-34.
-
[19]
Heclo, “In search of a role”, 18.
-
[20]
Heclo, “In search of a role”, 18.
-
[21]
Paul A. Sabatier, “An advocacy coalition framework of policy change and the role of policy-oriented learning therein”, Policy Science, 21(2/3), 1988, 129-68; David Marsh and R. A. W. Rhodes (eds), Policy Networks in British Government (Oxford: Clarendon Press, 1992).
-
[22]
John W. Kingdon, Agendas, Alternatives, and Public Policies (New York: Longman, 2003) [1st edn 1984].
-
[23]
Cf., for example, Donald E. Abelson, Do Think Tanks Matter? Assessing the Impact of Public Policy Institutes (Montreal: McGill-Queen’s University Press, 2009) [1st edn 2002]; Andrew Rich, Think Tanks, Public Policy, and
the Politics of Expertise (Cambridge: Cambridge University Press, 2004); James G. McGann and R. Kent Weaver (eds), Think Tanks & Civil Societies: Catalysts for Ideas and Action (New Brunswick: Transaction Publishers, 2006) [1st edn 2000]. -
[24]
This research concerning American elites was carried out within the framework of ANR OPERA directed by William Genieys (ANR-08-BLAN-0032). This ANR has produced other publications on the transformation of the American state. Cf. in particular Mohammed-Saïd Darviche, William Genieys, Catherine Hoeffler, and Jean Joana, “Des ‘long timers’ au sommet de l’État étasunien: les secteurs de la défense et de la santé? (1988-2010)”, Gouvernement et action publique, 1(1), 2013, 9-38; William Genieys and Jean Joana, “Les gardiens des politiques de l’État en Europe et aux États-Unis”, Gouvernement et action publique, 4(3), 2015, 57-80.
-
[25]
Jonathan Engel, Doctors and Reformers: Discussion and Debate over Health Policy, 1925-1950 (Columbia: University of South California Press, 2002); Theodore R. Marmor, The Politics of Medicare (New York: Aldine de Gruyter, 2000) [1st edn 1973].
-
[26]
Ulrike Lepont, “Les conditions préalables au ‘tournant néo-libéral’. Le cas de la protection maladie aux États-Unis”, Politix, 116(4), 2016, 193-220.
-
[27]
Peter deLeon, “The historical roots of the field” in Michael Moran, Martin Rein, and Robert E. Goodin (eds), The Oxford Handbook of Public Policy (New York: Oxford University Press, 2006), 39-57; Beryl A. Radin, Beyond Machiavelli: Policy Analysis Comes of Age (Washington: Georgetown University Press, 2000).
-
[28]
Corinne Delmas, Sociologie politique de l’expertise (Paris: La Découverte, 2011).
-
[29]
CRESAL, “Situations d’expertise et socialisation des savoirs”, Proceedings of the round table of 14 and 15 March 1985, Saint-Étienne, 1985 (mimeograph).
-
[30]
Pierre Lascoumes, “L’expertise entre sciences et pouvoir”, Problèmes politiques et sociaux, 912, 2005, 5-8.
-
[31]
The number of individuals initially identified was very large, but by excluding individuals who had never published or had never held a political position, I was able to eliminate over 11,000 individuals from the database. The precise choice of filters was then refined during the course of the first two years of research, as knowledge of the qualitative fieldwork improved.
-
[32]
Although it is not the main objective of this article, I should add that one of the major revelations of this database was to identify individuals who publish a great deal without being consulted. It was therefore possible to investigate how individuals entered and exited the category of “most consulted experts” as well as its margins, by applying the same study method to marginalized actors.
-
[33]
This category includes industry, professional and industrial interest groups, consultancy (freelance or agency), and private practice medicine.
-
[34]
Cf, for example, Rich, Think Tanks, Public Policy.
-
[35]
Daniel M. Fox, “Health policy and the politics of research in the United States”, Journal of Health Politics, Policy and Law, 15(3), 1990, 481-99 (485-46). Lisa Stampnitzky has also noted this in regard to terrorism. Cf. Lisa Stampnitzky, Disciplining Terror: How Experts Invented “Terrorism” (New York: Cambridge University Press, 2013).
-
[36]
Interview with Thomas Rice (PhD in Economics, 1982), Professor at the UCLA Fielding School of Public Health, October 2012.
-
[37]
To provide some examples, the variable component is 100% of the salary at the Johns Hopkins Bloomberg School of Public Health, and 50% at the Columbia University Mailman School of Public Health.
-
[38]
This criticism was formulated in a particularly persuasive manner by Thomas Medvetz, “Terra Obscura: vers une théorie des think tanks américains” in Yann Bérard and Renaud Crespin (eds), Aux frontières de l’expertise. dialogues entre savoirs et pouvoirs (Rennes: Presses Universitaires de Rennes, 2010), 177-95. Despite this critique, Medvetz continues to use the concept of the think tank as a category of analysis for his work, which I find problematic. Cf. Thomas Medvetz, Think Tanks in America (Chicago: The University of Chicago Press, 2012).
-
[39]
Abelson, Do Think Tanks Matter?; Rich, Think Tanks, Public Policy; McGann and Kent Weaver, Think Tanks & Civil Societies.
-
[40]
Interview with Joshua Wiener (PhD in Sociology, 1973), Director of the Aging, Disability, and Long Term Care Program at the RTI International think tank, April 2010.
-
[41]
Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).
-
[42]
These were only five in number at the beginning of the 1970s, but there were several hundred by the end of the 2000s. One index is provided by the survey carried out by the Association of Schools and Programs of Public Health (ASPPH) of the health policy and management courses on which the experts studied mainly teach. These courses were still marginal in the 1980s but numbered over 300 by 2012. Cf. Association of Schools and Programs of Public Health website, <http:/www.aspph.org> (accessed: 28 March 2017).
-
[43]
The late nature of retirement in comparison to the national average (62 years) is common for higher intellectual professions in the USA. Cf. National Institute of Aging, Growing Older in America: The Health and Retirement Study (Washington: US Department of Health and Human Services, 2015). However, the unusual nature of certain cases, who have retained their expert status after the age of 75, suggests the exceptional dimension of the highly-consulted expert, akin to that of political careers. This is rather like certain “special advisors” in France, e.g. Jacques Attali.
-
[44]
Ulrike Lepont, “Façonner les politiques aux marges de l’État. Le rôle des experts dans l’évolution des réformes de protection maladie aux États-Unis (1970-2010)”, PhD thesis, Université de Montpellier 1.
-
[45]
deLeon, “Historical roots”.
-
[46]
Cécile Robert, “Expertise et action publique” in Olivier Borraz and Virginie Guiraudon (eds), Politiques publiques. 1. La France dans la gouvernance européenne (Paris: Presses de Sciences Po, 2008), 309-35.
-
[47]
On the different compositions of the profession of “policy analyst”, cf. the excellent analysis by Thomas Medvetz, “‘Public policy is like having a vaudeville act’: languages of duty and difference among think tankaffiliated policy experts”, Qualitative Sociology, 33(4), 2010, 549-62.
-
[48]
Ulrike Lepont, “De Clinton à Obama: effets d’apprentissage et filtrage des alternatives. La convergence des experts sur la réforme de santé aux États-Unis (1993-2010)”, Gouvernement et action publique, 5(3), 2016, 9-31.
-
[49]
Interview with Alan Weil (J.D., Harvard, 1989), Director of the National Center for State Health Policy think tank, May 2010. Weil was a member of the “Clinton Task Force” in 1993.
-
[50]
Interview with Judy Feder (PhD in Political Science, 1977), Dean of the Public Policy Institute at Georgetown University, November 2011.
-
[51]
At a very general level, these values concern different ways of thinking about individual freedom, with the experts closest to the Democrats more willing to recognize the social constraints that influence individuals. From the point of view of health policy, this has major implications for proposals in terms of the responsibility of individuals to provide for and take care of themselves or, conversely, of solidarity and the decommodification of risk.
-
[52]
Claudio Radaelli, Technocracy in the European Union (London: Longman, 1999), 48.
-
[53]
Donald T. Critchlow, “Think Tanks, antistatism, and democracy: the nonpartisan ideal and policy research in the United States, 1913-1987” in Michael J. Lacey and Mary O. Furner (eds), The State and Social Investigation in Britain and the United States (Cambridge: Cambridge University Press, 1993), 279-322.
-
[54]
Yves Dezalay and Bryant Garth, “Droits de l’homme et philanthropie hégémonique”, Actes de la recherche en sciences sociales, 121(1), 1998, 23-41 (32).
-
[55]
However, as Heclo notes, these are not first tier political appointees (e.g. secretary, deputy secretary) but those at an intermediate level (Heclo, “In search of a role”).
-
[56]
This is even truer when the first post occupied is at a high level of responsibility since return to the administration is always motivated by a position at least equal and, most often, at a higher level than the previous one – which is harder to obtain if the first was already very prestigious.
-
[57]
Cf. Jean-Yves Trepos, La sociologie de l’expertise (Paris: PUF, 1996).
-
[58]
Interview with Robert Blendon (PhD in Health Policy, 1969), Professor at the Harvard School of Public Health, October 2011.
-
[59]
Interview with Robert Brook (M.D., 1968, Sc.D., 1972), Senior Fellow at the RAND Corporation, October 2012.
-
[60]
Interview with Robert Brook.
-
[61]
The strong showing of Boston is explained by the importance of this city as a university center and more particularly by the place of Harvard University in the area of health policy. Generally, I note that the experts who do not live in Washington are attached to more prestigious universities than those who live in Washington who, in addition, work more frequently in think tanks, foundations, or consulting groups. This suggests that the prestige of a university institution may, in some way, “compensate” for geographic distance from the capital. However, this is only true to a certain extent: the biggest West Coast universities are hardly represented at all.
-
[62]
This confirms research into the sociology of elites, which has shown the consolidation of Washington in the geographic origin of American elites. Cf. National Academy of Public Administration, “Recruiting presidential appointees: a conference of former presidential personal assistants”, Washington, 13 December 1984, proceedings published in 1985; Darviche, Genieys, Hoeffler, and Joana, “Des ‘long timers’ au sommet”.
-
[63]
This network is however too restricted and too informal to be called a profession, or even a professional group (Didier Demazière and Charles Gadéa, “Introduction” in Sociologie des groupes professionnels ([Paris: La Découverte, 2010], 13-24). Dynamics of professionalization can be observed, which the most consulted health policy analysts do take advantage of, but at the broader level of “health services research”: Lepont, “Façonner les politiques…”.
-
[64]
Cf. the second chapter of Robert Lerner, Althea K. Nagai, and Stanley Rothman, American Elites (New Haven: Yale University Press, 1996).
-
[65]
27% of Americans have a level of education at least equivalent to a Bachelor’s degree. Cf. U.S. Department of Education, “Structure of U.S. Education”, <https://www2.ed.gov/about/offices/list/ous/international/usnei/us/edlite-structure-us.html>, accessed 28 March 2017.
-
[66]
This classification of universities is that used in Joel D. Aberbach and Bert A. Rockman, In the Web of Politics: Three Decades of the U.S. Federal Executive (Washington, Brookings Institution Press, 2000).
-
[67]
Evelyn L. Forget, “Contested histories of an applied field: the case of health economics”, History of Political Economy, 36(4), 2004, 617-37.
-
[68]
Steven E. Rhoads, “Economists and policy analysis”, Public Administration Review, 38(2), 1978, 112-20.
-
[69]
Interview with Judy Feder.
-
[70]
Rhoads, “Economists and policy analysis”.
-
[71]
These perspectives are developed in Lepont, “De Clinton à Obama”.
-
[72]
Interview with Marilyn Moon (PhD in Economics, 1974), Director of the Health Program at the AIR (American Institutes for Research) think tank, May 2010.
-
[73]
Interview with Henry Aaron (PhD in Economics, 1963), Senior Fellow at the Brookings Institution, October 2011.
-
[74]
Interview with Judith Waxman (J.D., 1976), Vice President of Health and Reproductive Rights at the National Women’s Law Center, May 2010.
-
[75]
Interview with Judith Waxman (J.D., 1976), Vice President of Health and Reproductive Rights at the National Women’s Law Center, May 2010.
-
[76]
Interview with Henry Aaron. It is interesting to note in this quotation the parentheses seeking to situate the individual in question within the network of highly consulted experts.
-
[77]
Interview with Marilyn Moon.
-
[78]
Interview with Henry Aaron.
-
[79]
Interview with Robert Blendon.
-
[80]
Heclo, “In search of a role”.
-
[81]
Françoise Dreyfus, L’invention de la bureaucratie. Servir l’État en France, en Grande Bretagne et aux États-Unis (XVIIIe-XXe siècle) (Paris: La Découverte, 2000); Françoise Dreyfus and Jean-Michel Eymeri, Science politique de l’administration. Une approche comparative (Paris: Economica, 2006); Jean-Michel Eymeri-Douzans, Xavier Bioy, and Stéphane Mouton (eds), Le règne des entourages. Cabinets et conseillers de l’exécutif (Paris: Presses de Sciences Po, 2015).
-
[82]
Jean-Michel Eymeri, “Frontières ou marches? De la contribution des hauts fonctionnaires à la production du politique” in Jacques Lagroye (ed.), La politisation (Paris: Belin, 2003), 47-77.
-
[83]
Eymeri-Douzans, Bioy, and Mouton, Règne des entourages.
-
[84]
Patrick Hassenteufel, Sociologie politique. L’action publique (Paris: Armand Colin, 2011) [1st edn 2008)], 155-66.
-
[85]
In this they resemble not the figure of the generalist senior civil servant, but that of the specialized senior civil servant, whose growing role since the 1980s has been demonstrated by William Genieys and Patrick Hassenteufel. Cf William Geneiys and Patrick Hassenteufel, “Entre les politiques publiques et la politique: l’émergence d’une élite du Welfare”, Revue française des affaires sociales, 55(4), 2001, 41-50; William Genieys, L’élite des politiques de l’État (Paris: Presses de Sciences Po, 2008).
-
[86]
Renate Mayntz and Hans Ulrich Derlien, “Party patronage and politicization of the west German administrative elite 1970-1987: toward hybridation?”, Governance, 2(2), 1989, 384-404.
-
[87]
Marie-Christine Kessler, Les grands corps de l’État (Paris: Presses de Sciences Po, 1986).
-
[88]
Lepont, “De Clinton à Obama”.
-
[89]
Anne-Laure Beaussier, “L’assurance-maladie américaine à l’heure de la polarisation partisane”, Revue française de science politique, 64(3), 2014, 383-405; Jacob Hacker, “Why reform happened”, Journal of Health Politics, Policy and Law, 36(3), 2011, 437-41; Lawrence R. Jacobs and Theda Skocpol, Healthcare Reform and American Politics. What Everyone Needs to Know (New York: Oxford University Press, 2012).
-
[90]
Cf. King and Lieberman, “American state building”.
-
[91]
Genieys and Joana, “Gardiens des politiques de l’État”; Stampnitzky, Disciplining Terror. In comparison to expertise in terrorism, the difference seems to relate above all to the degree of structuring and the homogeneity of the experts involved.
