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Since the 1990s, most presidential elections have featured big battles over healthcare: How to lower costs and expand coverage, and what role the government should play.

Not this year. Democrat Kamala Harris and Republican Donald Trump both have a variety of piecemeal policies, but the big fights involve inflation, taxes, immigration, and trade. In open-ended questions, only 2% of respondents tell Gallup that healthcare is the nation’s top problem.

An unheralded development helps explain why healthcare is receding as a voter concern: The Affordable Care Act (ACA), signed into law by President Barack Obama in 2010 with no Republican support, now covers a record number of Americans and is more popular than ever. A program many Americans despised at the outset has now become an integral source of coverage for 45 million Americans.

Obamacare, as it’s known, got off to a rocky start when its main provisions went into effect in 2014. Many Americans with individual insurance plans lost cheap coverage and had to pay more for benefits they didn’t necessarily want. Obama earned the Politifact “lie of the year ” distinction for the infamous claim, “If you like your healthcare plan, you can keep it.”

The ACA covered a few million people in its first full year, but patients blamed it for higher costs and other problems. From 2014 through 2017, more people opposed the law than approved of it. Republicans who opposed the ACA from the start tried to kill it in the courts and repeal it in Congress, but couldn't. Trump vowed to "repeal and replace" Obamacare when he ran for president in 2016, but a repeal effort failed in Congress the following year even though Trump was president and Republicans controlled the House and the Senate.

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Even Democrats weren’t satisfied. One of the biggest issues in the 2020 Democratic presidential primaries was “ Medicare for All ,” a huge government-run health plan that supplants the existing system. Progressives including Bernie Sanders (I-Vt.), Elizabeth Warren (D-Mass.), and — yes — Harris felt Obamacare didn’t go far enough, and the government should simply cover everybody. Joe Biden had a different plan: Forget Medicare for All and simply patch up Obamacare so it would cover more people.

Biden’s pragmatic approach helped him win the Democratic primaries and the general election against Trump, and he has, in fact, done what he promised. Biden signed into law measures that expanded eligibility for Obamacare and added subsidies for higher-income families, which last through 2025.

That brought coverage levels under the ACA to new record highs, while the program grew in popularity. About 45 million Americans — 15% of the population — now get health coverage under one of the ACA provisions, mostly through a marketplace plan or through expanded Medicaid. The uninsured rate has plunged from 16% in 2010 to 7.7% in 2023 . From its low point in 2013, public approval of the ACA has soared from 33% to 62% .

The ACA would cover even more people, but 10 states — Florida, Georgia, South Carolina, Tennessee, Alabama, Mississippi, Texas, Kansas, Wyoming, and Wisconsin — haven’t adopted Medicaid expansion , which limits the options for low-income residents of those states to get coverage. The remaining uninsured are mostly people who don’t get coverage through an employer and feel they don’t need it or still can’t afford it. (Contrary to some propaganda, undocumented migrants don’t qualify for any federal coverage.)

Voters trust Democrats considerably more than Republicans on healthcare, which helps offset Democratic weaknesses on immigration and the economy. Harris, now the Democratic presidential candidate, wants to frame healthcare as an economic issue, which it assuredly is. She no longer supports Medicare for all, and her plans are more marginal efforts to address ongoing problems one by one. They include efforts to cancel medical debt, negotiate more drug prices through Medicare, and make permanent the ACA subsidies that expire in 2025.

Trump insists that " Obamacare sucks ," but he's gone from trying to repeal it to saying he'll make it better and cheaper, without explaining how. Maybe he noticed that Obamacare's approval rating is nearly 20 points higher than his own and that voters appreciate having healthcare.

Rick Newman is a senior columnist for Yahoo Finance . Follow him on X at @rickjnewman .

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