Last Tuesday, President Donald Trump sat down for a power dinner with some very powerful executives. Among the dozen or so business icons supping at Trump’s country club in Bedminster, N.J., were Michael Manley of Fiat Chrysler, Frederick Smith of FedEx, Ajaypal Banga from Mastercard and Dennis Muilenburg from Boeing.

The intent, according the Lindsay Walters, the administration’s deputy press secretary, was to “hear how the economy is doing from their perspective and what their priorities and thoughts are for the year ahead.”

Noticeably absent from the conversation? Healthcare executives, save for Alex Gorsky, chairman and CEO of Big Pharma’s Johnson & Johnson.

Healthcare is one-fifth of the nation’s economy and a job creator, adding 16,700 positions in July, on top of the 25,200 added in June. So it is a bit of a head scratcher as to why industry executives weren’t part of the conversation.

Meanwhile, in central Ohio, polls closed on one of the most critical and most watched special elections of the year. In the last showdown before the midterms, Democrat Danny O’Connor went toe-to-toe with Republican Troy Balderson in a battle that ended up being much more competitive than observers normally predict for a district that has been in GOP hands since 1983.

At deadline, the race was still too close to call with about 3,400 provisional ballots to be counted. And Balderson’s slim lead was likely to trigger an automatic recount.

Wisely, O’Connor did not make the election a referendum on Trump, who won the district by 11 points in 2016. Nor did he embrace ideas being bandied about by his party’s more progressive wing, including Medicare for all. That rhetoric does not play well in red districts and can fall flat in purple and blue districts in states that Trump carried in 2016. O’Connor instead focused on pocketbook issues. For healthcare, that meant coverage. He campaigned to keep Ohio’s Medicaid expansion and professed support for the Affordable Care Act, especially its patient protections.

Reading too much into O’Connor’s strong showing—especially if it turns out to be in a losing cause—is just as foolhardy as overstating the impact of Alexandria Ocasio-Cortez’s primary win in the Bronx. Politics is still a local game.

But those elections and national polls foreshadow that healthcare will be a major factor in November and, likely, in 2020. An Ipsos/Reuters poll released this month found that healthcare (18%) was the most pressing issue for voters, beating out immigration (15%). Democrats ranked healthcare as their top issue, while Republicans ranked immigration higher. Importantly, independents were more concerned about healthcare.

It’s a trend that has been building for a while. A Kaiser Family Foundation poll released in May found that 22% of registered voters ranked healthcare as their top issue, just behind the economy/jobs. In battleground states, healthcare was No. 3 at 20%, trailing gun policy and the economy/jobs.

While Republicans in particular may be inclined to pin their elections hopes on a robust economy, they’d be wise to heed the advice of one of their own.

“They are mostly right, except for one area—health care,” former House speaker Newt Gingrich wrote in an opinion piece last week for Fox News. “Republicans should be proud of the enormous success of the economy. But the economy won’t reach its full potential and the GOP will not win big in the 2018 elections unless Republicans deal with the cost of health care in America.”

Voters will be heading to the polls in November just as open enrollment for 2019 starts. Insurers are already filing their rates and there are, as expected, wide swings. The Congressional Budget Office has predicted premiums for benchmark ACA plans—those used to determine subsidies—will rise 15%. And then there are those pesky drug prices.

These are real pocketbook issues. As Gingrich pointed out, any politician failing to have a meaningful conversation about healthcare costs (and let’s add quality for the heck of it) may be doing so at his or her own peril.

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