Abdul El-Sayed is among America’s most prominent proponents of Medicare-for-all. 

The frontrunner in Michigan’s Democratic Senate primary literally wrote the book on that policy (or at least, a book on it). In El-Sayed’s view, Medicare should cover “all necessary healthcare” for every American — without co-pays, premiums, or deductibles — and be “accepted everywhere.”

Alas, despite his many years of advocacy, El-Sayed has seemingly failed to persuade his wife of that last point: According to a recent report from the Washington Free Beacon, El-Sayed’s partner, the psychiatrist Sarah Jukaku, does not accept Medicare as a form of payment at her private practice.

This bit of gossip is of little importance, in and of itself. The Free Beacon’s story does nothing to refute the case for El-Sayed’s candidacy or his healthcare plan (his wife’s business is, well, her business). As hit pieces go, it’s weak tea.

Nevertheless, the tension between El-Sayed’s healthcare proposals and his wife’s business practices is real. And it is illustrative of a major challenge facing anyone who wishes to reform our nation’s misbegotten healthcare system: To meet the medical needs of all Americans, reformers will need to defy the interests of most doctors — and in many cases reduce their compensation. 

And that won’t be easy. Few people feel a deep fondness for insurance companies. But El-Sayed is far from the only American who loves a physician.

The biggest obstacle to Medicare-for-all

To understand why Medicare-for-all would be bad news for many doctors — and how the Free Beacon’s story illustrates that point — we must first dwell on one fundamental fact about America’s healthcare system: It’s a rip-off. 

The US spends about twice as much per person on medical goods and services as other wealthy countries. And yet, all that money does not actually buy us much more care. Compared to our peers abroad, Americans are less likely to see a doctor, secure a long hospital stay, or access a timely appointment for medical treatment. On the other hand, we do have the privilege of paying radically higher healthcare prices.

To take just one telling example: In the United States, a coronary bypass surgery will typically cost more than $89,000; in Australia, it costs just $17,741.

Such exorbitant prices are the chief obstacle to any version of universal healthcare. Even with one-third of working-age Americans uninsured or underinsured — and thus, consuming too little medical care — the bill for America’s health sector ran to $5.7 trillion in 2025. 

In El-Sayed’s vision, Americans would consume vastly more medical services than they do today: The uninsured would suddenly have access to every doctor in the country, while everyone else would see their co-pays and deductibles drop to zero, encouraging them to schedule far more doctors’ visits.

This would be a costly proposition in any country. At America’s current healthcare prices, it would be prohibitively expensive. There is simply no way to realize anything approaching the left’s healthcare ambitions without slashing the amount of money that Americans pay per medical service. 

Doctors will pay a price for universal healthcare

Medicare-for-all advocates are aware of this fact. And they’re typically eager to talk about one source of America’s high healthcare prices: The inefficiencies of our private health insurance model. 

In America’s byzantine system, each insurer needs its own teams of auditors, claims reviewers, and myriad other specialists, while every major healthcare provider needs a horde of administrators to navigate the idiosyncratic rules of all these different insurance companies. Americans pay dearly for this bureaucratic bloat. By one estimate, our system’s administrative costs are $500 billion higher than they would be if the insurance industry was consolidated into a single public insurer. 

And yet, as large as that figure may seem, it still represents a fraction of America’s excess healthcare costs. The primary cause of our nation’s exorbitant medical prices is simpler than administrative redundancies: our healthcare providers charge exceptionally high rates.

Hospitals are the biggest culprits on this front. But physicians are also part of the problem.

According to a 2026 study from economists at the University of Chicago, Stanford, and the US Census Bureau, American physicians earn about twice as much as Canadian ones — and four times as much as Swedish doctors. 

Critically, this does not merely reflect America’s greater wealth or wage inequality. It is true that educated professionals of all kinds — financial analysts, lawyers, software engineers, etc. — earn more in the US than they do in other rich countries. But American doctors don’t just earn unusually high absolute incomes — they also occupy an atypically rarified place within their own country’s class hierarchy. About 42 percent of American specialty physicians are in the top 1 percent of their nation’s income earners. Among Canadian specialists, that figure is just 27 percent; for Swedish ones, it is 7 percent.

The main driver of these disparities is straightforward: America imposes fewer price controls on its healthcare sector than other nations do. 

And this is where Jukaku’s practice reenters the picture. 

The public parts of America’s insurance system — Medicare and Medicaid — pay rates that are only modestly above international norms. It is when American doctors bill private insurers — or the rich consumers of boutique medicine — that they really make bank.

As a result, top clinicians like Jukaku often decline to take Medicare. If you’ve got affluent patients beating down your door, accepting Uncle Sam’s rates just doesn’t pay.

Unless the government forces doctors and hospitals to swallow steep pay cuts, however, Medicare-for-all won’t pencil out. According to a widely cited 2018 analysis by the economist Charles Blahous, if a single-payer system kept provider payments constant, national health spending would rise by $3.25 trillion over a decade, even with administrative savings taken into account. By contrast, if all providers were forced to accept Medicare’s rates, health spending would actually fall by $2.05 trillion over the same period.

Soaking physicians is tough politics

Thus, there is a clear conflict between progressives’ healthcare ambitions and medical providers’ material interests. 

Yet the left is often reluctant to acknowledge this reality. El-Sayed tends to portray insurers as the sole economic beneficiaries — and political defenders — of America’s inequitable healthcare system. The fact that hospitals and doctors also profit off the status quo’s dysfunctions does not feature prominently in his rhetoric. To the contrary, El-Sayed suggested in 2020 that doctors like his wife are actually underpaid, even though American psychiatrists earn far higher salaries than their counterparts abroad. 

To be fair, progressives aren’t alone in eliding providers’ culpability. Virtually all Democratic politicians do the same. And not without reason. Politically speaking, it is one thing to denounce the greed of private insurers — the faceless bureaucracies standing between Americans and their desired treatments. It’s quite another to call for reducing the wages of doctors, men and women who perform laudatory work and enjoy widespread admiration. 

Precisely for this reason, however, reformers must grapple with healthcare providers’ investment in the current system. The American Medical Association (AMA), the lobby representing our nation’s physicians, was instrumental in killing past attempts to move toward single-payer. And at least some segments of the medical profession would surely mobilize against any contemporary Medicare-for-all bill that imposed substantial cost controls on the healthcare sector. What’s more, in doing so, they would be able to draw on a resource the private insurance industry lacks — the public’s trust.

How to make healthcare less expensive right now

There is no easy answer to the problems all this presents. But part of the solution is to chip away at providers’ payment rates where progressives already have the power to do so. This would not only help drive down costs for existing healthcare in the short term, an urgent priority all its own, but also would smooth the path to universal coverage in the long run.

That project can take many forms. One would be state-level payment regulations. In Maryland, hospitals receive the same rates, no matter whether their patients pay with Medicare, private insurance, or cash. And their budgets are also fixed, so that they aren’t able to milk fees out of unnecessary care. Rhode Island, meanwhile, caps the growth of its hospital reimbursement rates at the pace of overall inflation. Other states could follow their lead. 

But policymakers should also address the supply constraints that undergird American doctors’ high salaries. US physicians’ ability to command high pay doesn’t just reflect America’s weak cost controls but also a persistent shortage of working doctors. The US has roughly 2.7 physicians for every 1,000 of its residents; the average among comparable countries is 3.9, according to a Kaiser Family Foundation analysis.

In this context, forcing down doctors’ pay might seem perilous. After all, doing so would reduce young people’s incentive to pursue a medical career, potentially deepening the shortage. 

In reality, however, there is no dearth of qualified people who want to practice medicine in the US. We just don’t let many of them do so.

This is partly because American policymakers consciously sought to restrict the number of doctors in the country, beginning in the 1980s. As Robert Orr of the Niskanen Center explains, the US government issued a report in 1981 warning of an imminent “physician surplus” and recommending “immediate action to curtail both the domestic training of physicians as well as the admittance of those trained outside of the country.”

The report’s argument rested on false premises; it failed to anticipate that Americans’ demand for healthcare would rise sharply as they grew wealthier. Nonetheless, its recommendations were largely implemented: Federal support for medical-school scholarships was pared back while funding for residencies has been capped since 1997. 

At the same time, policymakers maintained high barriers to the immigration of fully-trained foreign doctors: Even physicians with years of experience, and credentials in nations with high medical standards, are typically required to complete a multi-year residency before being able to practice in the US.

Ending the federal freeze on residency funding will require congressional action. But states can immediately make it easier for foreign doctors to practice within their borders. In fact, Tennessee established a pathway for such physicians to ply their trade in the state, without having to repeat a residency, in 2023. And many states subsequently enacted similar reforms.

Removing the bottlenecks on America’s doctor supply won’t eliminate the political hurdles to Medicare-for-all. But it would put downward pressure on doctors’ salaries, reduce the risks of capping physician pay, and make the left’s vision of healthcare abundance more feasible. After all, you can’t actually eliminate the care rationing that so many Americans resent by extending insurance coverage or enacting price controls alone. No matter how we pay for our medical services, we can only deliver as much care as our health sector’s resources allow. 

Don’t hate the doctor, love the sick

In saying all this, I don’t mean to convey disdain for the medical profession. Like El-Sayed, some of my best friends are doctors! In fact, my mother, father, brother, and sister-in-law are all physicians. And they all have contributed far more to American society than I ever will. My brother spends his workdays providing lifesaving treatments to cancer patients; I often spend mine sitting at a desk in my pajamas, arguing about politics on the internet. 

Physicians deserve to be well-paid for their strenuous labor. But if we want healthcare in America to be universally affordable and widely accessible, we will need to pay many of them a bit less.

The Democratic Socialists of America say they are fighting for “a government by, for, and of the working class.” 

Yet the organization’s membership and candidates consist largely of educated professionals. As of 2021, 80 percent of DSA members over 25 were college-educated, while 28 percent earned more than $100,000 a year (putting them in roughly the top 15 percent of America’s income distribution), according to a DSA internal survey. Among the group’s most prominent politicians, meanwhile, is an Ivy League graduate student, a lawyer, and the well-educated son of a Hollywood director and famous academic. 

In recent weeks, as the DSA has racked up victories in Democratic primary elections, the apparent tension between the group’s self-conception and demographics has attracted critical scrutiny.

In the New York Times, Thomas Edsall argues that most of the DSA’s members and supporters in the electorate are “in no way working class.” The libertarian commentator Robby Soave, right-wing pundit Batya Ungar-Sargon, and liberal economics writer Noah Smith have all voiced similar sentiments. 

There are many cogent ways for socialists to respond to such criticism. One would be to note that an organization doesn’t need to have a uniformly working-class membership in order to fight for working-class interests. Another would be to observe that not all college graduates are well-heeled professionals, even as pundits often use educational attainment as a stand-in for class in political analysis. 

But some socialists prefer a simpler retort: The DSA’s critics are simply mistaken; in reality, the group’s membership is more or less entirely “working class” — because that term describes everyone who must sell their labor in order to meet their needs. 

This conception of the “working class” has deep roots on the left. As Jacobin’s Ben Burgis explains, orthodox socialists subscribe to a “two-class map of capitalist society,” in which “Some people are capitalists who own their own ‘means of production’ (like factories, farms, offices, or grocery stores) and other people work for the capitalists.”

Many contemporary socialists (including Burgis) find this dichotomy reductive, and endorse more nuanced portraits of America’s class structure. But the orthodox, “two-class” model informs a great deal of the modern left’s rhetoric, among both socialists and progressives. And the notion that lawyers and day laborers both belong to the “working class” is widely held among anti-capitalists. 

There’s something to be said for this idea. Educated professionals and manual workers surely do have some shared interests, due to their common status as laborers. For example, both benefit from the existence of a well-funded unemployment insurance system, in a way that the Elon Musks of the world do not. 

For the most part though, orthodox socialism’s “map” is badly out of date. And its expansive conception of “the working class” does less to illuminate modern America’s economic divisions than to obscure them.  

The long afterlife of Marx’s failed prophesies

Karl Marx and Frederich Engels laid the foundations for the modern left’s conception of class in The Communist Manifesto of 1848. 

In that book, the claim that there were just two important classes under capitalism — capitalists and workers — rested on a set of grim predictions about where industrialization was headed. 

According to Marx’s analysis, technological progress was in the process of obliterating “all distinctions” between different strata of working people, as automation was driving virtually everyone’s wages down to “the same low level.” The middle class of small manufacturers and shopkeepers, meanwhile, was poised to “decay and finally disappear,” as more productive, large-scale enterprises left them in the dust.

Society was therefore splitting into “two great hostile camps” — the capitalist and working classes, whose interests were impossible to reconcile. 

Under these conditions, a binary conception of class makes perfect sense. If all workers will soon be condemned to low wages, then there’s little point in dwelling on the (temporary) distinctions between them. Likewise, if shopkeepers and small-time capitalists have gone the way of the triceratops, one can more comfortably cast all business owners as members of the ruling elite.

You can’t navigate modern capitalism with a 19th-century map

But we don’t live in the future that Marx foresaw. 

Rather than melting all workers into a uniform proletariat, capitalism cultivated a kaleidoscopically diverse laborforce — one segmented by countless fine-grained distinctions of pay and prestige. And instead of immiserating ordinary people, industrial development brought unprecedented mass prosperity (albeit, with the aid of many socialistic reforms). 

As a result, old-school socialists’ “two-class map” makes for a poor guide to modern capitalism’s terrain. And anyone trying to impose Marx’s cartography onto the landscape will encounter several problems.

For one, in a world where some workers earn as much in a year as others do in a lifetime, the idea that there is only one fundamental class division — that between laborers and capitalists — becomes unconvincing. 

In the United States, some convenience store owners make $70,000 a year, while many surgeons earn upward of $600,000. It would be odd to say that the former are members of society’s dominant class (since they live off business income), while the latter belong to its subordinate one (since they live off salaries). After all, the minimart owner and Musk do not have especially similar material interests. Nor, for that matter, do the impoverished farmworker and high-earning neurosurgeon (much less, the superstar athlete with a $40 million salary). Yet this is what orthodox socialism’s binary would suggest. 

Ultimately, in a modern capitalist society, it makes a lot more sense to see class as a multidimensional continuum than as a binary.

A second, related difficulty is that the border between labor and capital has grown fuzzier since Marx’s time. Today, American workers often own both a home and some share of their nation’s financial assets, like a 401(k) filled with stock from major corporations. Many billionaires, meanwhile, choose to work. 

Socialists are well aware of this reality, which is why they define a person’s class status by their dependence on labor: The typical white-collar worker may own a little stock, but not enough to quit her job and live off dividends. Unlike a billionaire CEO, such a professional must work in order to meet her needs. 

This is a sound distinction. But it does not actually resolve the challenge of distinguishing the working class from the ruling one. This is because, in an advanced economy, whether someone “needs” to work is partly subjective. Millions of Americans survive on less than $25,000 a year in market income. If upper-middle-class families were willing to accept a similarly austere living standard, many would be able to live entirely off their investments.

Of course, Americans shouldn’t be content to live in poverty. But it is harder to say precisely what standard of living qualifies as “enough.” In Marx’s time, a relatively good life for a wage worker might have meant reliable access to food and shelter for one’s family and a little time and money left for simple leisure. Today, the list includes high-quality education for one’s children, access to advanced medical treatments, modern home appliances for cooking and cleaning, Internet-connected devices for entertainment, and often personal transportation, like a car — all of which are typically (and justifiably) treated as basic necessities.

This raises the question: At what level of wealth does a person stop needing to work — even if they must keep clocking in to achieve their desired lifestyle? The socialist writer Matt Bruenig has proposed drawing the line at about $1.4 million (or roughly 20 times America’s average wage): Once you’ve accrued that much in housing and financial assets, your decision to sell your labor becomes voluntary and you cease to be working-class. 

This is a reasonable cut-off. But it’s still fairly arbitrary. Ask an American with a net worth of $1.4 million whether they need to work, and they’re liable to say yes. And typically, they will be correct — at least, in the sense that they could not sustain their way of life without earning a paycheck. You could say that their present lifestyle is too lavish — and that $1.4 million in assets is all that’s required to generate the amount of income one truly needs. But it’s not obvious why this threshold doesn’t actually lie at $1.6 million, or $800,000, or $500,000.

As a result, the only way to draw the upper boundary on who “needs” to work — without making arbitrary judgments about what standard of living is necessary — is to place it extremely far up the class hierarchy: The superrich generally don’t need to choose between sustaining their lifestyles and abstaining from work. But once your definition of “working class” becomes capacious enough to include low-end multimillionaires, it loses all plausibility. 

Ultimately, in a modern capitalist society, it makes a lot more sense to see class as a multidimensional continuum than as a binary. An individual’s degree of economic freedom and power is determined by a host of factors — above all, their household incomes and net worths, but also the market value of their skills (which shapes their future earning prospects) and familial wealth and connections. Even one’s eligibility for social welfare benefits can matter; after all, the largest group of Americans who don’t need to work to meet their needs are Social Security recipients.

Precisely how we should weigh these different sources of advantage is a tricky question. And implicit disagreements over it shapes our discourse about “the working class.” 

Take Graham Platner, the former Democratic Senate candidate in Maine. To his champions, Platner was a working-class candidate, due to his lack of a college diploma, years of service in the military, and low-income, physically demanding job farming oysters (along with his gravelly voice and tattoos). To his detractors, meanwhile, Platner was a pseudo-proletarian due to his upper-middle-class childhood, prep school education, and receipt of steady financial help from his father and mother, a lawyer and entrepreneur. Meanwhile, Platner probably would not qualify as “working class” under the orthodox socialist definition for multiple reasons: For one, he does not need to work in order to get by, thanks to his disability benefits and family support. For another, he is the owner of his oyster business, rather than a salaried worker who answers to a boss. 

In any event, whichever factors one emphasizes, it’s clear that a person’s class privilege increases continuously as their income, net worth, familial wealth, and “human capital” rises. There is no single point on any of these scales past which a person’s class position is abruptly transformed. The gap between “the 99 percent” and the billionaire class matters — but so does that between the top 15 percent and the working poor.

Of course, in ordinary political discourse, we inevitably need to boil down reality’s intricacies into rough categories. No politician will ever promise to fight for the “bottom six deciles in combined SES score, nor will any labor activists ever chant, “The 30th to 60th percentiles in household income, united, will never be defeated.” 

But a taxonomy of classes with several subcategories (such as “the poor,” “the working class,” “the middle class,” “the upper-middle class,” “the rich,” and “the superrich”) will capture a bit more of reality than a taxonomy with only two. 

“Working-class” rhetoric can camouflage professional-class interests

All this said, even if orthodox socialism’s “two-class map” is analytically flawed, it could still be politically beneficial. Perhaps, when affluent professionals decide that they belong to the same class as the working poor, they become more inclined to fight for the latter’s interests. 

Some of the DSA’s own activities lend credence to this theory: Despite its largely white-collar membership, the organization advocates for many policies that would principally benefit America’s most disadvantaged. More broadly, in the wake of Occupy Wall Street, many college-educated millennials came to identify with “the 99 percent.” And as this cohort has grown more influential in Blue America, the Democratic Party has embraced more ambitious anti-poverty policies, such as a guaranteed monthly income for working-class families. 

The main fiscal barrier to American social democracy is that our middle class in general — and upper middle-class in particular — pays much lower taxes than their peers in Western Europe.

And yet, socialists’ expansive conception of “the working class” can be put to more dubious uses. Specifically, it can help relatively well-off professionals disguise their class’s particular interests as those of all working people.  

The left’s push to cancel all graduate student debt is arguably a case in point. During Joe Biden’s presidency, the DSA criticized the White House for attempting to forgive only $10,000 of most borrowers’ student loans (a plan that was ultimately blocked by the Supreme Court). Instead, the socialists called on Biden to cancel all student debt, including the balances accrued by the graduates of elite medical schools and MBA programs. 

On its face, the idea that the US government should transfer tens of thousands of dollars to young doctors and Harvard MBAs would seem wildly regressive. The median US physician can expect to earn more than $6.5 million over the course of their lifetime, while the median graduate of a top-five business school can expect to earn more than $8 million. Virtually all Americans have worse prospects than this. And in the inflationary conditions of the Biden era, increasing young professionals’ disposable income was liable to push up prices for everyone else. In other words, blanket student debt forgiveness would have likely transferred purchasing power from low-income workers to early-career physicians and management consultants.

Many socialists would struggle to defend such a policy, were it presented in these terms. But by eliding the class distinctions between low- and high-income borrowers,  the DSA was able to convince itself (if not the public) that across-the-board forgiveness was in the interest of “the working class.”

The socialist framework is similarly unhelpful in the realm of tax policy. 

In recent years, as socialist and progressive politicians have grown more dependent on professional class support, they’ve become more averse to endorsing broad-based tax increases.

From Zohran Mamdani to Chris Van Hollen, the Democratic left tends to reserve its tax hike proposals for the superrich. And yet, the reason that America lacks a comprehensive welfare state is not that our billionaires pay unusually little in taxes; to the contrary, our top rates are comparable to those of some Scandinavian countries. The main fiscal barrier to American social democracy is that our middle class in general — and upper middle-class in particular — pays much lower taxes than their peers in Western Europe. Simply maintaining our existing programs, like Social Security, will likely require a major tax increase on higher-end salaried workers. 

In this context, binary conceptions of America’s class structure — which pit an undifferentiated “working class” against the capitalist elite, or the 99 percent against the 1 percent — can help educated professionals evade responsibility for bankrolling a more egalitarian economic system.

Check your class privilege

Ultimately, the DSA’s ability to serve working-class interests hinges less on its own demographics than its policies and politics. When an organization mistakes the preferences of its most privileged members for those of all working people, however, its campaigning and policymaking is liable to suffer. 

Perhaps, before this century’s end, AI will bring about the calamity that Marx prophesied — and Ivy League lawyers and delivery drivers will find their skills equally devalued by an all-powerful ownership class. Until the robot apocalypse, however, educated professionals and low-wage workers will live in very different circumstances — and harbor distinct economic interests. To safeguard the wellbeing of the disadvantaged, well-off egalitarians need to mind these gaps, not paper over them with obsolete class categories.