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.