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The study of American health care reform during the 1990s and 2000s reveals that, far from waning, the influence of federal policy elites has been reconfigured. Like Philip Selznick’s “custodians of policy,” small groups of elites with long-term careers and located at the heights of power in the executive and legislative branches have acquired strategic expertise in key policy sectors. Like their French counterparts, these health policy elites have positioned themselves as guardians of health policy by adapting the imperative of cost control to a historical, institutional, and political legacy – one that stands in opposition to comprehensive systemic reforms that would align the U.S. with the prevailing models of universal access in other western democracies. It was through confronting this “provincialism”, together with a determined quest for a political compromise, that the Obamacare initiative eventually succeeded in implementing changes which, despite not amounting to comprehensive systemic reform, nonetheless stand out as the most important American health care reforms since the 1960s.