The (somewhat obvious) conclusion that a person's life circumstances affect their health has become widely accepted in health care circles, but there's a budding disagreement over whose job it is to do something about it.

Why it matters: This is a debate about how far the health care system should go to keep people healthy.

• Doing so is something the U.S. is notoriously bad at compared with other wealthy countries, which spend way less than America on health care yet have better health outcomes.
• "We have a system that is very entrenched and we have a sick care system ... we focus a lot on care and we spend a lot of money," said Joe Betancourt, president of the Commonwealth Fund. "It becomes a health care conversation instead of a population conversation around the health of Americans."

Where it stands: The once-academic term "social determinants of health" has caught on like wildfire over the last few years, as have attempts to do something about them.

• The term refers to circumstances like housing, nutrition, transportation, education or income, all of which have a relationship to a person's health.
• Payers — perhaps most prominently Medicaid — have been experimenting with covering lifestyle factors as a way to reduce future health costs, and both payers and providers have waded into endeavors like investing in housing as a way to keep at-risk populations from needing so much health care.
• "From a broad kind of equity basis, anyone who is providing health care should be embracing something outside of just treating the disease that comes in the door. That's the essence of trying to prevent that particular condition," said Alonzo Plough, chief science officer and vice president at the Robert Wood Johnson Foundation.
• But there's an ongoing debate among academics and experts about whether it makes sense for the health care system to be heavily involved in factors that aren't directly health care, especially when other institutions may be more tailored to offer such services.

The other side: In a recent paper titled "Is Everything Health Care? The Overblown Social Determinants of Health," the Manhattan Institute's Chris Pope argues that "ultimately, social policies should not be pursued for the sake of their incidental impact on health."

• "Social services are best provided by social work agencies, not doctors or hospitals," he adds.

Between the lines: Unsurprisingly, this is a very nuanced conversation, and some experts say it's important to differentiate payer involvement in social determinants from providers'.

• "I don't think health care providers are the people who should be doing this," said Sherry Glied, dean of NYU's Robert F. Wagner Graduate School of Public Service. "If a state decides it wants to run its social welfare programs through managed care companies, that's fine."

And while many experts think hospitals and health systems should have a role in addressing social determinants, that role may largely be to gather data and connect patients with other community services.

• "It really involves better networking and connectivity between the clinic and the community. It doesn't require a social revolution," Plough said.
• "As community cornerstones, hospitals recognize that to improve the health of the populations they serve, it's important to engage and strategize with public and private stakeholders to determine what role they can play to address the social drivers of health throughout their communities," said Joy Lewis, senior vice president at the American Hospital Association.

The bottom line: "There's no one single solution," said Gaurav Dave, associate director of the Center for Health Equity Research at the University of North Carolina at Chapel Hill. "Medicaid can't do everything. The health care system can't do everything. Everyone has to work together."

More below about the financial components of this debate ...

There may not be a strong business case for health care companies to dive into lifestyle-based prevention, at least under traditional payment systems, but money is a huge factor in this conversation.

The big picture: The U.S. spends an enormous amount — more than 17% of GDP in 2022 — on health care, but much less on other social services.

• Some experts argue that using health care dollars to pay for things like housing or food access is essentially a way of gaming the system.
• "The SDOH push reflects the great skew of social welfare expenditures toward health-care programs and the desire of other social policy interests to tap into them," the Manhattan Institute's Pope writes.
• "Everyone, I think, who looks at the system agrees that the balance between spending on health care and spending on other social programs in the United States at present is not ideal," NYU's Glied said.
• "We're trying to do something where we're playing a game of Twister to get more money into the housing program, when really what we should just do … is we should put more money into the housing program."

The intrigue: Some experts say the case for addressing social determinants of health won't be made by arguing it pays for itself down the road, at least within the health care system.

• "Saving money and improving health are two completely different things. They don't have to be connected to one another," Glied said.
• That's partially just a math problem; building housing is expensive, and the costs of that may not be offset by savings in emergency room use, for example.
• But it's also reflective of how the U.S. system is set up. Many providers get paid per episode of care, and people frequently transition from one insurer to another throughout their lifetime.
• "I think it has been challenging for health care systems to say, because of the way we finance and pay for health care today ... that if I invest in housing it will yield me as a hospital or me as a payer a financial benefit," the Commonwealth Fund's Betancourt said.

What we're watching: Alternative payment models that reward providers for keeping patients healthy may increase the incentive for them to address patients' non-health life circumstances.

• In places with value-based payments, "those health care systems have realized, 'You know what, if I want these outcomes and I'm at risk, then yeah, it's really important for me to make sure … we're addressing those social drivers,'" Betancourt said.

Choosing Sen. J.D. Vance as the GOP's vice presidential nominee is a stark departure from the business-friendly wing of the party.

• In his own words, his populist vision amounts to "applying as much upward pressure on wages and as much downward pressure on the services that the people use as possible," as he told the NYT.
• But aside from his support of Medicare drug price negotiations — which is itself an enormous anomaly — he hasn't talked a lot about how his worldview would translate into health care reforms.
• More on his health record from my Axios Pro pals here.

So indulge me for a few minutes here as I lay out my questions about what this could look like ...

• Republicans have coalesced around price transparency and cracking down on consolidation. But in a lot of markets, the cat is out of the bag — they're consolidated and prices are high. What, if anything, should the government do in those places?
• Vertical integration has made insurance companies enormous. Are they too big? Would a Trump-Vance administration ever entertain the idea of breaking them up? Even more specifically, what about UnitedHealth Group?
• Many experts have concluded that immigration is key to addressing health worker shortages. How does that square with Vance's belief that immigration ultimately depresses domestic wages?
• How aggressive should the FTC and the DOJ be on health care antitrust issues?
• Should Medicare negotiate the price of more drugs, and should those prices be available to other payers? Should that system be replaced with international reference pricing?
• Are insurers making too much money from Medicare Advantage? What should be done about it?

The bottom line: If a future Trump administration embraced some version of health care populism, then there's a lot of room for creative policy ideas — if only because there's a lot of big businesses in health care, and the services they provide are very expensive.

• "I think it's safe to say that Vance will be unorthodox in health policy, creating new opportunities for Republicans to re-engage with what he calls 'forgotten communities,'" said David Cleary, formerly the GOP staff director for the Senate health committee.
• In general, the GOP's rift with big tech companies may preview where its relationship with health care companies is going.
• "It's the same philosophy applied to any industry, really, whether it's tech or health care, which is there are businesses that have grown to a size and scale that they become targeted," said Lanhee Chen, a longtime GOP campaign adviser.