International audience Policy elites-- what William Genieys has termed "custodians of state policy"-- have played crucial roles in shaping health care policy in the United States. The backgrounds and agendas of these elites have shifted, however, as the nation's struggles over national health insurance came to accommodate the preoccupation with cost containment and as policymakers sought to forge innovative combinations of public authority and market forces. Drawing on three important episodes-- legislation to promote health maintainance organizations in the early 1970s, the reform proposed by President Bill Clinton in 1993-94, and the creation of the Affordable Care Act in 2010-- this paper explores patterns of continuity and change in the composition and contributions of policy elites in the shaping of US health care policy.