THE DEATH SPIRAL DIARIES
WHY MEDICARE FOR ALL IS THE ONLY PRESCRIPTION AMERICA HASN'T TRIED YET
Or: How We Spent Twenty-Five Years Letting Billionaires Fix Healthcare With a Hammer — and Are Surprised the House Still Has No Roof
Let us begin with a bedtime story.
Once upon a time, a chorus of Very Serious People — hedge fund managers, insurance executives, think-tank scholars funded by foundations named after hedge fund managers and insurance executives — stood before the American public and made a solemn promise: Let the market handle it. Competition, they said, would drive down costs. Innovation, they insisted, would deliver efficiency. The invisible hand of private enterprise, they assured us with straight faces and very expensive ties, would deliver better healthcare, cheaper and faster, than any clunky government program ever could.
That was roughly 1993. We are now $5.3 trillion into proving them wrong.
ACT ONE: THE PREMIUM DEATH SPIRAL, OR, HOW TO BOIL A FROG IN A BUDGET SPREADSHEET
New Jersey's school employees didn't wake up one morning to find their health plan in crisis. The crisis arrived the way Hemingway described bankruptcy: gradually, then all at once.
The School Employees' Health Benefits Program (SEHBP) is now staring down proposed premium hikes of 34% to 39% for active school workers in 2027. Thirty-four to thirty-nine percent. To put that in terms a school board treasurer might appreciate: that is not a budget line item. That is a Category 4 hurricane wearing a spreadsheet as a disguise.
The mechanism is elegant in its cruelty. It is what actuaries call an insurance death spiral, and it works like this:
Healthy, low-cost school districts look at their premiums, do the math, and quietly slip out the back door to buy cheaper private-market coverage. Sensible! Rational! Also, catastrophically destructive to everyone left behind. Because when the low-risk groups flee, what remains is a pool of workers who — through no fault of their own — happen to be older, sicker, and more expensive to cover. Premiums rise to compensate. More districts flee. Premiums rise again. Repeat until the plan collapses under its own weight, leaving state legislators scrambling and actuaries sending each other very grim emails.
This is not a bug in the privatized managed care system. This is the feature. Adverse selection is the engine. The entire architecture of for-profit health insurance is built around the proposition that the insurance company should be rewarded for insuring people who don't really need insurance, and subtly — or not so subtly — punished for covering the ones who do.
The billionaires who promised us market efficiency forgot to mention that the market's efficiency is directed entirely at extracting profit, not delivering care.
ACT TWO: THE NUMBERS THAT THE "FREE MARKET" CROWD WOULD PREFER YOU NOT STARE AT TOO LONG
In the year 2000, the United States spent approximately $1.4 trillion on healthcare — roughly 13.3% of GDP. Costly, yes. Unsustainable, perhaps. But manageable.
Today? National health expenditures have blown past $5.3 trillion, accounting for 18% of the entire American economy. We are spending nearly one dollar in five on a system that still manages to leave tens of millions uninsured, rank dead last among peer nations on key health outcomes, and generate enough prior authorization paperwork to mulch the Amazon basin.
For state governments, Medicaid — the program conservatives have spent four decades trying to strangle — has expanded from roughly 12-15% of state budgets in 2000 to over 20-25% today, now routinely challenging K-12 education as the single largest chunk of state general funds. Every dollar Medicaid consumes to patch the holes left by the private insurance system is a dollar not going to roads, or universities, or — and let's linger here — schools.
Which brings us to the teachers.
ACT THREE: THE DEMOGRAPHIC TRAP, OR, WHY INSURING TEACHERS IS A SPECIAL KIND OF ACTUARIAL NIGHTMARE
Public school teachers are, from a health insurance perspective, a statistically fascinating and commercially inconvenient population.
Consider the math. Roughly 74-77% of K-12 teachers are women — rising to nearly 89% in elementary schools. Women, on average, utilize healthcare at higher rates than men: more primary care visits, more preventative screenings, more behavioral health services, more maintenance prescriptions. This is not a knock on anyone. This is biology and the entirely rational behavior of people who were raised in a culture that encouraged them to actually see a doctor when something was wrong.
Now layer in the age profile. Over 60% of public school teachers are 40 or older, clustering heavily in their 40s and 50s — the years when knees start filing formal complaints, cardiovascular systems begin demanding management, and the orthopedic surgeons of America start sending thank-you notes.
Add the occupational stress load — 77% of teachers report finding their jobs chronically, intensely stressful, according to Pew — and you have a workforce that is generating significant mental health claims, physical therapy visits, and the kind of pharmaceutical spend that makes a pharmacy benefits manager's eye twitch.
Put this population into a closed, isolated risk pool — one that cannot dilute its demographics by hiring 10,000 twenty-four-year-olds next quarter — and you have created the ideal conditions for a premium death spiral. You have, in essence, built a system perfectly engineered to fail these workers.
And then you have charged the school districts to absorb it.
ACT FOUR: THE BUDGET SQUEEZE THAT NEVER MAKES THE HEADLINES
Here is what a 34-39% premium hike actually means in a school district that is already legally barred from running a deficit:
It means larger class sizes — because the cheapest line item to cut is the teacher you didn't hire yet.
It means fewer counselors — because mental health support is always optional until it isn't.
It means stagnant teacher salaries — because the district's total compensation budget is a fixed pie, and every slice eaten by a BlueCross premium is a slice not available for the teacher trying to afford rent in the district where she works.
It means, in the elegant language of economists, crowd-out: the relentless, compounding displacement of everything else public education is supposed to provide by the bottomless appetite of the American healthcare financing system.
This has been going on for a quarter century. The average annual district medical cost per teacher has risen from roughly $9,673 in the early 2000s to over $18,839 today — a 46-52% inflation-adjusted increase. During the same period, teacher salaries grew at roughly half that rate. Teachers didn't get poorer because their unions failed them. They got poorer because the money was diverted to UnitedHealth Group.
ACT FIVE: WHAT MEDICARE FOR ALL ACTUALLY DOES (SPOILER: IT ENDS THE SPIRAL)
Critics of Medicare for All — many of whom receive generous speaking fees from the insurance industry — tend to frame the debate as a question of can we afford it?
The correct question is: can we afford not to?
Because what single-payer Medicare for All does, structurally, is something no amount of tinkering with managed care networks can achieve: it abolishes the fragmented risk pool problem entirely.
There is no death spiral in a system where everyone is in the same pool. There is no adverse selection when there is no alternative plan to flee to. The 53-year-old veteran teacher with chronic back pain and a behavioral health prescription is no longer a catastrophic actuarial liability — she is simply one of 330 million Americans in a national pool that also contains millions of healthy 28-year-olds who haven't been to a doctor since the Obama administration.
The risk dissolves. The spiral becomes mathematically impossible.
For school districts, the transformation is equally radical. Instead of paying volatile, compounding, unpredictable premiums to private insurance corporations, districts would pay a stabilized payroll tax — one that tracks wages, not the whims of the specialty drug market or the latest hospital revenue capture AI. Budgets become predictable. The zero-sum competition between healthcare and classroom resources ends.
For teachers' unions, the implications are profound: health insurance disappears from the bargaining table entirely. All those years of concession bargaining — agreeing to flat wages just to prevent deductibles from doubling — become a historical curiosity. Unions get to bargain for what actually matters: pay, class sizes, prep time, support staff.
CONCLUSION: ON BILLIONAIRES, BROKEN PROMISES, AND THE LONG WAIT FOR THE OBVIOUS
The managed care revolution was supposed to save us. The HMO was supposed to be the efficient alternative to bureaucratic government medicine. The insurance marketplace was supposed to harness competition into lower premiums. The pharmacy benefit manager was supposed to control drug costs.
Instead, we got prior authorization forms that require a medical degree to complete. We got networks so narrow that your doctor is out of network but the hospital parking lot is in-network. We got GLP-1 medications that cost $1,000 a month in the United States and $89 in Canada. We got school districts choosing between teachers and insurance premiums.
The billionaire oligarchy that funded two generations of think tanks to oppose Medicare for All did not suffer from these outcomes. They never do. The executives of UnitedHealth Group are not waiting for prior authorization. They are not choosing between their child's school supplies and their family deductible. They are not teaching 35 kids in a classroom because the district couldn't afford to hire.
Medicare for All is not a radical idea. It is the obvious solution hiding in plain sight behind thirty years of very expensive lobbying. Canada has it. Germany has it. Every peer nation we compete with economically has figured out that a healthy workforce is a productive workforce, and that the administrative overhead of 1,500 competing insurance billing systems is not, in fact, efficiency.
It is time to stop calling the ambulance a death panel and start calling the system what it actually is: a premium extraction machine that has been strip-mining school budgets, suppressing teacher salaries, and delivering inferior health outcomes for a generation — all while making a small number of people extraordinarily wealthy.
The prescription is not complicated. It never was.
Medicare for All.
The only question left is who benefits from our delay in filling it.
Previously on Big Education Ape: THE PROFITCARE PARADOX | DEMOCRATIC MEDICARE FOR ALL VS. REPUBLICAN DON'T CARE AT ALL | "WELL, THERE YOU GO AGAIN" | GROUNDHOG DAY AT THE CAPITOL
SOURCES & LINKS
The Death Spiral Diaries: Why Medicare for All Is the Only Prescription America Hasn't Tried Yet
THE NEW JERSEY SEHBP DEATH SPIRAL
- NJEA — "NJEA Urges Swift Legislative Action Following Proposal of 2027 Health Insurance Rates" (July 2026)
Primary source on the 34–39% proposed premium hikes for active school employees.
https://www.njea.org/njea-urges-swift-legislative-action-following-proposal-of-2027-health-insurance-rates/ - New Jersey Monitor — "Health Benefit Premiums for NJ School Workers Expected to Rise by 34%" (July 2026)
Detailed reporting on the SEHBP Commission hearing and Aon actuary findings, including the "death spiral" mechanism and Joe Tappe's testimony.
https://newjerseymonitor.com/briefs/health-benefits-nj-school-workers-rise/ - ROI-NJ — "School Employees Health Benefits Plan Facing Double-Digit Premium Rate Hikes for Plan Year 2027" (March 2026)
Early reporting on the structural outmigration problem and prescription drug cost drivers.
https://www.roi-nj.com/2026/03/26/healthcare/school-employees-health-benefits-plan-facing-double-digit-premium-rate-hikes-for-plan-year-2027/ - Insider NJ — "Treasury: School Employees Health Benefits Plan Midyear Projections Indicate Likely Double Digit Premium Rate Increases for Plan Year 2027" (March 2026)
Official NJ Treasury/Aon actuary report. First use of "death spiral" language in government communications.
https://www.insidernj.com/press-release/treasury-school-employees-health-benefits-plan-midyear-projections-indicate-likely-double-digit-premium-rate-increases-for-plan-year-2027/ - New Jersey Monitor — "Public Worker Health Plans Poised for Another Year of Premium Hikes" (July 2026)
Follow-up on stop-gap legislative response by Gov. Sherrill.
https://newjerseymonitor.com/2026/07/08/public-worker-health-plans-poised-for-another-year-of-premium-hikes/ - The Daily Princetonian — "Rising Health Insurance Costs Strain Local Government Budgets in New Jersey" (April 2026)
Ground-level district impact, including Princeton Public Schools' 15.2% private-market premium increase vs. SEHBP's 31.9%.
https://www.dailyprincetonian.com/article/2026/04/princeton-news-broadfocus-rising-benefits-provide-costs-public-health
NATIONAL HEALTHCARE SPENDING: $5.3 TRILLION & 18% OF GDP
- Centers for Medicare & Medicaid Services (CMS) — National Health Expenditure Data: Historical
Official federal source. U.S. health spending reached $5.3 trillion in 2024, accounting for 18.0% of GDP.
https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical - Peterson-KFF Health System Tracker — "How Has U.S. Spending on Healthcare Changed Over Time?" (Updated February 2026)
Longitudinal data on per-capita spending growth, GDP share trends, and prescription drug cost acceleration.
https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/ - Peterson-KFF Health System Tracker — "How Much Is Health Spending Expected to Grow?" (Updated 2025)
Projects healthcare reaching 18.6% of GDP in 2026, rising to 20.3% by 2033.
https://www.healthsystemtracker.org/chart-collection/how-much-is-health-spending-expected-to-grow/ - Peter G. Peterson Foundation — "Healthcare Spending Will Be One-Fifth of the Economy Within a Decade" (November 2025)
Projects $8.6 trillion in national health expenditures by 2033.
https://www.pgpf.org/article/healthcare-spending-will-be-one-fifth-of-the-economy-within-a-decade/ - Health Affairs — "National Health Expenditure Projections, 2024–33"
CMS Office of the Actuary's official projections. Health spending expected to average 5.8% annual growth, outpacing GDP.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.00545
MEDICAID'S GROWING SHARE OF STATE BUDGETS
- Peter G. Peterson Foundation — "Budget Explainer: How Do States Pay for Medicaid?" (July 2025)
Medicaid grew from 20.5% of state budgets in 2008 to 29.8% in 2024 — now the single largest state expenditure category.
https://www.pgpf.org/article/budget-explainer-how-do-states-pay-for-medicaid/ - The Pew Charitable Trusts — "The Share of State Budgets Spent on Medicaid Posts Largest Annual Increase in 20 Years" (June 2025)
FY2023 saw the biggest single-year Medicaid budget share increase in two decades — 15.1% of every state-generated dollar.
https://www.pew.org/en/research-and-analysis/articles/2025/06/16/the-share-of-state-budgets-spent-on-medicaid-posts-largest-annual-increase-in-20-years - National Association of Medicaid Directors — "Top Five Medicaid Budget Pressures" (2025)
Confirms Medicaid at 29.8% of total state spending in FY2024, second-largest general fund expenditure after K-12 education.
https://medicaiddirectors.org/resource/top-five-medicaid-budget-pressures-for-fiscal-year-2025/
TEACHER DEMOGRAPHICS: THE ACTUARIAL CASE
- Pew Research Center — "Key Facts About Public School Teachers in the U.S." (September 2024)
77% of K-12 public school teachers are women; cites NCES 2020-21 data.
https://www.pewresearch.org/short-reads/2024/09/24/key-facts-about-public-school-teachers-in-the-u-s/ - National Center for Education Statistics (NCES) — "Characteristics of Public School Teachers"
Official federal teacher demographic data. Confirms gender distribution and educational attainment trends.
https://nces.ed.gov/programs/coe/indicator/clr/public-school-teachers - Women In Academia Report — "Women Make Up More Than Three Quarters of All Teachers in K-12 Schools" (December 2022)
76.8% of public school teachers are women; nearly 90% in elementary schools.
https://wiareport.com/2022/12/women-make-up-more-than-three-quarters-of-all-teachers-in-k-12-schools/ - National Education Association — "Who Is the Average U.S. Teacher?"
NEA synthesis of NCES data on teacher demographics, including gender breakdown and salary satisfaction.
https://www.nea.org/advocating-for-change/new-from-nea/who-average-us-teacher
TEACHER STRESS & BURNOUT DATA
- K-12 Dive — "11% of Teachers 'Very Likely' to Look for a New Job as Stress Mounts" (April 2024)
Cites the 2023 Pew survey of 2,531 teachers: 77% report their job is frequently stressful, 68% call it overwhelming.
https://www.k12dive.com/news/teacher-stress-pew-survey/712274/ - RAND Corporation — "Findings from the 2023 State of the American Teacher Survey"
Multi-year tracking of teacher job-related stress, burnout, and coping difficulty.
https://www.rand.org/content/dam/rand/pubs/research_reports/RRA1100/RRA1108-8/RAND_RRA1108-8.pdf
MEDICARE FOR ALL: EDUCATION UNIONS & SCHOOL BUDGETS
- National Education Association — "The Education Case for Single-Payer Healthcare Systems" (Updated May 2026)
Key NEA analysis: switching to Medicare for All would save Springfield, MA $9.6 million — enough for 128 new educator positions. Covers the Labor Campaign for Single Payer and recent local union endorsements.
https://www.nea.org/nea-today/all-news-articles/education-case-single-payer-healthcare-systems - American Federation of Teachers — "Endorsing H.R. 676: Single-Payer Universal Healthcare"
AFT's formal resolution endorsing Medicare for All legislation.
https://www.aft.org/resolution/endorsing-hr-676-single-payer-universal-healthcare - Jacobin — "Why Did Labor Leaders Vote Against Medicare for All in the Middle of a Pandemic?" (July 2020)
Covers the 2019 AFT, NEA, and SEIU endorsements of Jayapal's Medicare for All Act, and the subsequent tensions at the 2020 Democratic platform negotiations.
https://jacobin.com/2020/07/democratic-party-platform-medicare-for-all-unions - Insider NJ — "NJ Unions and Labor Groups Call on Rep. Andy Kim to Co-Sponsor Medicare for All" (August 2022)
New Jersey-specific labor coalition statement on healthcare concession bargaining and single-payer.
https://www.insidernj.com/press-release/nj-unions-and-labor-groups-call-on-rep-andy-kim-to-co-sponsor-medicare-for-all-in-congress/ - Unions for Single Payer — Union Endorser List
Full list of 22 national/international unions endorsing H.R. 676, including NEA, AFT, SEIU, AFSCME.
https://unionsforsinglepayer.org/union_endorsers/
BEA BACKGROUND & RELATED EDITORIAL COVERAGE
- Big Education Ape — "The Profitcare Paradox: How America's Healthcare System Became a Billionaire's Playground and a Patient's Nightmare" (December 2025)
https://bigeducationape.blogspot.com/2025/12/the-profitcare-paradox-how-americas.html - Big Education Ape — "Democratic Medicare for All vs. Republican Don't Care at All" (December 2025)
https://bigeducationape.blogspot.com/2025/12/democratic-medicare-for-all-vs.html - Big Education Ape — "'Well, There You Go Again': A Tragicomic History of America's Eternal Healthcare Debate" (November 2025)
https://bigeducationape.blogspot.com/2025/11/well-there-you-go-again-tragicomic.html - Big Education Ape — "AFT and Medicare for All — Randi Weingarten" (September 2019)
https://bigeducationape.blogspot.com/2019/09/aft-and-medicare-for-all-randi.html - Big Education Ape — "Groundhog Day at the Capitol: Republicans Unveil Yet Another 'Concept' While 20 Million Americans Lose Coverage" (January 2026)
https://bigeducationape.blogspot.com/2026/01/groundhog-day-at-capitol-republicans.html




