The short answer
Medicine shows it can be done. Health care is moving from paying for each service to paying for whether patients get healthier, and about 45 percent of U.S. health care payments in 2024 were tied to arrangements accountable for quality and cost.
For most of the last century, doctors and hospitals were paid for every visit, test and procedure. In 2013 a national commission on physician payment reform said this contains "incentives for increasing the volume and cost of services, whether appropriate or not." Nobody got paid when you stayed well. Senator Tom Harkin put it bluntly in 2008: "We don't have a health-care system in America; we have a 'sick care' system."
Then the people paying the bill started to move. Hospitals now lose money when too many patients come back within thirty days. Groups of doctors share in the savings when they keep patients healthier. Medicare's accountable care organizations saved the program a record $2.4 billion in 2024.
Education has the same structure. A school paid by the hour is built to produce hours. A student loan pays the school in full whether or not the student learns. The medical story says a huge, regulated system can change what it pays for.
What would the education version need? Someone has to measure what a person can do, and the measure has to be trusted. That's why proof of skill matters. Without a credible record of what a person can do, there's nothing to pay for. With one, a funder can reward the school, the program or the employer that gets people there.
Think of it as the second door again. Build the measure beside the old gate first, and the money has somewhere to go.
If you fund, run or choose a program, ask what it's paid for. If the answer is enrollment or hours, ask what would change if some of the money followed a result a person can show.
The shift in medicine is slow and uneven. The Congressional Budget Office found the government's first decade of payment experiments cost more than they saved (September 2023). Education isn't medicine, and paying for results can create its own gaming, which is Goodhart's Law at work. That's why the measure has to be recorded, appealable and open to check.
Medicine is moving from paying for each service to paying for whether patients get healthier, which shows that a huge, regulated system can change what it pays for.
School is funded and measured by hours in a seat, so hours are what it is built to produce.
Nobody has to tear the old gate down. Build a second way in beside it, based on proof of skill, and let people walk through.