Massachusetts led twice on health care. It’s time for a third major reform – this one focused on keeping people well.

GOV. HEALEY won her second term promising, among other things, to lower health care costs and expand access to primary, mental, and maternal health care. She takes up that challenge in the 20th anniversary year of the law that made Massachusetts the national model for health coverage.

Twice, the Commonwealth has led the country on health care. If Healey wants affordable access to last, it will have to lead a third time, by building a system that pays to keep people well.

The first wave was coverage. The 2006 reform, signed by a Republican governor, Mitt Romney, and written with a Democratic Legislature, made near-universal insurance a state guarantee and a template for the Affordable Care Act. It worked: 97.9 percent of residents are insured, against about 92 percent nationally.

The second wave was cost. In 2012, Chapter 224 made Massachusetts the first state to set a target for health care spending growth, and created the Health Policy Commission to monitor it. For a while, it worked. Spending per resident grew an average of 3.5 percent a year from 2012 to 2019.

Since then, the benchmark has been left behind. Growth has averaged 5.3 percent a year since 2019. In 2024, the state spent $83.3 billion on health care, or $11,663 per resident, an increase of 5.7 percent against a 3.6 percent target, the fourth year in a row it was missed.

Two in five residents report trouble affording care. Family premiums for employer coverage reached $28,151, the highest in the country, and with out-of-pocket costs, a family’s health care cost $32,469. At recent growth rates, family premiums would reach a staggering $50,000 by 2032, according to Health Policy Commission projections presented last week.

Coverage is also under strain. Federal Medicaid changes are expected to double the state’s uninsured rate. Expanding access is the right goal. But access built on a cost curve like this one will not hold.

The benchmark measures what the system spends without changing what it buys. Meanwhile, primary care’s share of spending is shrinking, even though it is where most prevention happens: From 2019 to 2023, primary care spending grew 13.6 percent, against 20.6 percent for other medical care.

I have seen this problem from the inside. For eight years, I built and scaled an integrated health care platform across the US and Canada under the two basic ways care is paid for. Under global payment contracts, we were responsible for a population’s total cost of care, so a visit that kept a patient out of the hospital saved money.

Under fee-for-service, we were paid for each service delivered, so the same visit, by the same patient to the same clinician, earned only a modest fee, and keeping that patient out of the hospital earned us nothing at all. The contract, not the medicine, decided what got done.

Massachusetts sits between those two models. It pioneered global budgets, and MassHealth now pays for 92 percent of members in its accountable care and managed care plans that way.

But in commercial insurance, only about 35 percent of members’ care was under such arrangements in 2024, down from 39 percent two years earlier; the rest is still paid service by service.

And even global contracts are settled year by year against spending targets, rewarding savings that appear quickly rather than those that arrive a decade later. For most residents, the system still works the way fee-for-service always has. I call it find it, fix it. Wait for disease to appear, then pay to treat it. Coverage brought more people into that model, and the benchmark tried to make it cheaper, but neither changed it.

The third wave should finish what global payment began, and build a system to predict illness and prevent it.

Prevention is not a blank check. Screening everyone for everything costs money. The Congressional Budget Office found that about 80 percent of the preventive services it studied raised total spending.

What pays is prevention aimed at the right people. In the national Diabetes Prevention Program, an intensive lifestyle program cut new cases of type 2 diabetes by 58 percent among high-risk adults. And the opportunity for big gains with the right targets is huge: Only about one in four Americans with high blood pressure has it under control. That is why prediction comes first. Finding people whose risk is rising, before they become patients, is what makes prevention pay.

Massachusetts already owns most of the tools. Five moves would lay the foundation for a system built to predict disease and prevent it:

1. Measure health, not just spending. Alongside the cost growth benchmark, the Health Policy Commission should publish a yearly prevention scorecard for every major insurer and provider system. This should show the share of patients with blood pressure and blood sugar under control, and the hospital admissions that good primary care should have prevented.

2. Use the data the state already has. The state’s all-payer claims database already tracks claims across most of the state’s insurers. Used with strong privacy protections, it can show where residents’ risk is rising before a diagnosis, so prevention can be targeted.

3. Protect primary care’s share. The Legislature is close: the House and Senate have each passed bills requiring at least 15 percent of health care spending to go to primary care, more than double today’s share, and a conference committee is now reconciling them. Lawmakers should finish the job before the year ends, and keep the new primary care payment models both bills include, so that practices are paid for keeping patients well rather than for the number of visits they log.

4. Pay for results, starting with the state’s own plans. MassHealth and the Group Insurance Commission, which covers state and municipal employees, should tie a meaningful share of payments to those control rates and avoided admissions. The state is a long-term payer. It should act like one.

5. Give prevention time to pay. The same two plans should also offer multiyear global contracts that credit providers for prevention savings measured over five years or more, and the Health Policy Commission should judge prevention investments over the same horizon when it assesses performance against the benchmark.

None of this requires choosing between Democrats and Republicans. Romney, a Republican, signed the first wave into law with a Democratic Legislature. Gov. Deval Patrick, a Democrat, signed the second. Healey now has the chance to build the third. The Health Policy Commission has urged that Massachusetts “once again be the national leader in reimagining our health care system.”

Twenty years ago, the question was who would be covered. Fourteen years ago, it was how much the system should cost. The question now is what all that money buys. Massachusetts answered the first two questions for the country. It should answer the third by laying the foundation for a health system that is paid to predict illness and prevent it.

M. Vaman Rao is a Boston-based scientist, serial entrepreneur, innovator, and investor. He built and scaled an integrated health care platform across the US and Canada.