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President Donald Trump’s State of the Union address on Tuesday offered a preview of the economic debate that could tip the presidential election this fall.

The speech crystallized a key question: Will voters measure their personal economic well-being primarily through trends in unemployment and the stock market, or by whether their income is keeping up with their costs, particularly for health care? It’s a crucial distinction, because polls show that while a clear majority of Americans give Trump positive marks for his handling of the economy, a large majority also consistently disapprove of his record on health care.

“While economic indicators are generally moving in the right direction, health-care indicators are not,” says Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, a nonpartisan group.

On Tuesday night, Trump triumphantly rattled off figures about buoyant job growth, record-low unemployment among African Americans and Latinos, and soaring highs for the stock market. Though some of the figures were exaggerated, and others represented more of a continuation than a break from the economy’s performance under President Barack Obama, fact-checkers generally found relatively little to debunk.

But Trump’s treatment of health care was very different. Though he was just as assertive in his tone, the president made a series of false claims—in particular, he repeatedly lied about his administration’s unrelenting efforts to gut the Affordable Care Act. To Democrats, Trump’s determination to surround his health-care record with what Winston Churchill once called a “bodyguard of lies” clearly signaled that the president recognizes how vulnerable his record could prove this fall.

Polls leave little doubt that voters express much more positive assessments of the economy than the health-care system. “Because people see health care as so central to both their personal well-being and their financial well-being, health care stands out as Trump’s No. 1 vulnerability,” says the longtime Democratic pollster Geoff Garin. “The simplest way for people to understand the Trump economy is that whatever wage increases they are getting are smaller than the increases in their health-care premiums and out-of-pocket health-care costs.”

Over the past year, voters’ optimism about the economy has increased consistently across a wide array of polls. With this tailwind, the share of Americans who approve of Trump’s handling of the economy has also increased, settling in at about 55 percent. As I’ve written, Trump faces more resistance than any previous president among voters satisfied with the economy; about one-fifth of those who say they approve of Trump on the economy still say they disapprove of his overall performance.

But even so, that still means that most voters who approve of Trump’s economic performance approve of him overall. As Trump’s ratings for managing the economy have increased, so have his overall approval ratings. Just this week, Gallup showed his job approval spiking to 49 percent, its highest rating ever for him—although other polls have not recorded as dramatic an increase.

But the public assessment of Trump’s performance on health care tells a different story. In an Associated Press/National Opinion Research Center survey last month, just 38 percent of Americans said they approved of his record on health care—a grade that has stayed relatively stable since he took office—compared with 56 percent who approved of his handling of the economy, the highest of his presidency.

The latest monthly health-care poll from the Kaiser Family Foundation drilled down further into those views. In the survey, just about a third of adults gave Trump positive marks for dealing with preexisting conditions, the ACA, and prescription-drug costs. Detailed results provided to me by Kaiser showed that two key groups of swing voters shared this deep skepticism of Trump’s health-care record. A majority of college-educated white men disapproved of how Trump has handled each of the three issues. And while white women without a college degree—a group that could decide the Rust Belt states that tilted the 2016 election to Trump—broke against him more narrowly on the ACA and preexisting conditions, just 31 percent of them gave him positive marks on prescription-drug costs.

The Republican pollster Gene Ulm told me that easing those doubts about his handling of health-care issues is crucial for Trump’s reelection prospects. “No president would be in the game without people believing the economy is getting better than it was,” Ulm said. But for “the next cluster of voters” beyond those immediately drawn to him, “it’s the cost of health care, prescription drugs, and the whole cluster of premiums, co-pays, [and] out-of-pocket expenses” that matter most.

And on those fronts, the best measure of Trump’s anxiety was his mendacity in describing his record on Tuesday night.

Trump, not for the first time, flatly lied about his efforts to revoke the ACA’s protections for those with preexisting conditions. Not only is his administration currently in federal court seeking to invalidate the entire ACA, but in 2017 he endorsed Republican proposals in Congress to effectively erase those protections by allowing insurance companies to charge people who have greater health needs more. “It’s notable that the president feels the need to say he’s protecting people with preexisting conditions,” Levitt says, “but the facts just don’t back that up.”

On prescription drugs, the gap between Trump’s words and actions isn’t quite as stark. Kenneth Thorpe, a health economist at Emory University who served in President Bill Clinton’s administration, told me Trump was correct when he said that federal data showed a decline in overall prescription-drug costs last year. The problem is that prices for some high-profile drugs (such as insulin) are still rising, and the overall cost has stabilized at a level that is unaffordable for many Americans. An added concern, Thorpe said, is that more insurance plans are including prescription drugs in their total deductibles—meaning that patients must spend more out of pocket until they reach that threshold. “What people care about is what they pay, not what the overall cost of the medication is,” he told me.

Trump has talked about confronting prescription-drug costs since his 2016 campaign, when he embraced the long-standing Democratic idea of allowing Medicare to negotiate for lower prices with drug companies. But amid opposition from the pharmaceutical industry, and Republicans leery of an aggressive federal role in health care, he renounced that proposal.

Democrats, meanwhile, have picked up the mantle, putting it at the center of the H.R. 3 legislation that the House passed in December. (That was the bill House Democrats were alluding to when a group of them rose to chant “H.R. 3” during Trump’s State of the Union address.)

The GOP-led Senate hasn’t taken up the bill, but the public’s intense focus on drug costs makes it possible that Trump will offer some proposals on the issue before Election Day. That’s why it’s so essential for Democrats to more sharply define the terms of debate right now. “It is really important for Democrats to set the bar on the drug-pricing issue at whether someone supports or opposes giving Medicare the power to negotiate,” Garin warns.

As of now, though, the party’s 2020 presidential candidates have provided almost no visibility to drug pricing, while incessantly arguing over a single-payer system that would eliminate private health insurance. That’s symptomatic of the Democratic candidates’ broader failure to explicitly make a case against Trump’s health-care record, even as they release extensive health-care plans of their own.

Health-care issues—in particular, promises to protect people with preexisting conditions and to tackle prescription-drug prices—were a central reason Democrats notched big gains in the 2018 midterm elections, even as a clear majority of voters viewed the economy positively. In 2020, health care again probably offers Democrats their best chance to inoculate themselves against Trump’s claim that the economy is working for most Americans. But so far at least, Democrats on the campaign trail are letting the president off the hook.

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