ACA is MIA from campaign fights for first time in more than a decade

• What's noteworthy is that Democrats aren't touting the law's affordable coverage in inflationary times, especially after they extended ACA subsidies for three years in the Inflation Reduction Act and prevented steep premium hikes for marketplace enrollees.

What they're saying: "This is really the first campaign in a decade where the ACA hasn’t been a dominant issue. That may be because Democrats generally have better success when they’re fighting against Republican plans than when they’re advocating for their own efforts," Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation told Axios.

• "In this campaign, Democrats had an opportunity to positively campaign on things they have accomplished but don’t seem to have gotten a lot of traction," Levitt added.

Driving the news: Most campaigns have focused on abortion, when they've discussed health care at all. Some Democrats have also touted the IRA's drug price controls for Medicare recipients, and the way their party prevailed over powerful drug industry interests.

• One exception was in North Carolina's Senate race, where an Oct. 7 debate featured an exchange between Republican Ted Budd and Democrat Cheri Beasley over her support for a public insurance option. Budd also dodged a question about whether he would support repealing and replacing the ACA.
• The ACA also is a factor in South Dakota's referendum on expanding its Medicaid program to more than 42,000 residents. The health law gives states enhanced federal funding for their expansion populations; some opponents have said that put states on an unsustainable spending path.
• President Biden has been trying to cast Democrats' efforts to build on the ACA as a tonic against inflation, promoting the way the IRA would lower health care costs as he stumped in states like Oregon, California and New York.
• Meanwhile, Republicans in battleground states have gone silent on the ACA, and the House GOP's "Commitment to America" makes no mention of striking the law.

Flashback: Health care cost and coverage fights played defining roles in the past six election cycles.

• The GOP flipped control of the House in the 2010 midterms, spurred by backlash to the passage of the ACA.
• Republicans continued to bang on the "repeal and replace" message for the next six years, including in Mitt Romney and Donald Trump's presidential campaigns.
• Democrats retook the House in 2018, with messaging around GOP efforts to take away ACA protections for people with pre-existing conditions.
• Biden in 2020 campaigned on both creating a public option and expanding the ACA. Trump meanwhile promised to bring forward an alternative Republican health care plan which never materialized.

Yes, but: Recent Senate debates haven't featured much tangling on health coverage. Nor have political ads, per the Washington Post.

• In battleground states like Arizona, Ohio, Wisconsin and Georgia, the economy, immigration, abortion and crime have dominated the conversation.
• Republicans also haven't lobbed much criticism at the new drug price negotiations, even though vulnerable incumbent Democrats voted for the legislation.
• Dodging health care could be a misstep: A new Gallup/West Health poll finds that almost 40% of voters would be willing to cross party lines for a candidate who made lowering health care costs a top priority of their campaign.

What's next: Just because campaigns are going silent doesn't meant there aren't fights to come.

• If Republicans do try to repeal or alter the IRA's drug price provisions, they will face major pushback from Democrats.
• Democratic congressional aides have signaled that making the ACA subsidies permanent will be a priority if Democrats retain control of either the House or the Senate. Such a move would likely trigger intense Republican opposition.

Our thought bubble: Democrats' great debate over how involved the government should be in health policy has yielded to a campaign driven by reproductive health care in the wake of the Supreme Court's decision to overturn Roe v. Wade

• Rather than campaign on Medicare for All or a public option – both non-starters in a divided Congress – Democrats have mostly looked backwards, touting the Inflation Reduction Act's health care provisions.
• "Democrats do face a challenge in the future of defining what the next stage of their agenda is," said Levitt. "The ACA was culmination of decades of work and then Democrats spent another decade defending the law. Now there is a question of what is next for Democrats on health care?"