This analysis was prepared by Venable, LLP on behalf of AACOM.
House Judiciary Subcommittee on Administrative State, Regulatory Reform, and Antitrust
“The MATCH Monopoly: Evaluating the Medical Residency Antitrust Exemption”
May 14, 2025
WITNESSES
Dr. James Lin, Geriatric Medicine Specialist, Clinical Professor, and President, Lake Erie College of Osteopathic Medicine Institute for Successful Living (LECOM) | testimony
Sherman Marek, Attorney and Principal, Marek Health Law | testimony
Thomas Miller, Senior Fellow, American Enterprise Institute | testimony
William B. Feldman, M.D., D.Phil., M.P.H. Associate Physician, Division of Pulmonary and Critical Care Medicine Faculty, Program On Regulation, Therapeutics, And Law (PORTAL) | testimony
OPENING STATEMENTS
Subcommittee Chairman Scott Fitzgerald (R-WI-05) opened by criticizing the Accreditation Council for Graduate Medical Education (ACGME) for controlling where Americas doctors apply for residency calling them a “single accreditation monopoly,” along with “the Match,” as the single hiring system. Fitzgerald noted that there had been a previous attempt to challenge this arrangement under antitrust laws, but Congress instead installed an antitrust exemption for graduate medical resident matching programs. Fitzgerald went on to criticize the system for not allowing competition and not allowing negotiation of pay and forcing applicants to accept whatever slot they receive if they match. Fitzgerald added that the Match system discourages doctors at a time when they are needed most, due to many applicants not receiving a slot, and therefore, not being able to become a licensed doctor. Fitzgerald also criticized the system for forcing doctors to choose high paying specialties instead of primary care. Fitzgerald also argued that the need for an ACGME accreditation limits the number of residencies possible as doctors must graduate from an ACGME accredited school to practice medicine and without that accreditation, programs lose access to billions of dollars in Medicare and Medicaid funding. This specifically hurts rural programs. [Emphasis added.]
Ranking Member Jerrold Nadler (D-NY-12) called the hearing “beside the point” and used the first part of his opening statement to criticize the cuts to HHS (Department of Health and Human Services) proposed by President Trump and described how the cuts to research funding and attacks from President Trump towards universities would do nothing but harm researchers. Nadler then explained that there are valid issues with the Match program to consider, including issues concerning salary, hours, working conditions, etc., and praised collective bargaining, which has led to 20 percent of the resident physician workforce becoming unionized. Nadler also explained that the Match program was created in 1952 to solve problems in the placement process that were created by unfettered market competition. Nadler explained that before the Match was instituted, residency programs competed to make offers earlier and earlier to preempt other programs. This resulted in students receiving limited time offers as early as the beginning of their junior year of medical school when they had limited exposure to clinical practice before they had done rotations. Nadler then shut down claims that foreign students are taking residency slots from Americans, and instead advocated for increasing residency slots.
Dr. James Lin used his opening testimony to discuss what he described as the “increasingly detrimental impact of ACGME standards on the sustainability of medical residency fellowship programs in rural and underserved areas.” Lin then criticized ACGME for causing LECOM Graduate Medical Education programs to be dismantled due to “arbitrary urban centric inflexible accreditation policies.” Lin called out the ACGME for creating accreditation criteria tailored towards high-resource university hospitals, not for the realities of rural health systems. For example, the LECOM Orthopedic Surgical Residency Program, despite positive outcomes, premier training partnerships, and high board pass rates, was closed due to inflexible rules about program mix and rotation supervision that displaced residents, disrupted their careers, and stripped Erie County of essential orthopedic care. Lin then noted that the loss of a residency program is directly tied to reduced patient access today and said that without local training opportunities, DOs and candidates face increasing exclusion from competitive specialties due to documented disparities in the Match. Lin then added that rural systems and urban underserved are left with workforce shortages, longer wait times, and higher recruitment costs. Lin concluded by proposing some solutions: revise accreditation criteria; modernize standard to allow flexibility in rural and consortium-based models; support diversity review committees which ensure rural osteopathic educators have a voice in shaping specialty standards; create an alternative accreditor; promote innovative training track models specifically designed for rural and urban underserved areas; streamline administrative burdens; shift focus from bureaucratic checklists to actual outcomes in training and patient care; protect federal investments; and align ACGME’s definition with federal and rural health policies to avoid undermining HRSA’s support initiative.
Sherman Marek began by sharing that the 2004 Match Antitrust Exemption was created to stop a lawsuit he had filed in 2002 on behalf of medical residents. According to Marek, the exemption protects market distortions, undermines free market principles, limits personal freedom and choice, prevents normal employment negotiations, shields wage suppression, and contributes to the nationwide physician shortage. Additionally, because when residents leave their program are usually unable to go to another program, taxpayers generally lose their entire investment in that resident (Medicare pays hospitals $150,000 to $180,000 annually for each one). Marek then listed additional harms he has seen after the exemption was instituted, including artificially suppressed wages for residents, long work hours dangerous to patients, wasted taxpayer funds, disadvantaged recruiting for rural programs, and a worsening nationwide physician shortage. Marek then argued that removing the exception would dismantle the Match program, but simply allow the courts to decide its legal merits fully and fairly.
Thomas Miller criticized the implementation of the antitrust exemption, which he described as “unusual.” Miller then argued that at a “minimum, this subcommittee and the current Congress should seriously consider ways to limit, if not repeal, the current antitrust exemption, and it certainly should review it extensively for the first time in over 20 years.” Miller then described the Match program as solving non-issues and delivering, “efficient sorting of bounded preferences, finality, and fewer unfilled positions.” Miller then suggested various incremental changes since he believes a singular focus on antitrust law will not solve all the problems of physician labor markets nor the issues of cost, quality, or access to care. These are things Miller argued that policymakers can address through a broad inventory of tools that help the initial supply of new physicians but also facilitate how all health care providers can deliver more accessible, effective, and affordable care. This is all while keeping in mind the rights of states to take their own actions.
William B. Feldman used his testimony to argue against popular narratives for why the exemptions should be eliminated. First, Feldman argued that the Match is not the bottleneck in the physician shortage, but rather the issue is the need for more residency slots, which would require increased additional funding from Medicare and Medicaid and the hospitals themselves. Feldman also called for increasing the amount of international medical graduates in the workforce. On residency wages, Feldman argued that there are other successful ways to increase salaries including collective bargaining, without eliminating the Match and causing disruption. Feldman then listed multiple ways he felt Congress could facilitate more support for residents including increasing CMS (Centers for Medicare & Medicaid Services) funding of residency programs and supporting the right to unionize, to setting minimum salary floors and implementing more generous loan forgiveness programs. Feldman then concluded by calling President Trump’s budget proposed cuts to HHS as the biggest threats to medical education, residency Match, and the overall practice of medicine.
QUESTION AND ANSWER
Rep. Darrell Issa (R-CA-48) immediately criticized Feldman for going overtime to “rant,” against President Trump. Issa then asked Marek if it was true that the federal government essentially pays more for residents than they receive. Marek agreed with this assessment. Issa than expressed disbelief at Feldman’s claim that this disparity in payment is the fault of the Trump Administration. Miller agreed with this and then explained that there is no correlation between federal funding and the supply of physicians and that while Congress could change the rules and make it more targeted to incentivize the expansion of certain types of physicians or other areas, the money goes to certain favored parties over time. It is not allocated on a need basis. Issa then asked Lin if he felt unions were the solution or if markets were. Lin chose markets as the answer for rural communities and said that artificial inflation of wages through a union would be detrimental. Issa then asked Miller if Congress should make it clear that the selection process enjoys an antitrust exemption, but all other aspects of the process should never have enjoyed an antitrust exemption, to which Miller agreed.
Ranking Member Rep. Nadler first asked Feldman if he would like to defend himself from some of the claims from the previous questioning. Feldman clarified that additional funding refers to funding more physicians. Nadler then asked Feldman if he believed there was value in accounting for diversity in the provision of medical care. Feldman responded that he does believe there is value in accounting for diversity and that having classes with a diverse set of interests and backgrounds can help strengthen the medical care that doctors provide and can strengthen residency classes. Nadler then asked Feldman about what he feels would be the consequences if the Match was eliminated. Feldman answered that he is worried this would lead to a free-for-all that would make it harder for applicants. Nadler and Feldman then discussed anti-competitive practices in the pharmaceutical industry. Nadler and Feldman followed up and discussed the current policies the administration is taking towards research grants and foreign students.
Rep. Ben Cline (R-VA-06) first asked Lin if he believed the ACGME should be in the business of forcing programs to hire residents based on race or gender instead of merit. Lin responded that he does not believe ACGME should impose its will on individual programs, but that as of May 9th, the ACGME has suspended its common standard for DEI practices. Cline then asked Miller if removing the medical residency antitrust exemption would make the market more competitive. Miller responded that it would help, but he would not exaggerate its effects. Cline then asked Miller what issues he sees with state medical licensing boards rubber stamping monopolistic conduct like that of the ACGME. Miller responded that, in general, programs that encourage an anti-competitive atmosphere are being carved back. Cline then asked how creating an alternative certification process for Medicare and Medicaid funding would loosen the ACGME's power over the medical residency market. Miller responded that there is always room for competition that would increase supply – something much needed when there is a shortage.
Rep. Hank Johnson (D-GA-04) called this hearing an “outgrowth of MAGA Republican ongoing attacks on science and research” and then criticized the proposed cuts from the Trump Administration. Johnson then asked what the impact would be if this country lost international medical graduates. Feldman responded that it would be devastating as international graduates often serve in rural communities, in primary care roles, and help solve the physician shortage. Johnson then asked Feldman why programs would be impacted if Congress increased funding for residency programs through CMS rather than trying to cut funding for those programs. Feldman answered that he believes there is a need to increase funding because there is a physician shortage and the best way to solve this issue is in part through more positions.
Rep. Harriet M. Hageman (R-WY-01) gave Miller the opportunity to speak on some of the claims from the previous questioning. Miller argued that supplying more money is not the solution to the physician shortage problem. Hageman then asked Lin if it is difficult for rural hospitals to meet ACGME's accreditation requirements. Lin responded yes and noted some of those challenges include distance radius. Lin suggested a solution based on what they previously did, which was follow an alternative accreditation body that supported a consortium model and allowed rural hospitals to leverage each other’s strengths. Hageman then asked Miller if he believes placing qualifications on job positions that are not based on merits, such as the DEI requirements, exacerbates the shortage. Miller called for more focus on what physicians are doing at the point of care and what they're producing, as opposed to any other “ancillary considerations.” Hageman then asked Miller how far back harm from the ACGME towards his clients and other medical students goes. Marek responded, back to 1952.
Rep. Chuy García (D-IL-04) described the exemption for the Match as having multiple pros and cons including the Match limiting candidate choices and the lack of the ability to negotiate pay or benefits but also noted the potential for elimination of the exemption to worsen outcomes for medical residents. García then asked Feldman if repealing the exemption could inadvertently benefit the most well-resourced hospitals, medical schools, and residency programs. Feldman responded that it could due to the potential of insiderism (those with well-resourced applicants with well-resourced mentors who are connecting with well-resourced institutions). García then echoed criticisms his colleagues had about the proposed budget cuts from the Trump Administration, as well as called for focus on other, more pressing, anticompetitive practices in the health care field.
Rep. Bob Onder (R-MO-03) waived on to the committee and first asked Li about LECOM losing its program director and later its general surgery program due to non-compliance with the ACGME’s COVID-19 vaccination policy. Lin then explained that since the merger of ACGME and AOA, approximately 670 programs have closed and disproportionately, it's always the smaller community program that is not as resourced as the tertiary care center or a university-based center that can't meet the standards that are getting shut down. Onder then also asked about the ACGME’s DEI policy, which Lin confirmed had been paused. Onder followed this up with his concern that even with this being paused or ended, various institutions already have a staff member whose focus is on enforcing these policies and may continue doing this work.
Ranking Member of the full committee Jamie Raskin (D-MD-08) asked Feldman to speak to the direct effects of the large budget reductions proposed by the Trump Administration on health care delivery and on the progress of health care research. Feldman responded that the effects would be drastic and reduce the number of breakthrough therapies of game-changing therapies that patients would see in the future. Raskin and Feldman then continued to discuss various effects on disease research as well as the consequences of cutting Medicaid.
Rep. J. Luis Correa (D-CA-46) asked what the downsides are of the Match system. Feldman responded that some issues include the inability to negotiate salaries or benefits directly with institutions. Correa then asked if the solution was money, and then noted that some funding for residency positions comes from Medicaid – something Republicans are looking to cut. Feldman repeated his previous answer which was, more residency slots are needed and added that cuts to Medicaid are counterproductive and will hurt populations that rely heavily on Medicaid (inner city, rural areas, farms, Midwest). Feldman then called for more incentives for primary care doctors to serve in underserved communities including rural communities. An example of an incentive Feldman provided was loan forgiveness.