    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                                     ______

        THE MATCH MONOPOLY: EVALUATING THE MEDICAL RESIDENCY ANTITRUST
                                   EXEMPTION

    =======================================================================

                                    HEARING

                                   BEFORE THE

       SUBCOMMITTEE ON THE ADMINISTRATIVE STATE, REGULATORY REFORM, AND
                                   ANTITRUST

                           COMMITTEE ON THE JUDICIARY

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                            WEDNESDAY, MAY 14, 2025

                                   __________

                               Serial No. 119-21

                                   __________

             Printed for the use of the Committee on the Judiciary

      GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

                   Available via: http://judiciary.house.gov

                             ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
     60-419            WASHINGTON : 2025

                           COMMITTEE ON THE JUDICIARY

                            JIM JORDAN, Ohio, Chair

    DARRELL ISSA, California             JAMIE RASKIN, Maryland, Ranking
    ANDY BIGGS, Arizona                      Member
    TOM McCLINTOCK, California           JERROLD NADLER, New York
    THOMAS P. TIFFANY, Wisconsin         ZOE LOFGREN, California
    THOMAS MASSIE, Kentucky              STEVE COHEN, Tennessee
    CHIP ROY, Texas                      HENRY C. ``HANK'' JOHNSON, Jr.,
    SCOTT FITZGERALD, Wisconsin              Georgia
    BEN CLINE, Virginia                  ERIC SWALWELL, California
    LANCE GOODEN, Texas                  TED LIEU, California
    JEFFERSON VAN DREW, New Jersey       PRAMILA JAYAPAL, Washington
    TROY E. NEHLS, Texas                 J. LUIS CORREA, California
    BARRY MOORE, Alabama                 MARY GAY SCANLON, Pennsylvania
    KEVIN KILEY, California              JOE NEGUSE, Colorado
    HARRIET M. HAGEMAN, Wyoming          LUCY McBATH, Georgia
    LAUREL M. LEE, Florida               DEBORAH K. ROSS, North Carolina
    WESLEY HUNT, Texas                   BECCA BALINT, Vermont
    RUSSELL FRY, South Carolina          JESUS G. ``CHUY'' GARCIA, Illinois
    GLENN GROTHMAN, Wisconsin            SYDNEY KAMLAGER-DOVE, California
    BRAD KNOTT, North Carolina           JARED MOSKOWITZ, Florida
    MARK HARRIS, North Carolina          DANIEL S. GOLDMAN, New York
    ROBERT F. ONDER, Jr., Missouri       JASMINE CROCKETT, Texas
    DEREK SCHMIDT, Kansas
    BRANDON GILL, Texas
    MICHAEL BAUMGARTNER, Washington
                                     ------

                   SUBCOMMITTEE ON THE ADMINISTRATIVE STATE,
                        REGULATORY REFORM, AND ANTITRUST

                       SCOTT FITZGERALD, Wisconsin, Chair

    DARRELL ISSA, California             JERROLD NADLER, New York, Ranking
    BEN CLINE, Virginia                      Member
    LANCE GOODEN, Texas                  J. LUIS CORREA, California
    HARRIET HAGEMAN, Wyoming             BECCA BALINT, Vermont
    MARK HARRIS, North Carolina          JESUS G. ``CHUY'' GARCIA, Illinois
    DEREK SCHMIDT, Kansas                ZOE LOFGREN, California
    MICHAEL BAUMGARTNER, Washington      HENRY C. ``HANK'' JOHNSON, Jr.,
                                             Georgia

                   CHRISTOPHER HIXON, Majority Staff Director
                      JULIE TAGEN, Minority Staff Director
                                C O N T E N T S

                                  ----------

                            Wednesday, May 14, 2025

                               OPENING STATEMENTS

                                                                       Page
    The Honorable Scott Fitzgerald, Chair of the Subcommittee on the
      Administrative State, Regulatory Reform, and Antitrust from the
      State of Wisconsin.............................................     1
    The Honorable Jerrold Nadler, Ranking Member of the Subcommittee
      on the Administrative State, Regulatory Reform, and Antitrust
      from the State of New York.....................................     3

                                   WITNESSES

    Dr. James Lin, President, Institute for Successful Living
      Oral Testimony.................................................     5
      Prepared Testimony.............................................     8
    Sherman Marek, Esq., Attorney, Principal, Marek Health Law
      Oral Testimony.................................................    18
      Prepared Testimony.............................................    20
    Thomas Miller, Senior Fellow, American Enterprise Institute
      Oral Testimony.................................................    27
      Prepared Testimony.............................................    29
    Dr. William Feldman, Assistant Professor, Harvard Medical School
      Oral Testimony.................................................    49
      Prepared Testimony.............................................    51

              LETTERS, STATEMENTS, ETC. SUBMITTED FOR THE HEARING

    All materials submitted for the record by the Subcommittee on the
      Administrative State, Regulatory Reform, and Antitrust are
      listed below...................................................    72

    Materials submitted by the Honorable Jerrold Nadler, Ranking
      Member of the Subcommittee on the Administrative State,
      Regulatory Reform, and Antitrust from the State of New York,
      for the record
        An article entitled, ``More Medicare-supported GME slots
            needed to curb doctor shortages,'' Oct. 4, 2024, American
            Medical Association
        A statement from the Association of American Medical Colleges
            (AAMC), May 14, 2025
    Materials submitted by the Honorable Scott Fitzgerald, Chair of
      the Subcommittee on the Administrative State, Regulatory
      Reform, and Antitrust from the State of Wisconsin, for the
      record
        A statement from Jon R. Ward, MD, Board-Certified
            Dermatologist & Board-Certified Mohs Surgeon, May 14,
            2025
        A statement from Caleb C. Atkins, M.D., Family Medicine
            Resident, Watertown, New York, May 14, 2025
        A statement from the National Board of Physicians and
            Surgeons (NBPAS), May 14, 2025
        A statement from Jeffrey Singer, Senior Fellow, Health Policy
            Studies, CATO Institute, May 15, 2025

                                    APPENDIX

    A statement from the Accreditation Council for Graduate Medical
      Education, May 14, 2025, submitted by the Honorable Henry C.
      ``Hank'' Johnson, Jr., of the Subcommittee on the
      Administrative State, Regulatory Reform, and Antitrust from the
      State of Georgia, for the record

                              THE MATCH MONOPOLY:

              EVALUATING THE MEDICAL RESIDENCY ANTITRUST EXEMPTION

                                  ----------

                            Wednesday, May 14, 2025

                            House of Representatives

                   Subcommittee on the Administrative State,

                        Regulatory Reform, and Antitrust

                           Committee on the Judiciary

                                 Washington, DC

        The Subcommittee met, pursuant to notice, at 11:04 a.m., in
    Room 2141, Rayburn House Office Building, the Hon. Scott
    Fitzgerald [Chair of the Subcommittee] presiding.
        Present: Representatives Fitzgerald, Issa, Cline, Hageman,
    Schmidt, Nadler, Correa, Garcia, Lofgren, and Johnson.
        Also present: Representative Onder.
        Mr. Fitzgerald. The Subcommittee will come to order.
    Without objection, the Chair is authorized to declare a recess
    at any time.
        We welcome everyone to today's hearing on medical residency
    antitrust exemption.
        I will now recognize myself for an opening statement.
    Before I do that, I want to waive on, we have one Member, Mr.
    Onder, Dr. Onder, who will be waiving on to today's hearing.
        Without objection, Mr. Onder will be permitted to
    participate in this hearing to question the witnesses if a
    Member yields him time for that purpose.
        When America's future doctors apply for residency, they
    enter a closed market controlled by a single accreditation
    monopoly. The Accreditation Council for Graduate Medical
    Education (ACGME), and the centralized hiring system called the
    MATCH, quote, ``the MATCH, together those two gatekeepers
    dictate who trains, where they train, and at what wage.''
        Through mountains of red tape, the ACGME alone decides
    which programs survive and how they operate. Because most
    opportunities are filled through the MATCH, the algorithm
    wields unrivaled power over resident hiring. Twenty-three years
    ago, residents tried to challenge this setup under America's
    antitrust laws. They argued that the ACGME and MATCH, and the
    programs operating under them, colluded to restrict slots,
    limit choice, and keep wages low. Before the case could be
    heard Congress hightailed to the hospital lobby and slid an
    antitrust exemption for a graduate medical resident MATCHing
    programs into the unrelated pension bills.
        As a result, there's no competition now, and it decides the
    fate of more than 50,000 residents and fellows each year.
    Applicants cannot negotiate pay. They must accept whatever slot
    the algorithm hands them or whatever terms they are given.
        The command-and-control model eliminates competition and
    flattens salaries. Last year, the average first-year resident
    earned just $66,000. That's roughly $60,000 less than a
    physician assistant or a $100,000 less than a nurse
    practitioner, despite working long hours and holding more
    advanced credentials.
        The MATCH monopoly doesn't just pinch paychecks, it worsens
    the doctor shortage. Each cycle, thousands of graduates fail to
    match with the program. Last year alone, 8,869 applicants,
    about one in five were left without a slot. Because every State
    requires a residency to become a licensed doctor, those
    unmatched doctors can get a license or board certification.
    Thus, the MATCH acts as a bottleneck for the training of
    American physicians precisely when we need more doctors--not
    fewer. This oppressive process discourages smart young students
    from pursuing medical degrees. The squeeze also comes as
    America's population ages and demands more care.
        Today, over 77 million people already live in areas with a
    shortage of primary care doctors. That figure is projected to
    climb sharply in the years ahead. As a result of the monopoly
    power given to the teaching hospitals, our future doctors are
    not choosing primary care. Instead, they're turning to more
    specialized medicine hoping to more quickly recoup their
    investment with the higher salary in specialized practices like
    orthopedics, cardiology, and anesthesiology.
        According to Medscape's 2024 Physician Compensation Report,
    the average salary for a primary care physician in the United
    States is $277,000. By contrast, specialists earn an average of
    over $394,000. This leaves our communities with fewer family
    doctors, longer waiting times, and a decreased level of care.
        A second chokepoint is the ACGME's accreditation monopoly.
    The ACGME is the sole gatekeeper for the residency program
    approval in the United States. Without its blessing, programs
    lose access to billions of dollars in Medicare, Medicaid
    funding. Doctors must graduate from an ACGME accredited program
    to practice medicine. The organization uses that leverage to
    impose one-size-fits-all rules that crush community hospitals
    and rural programs. Many small rural residency programs have
    closed their doors under the weight of the costly mandates.
    When programs close, residents lose positions, and patients
    lose access to care.
        Two decades after Congress granted the carveout for this
    system, the market is more conclusive and less competitive than
    ever. Resident wages are completely stagnant. America is
    producing fewer practicing doctors even as demand for
    affordable high-quality care grows at a rapid pace.
        Today's hearing asks a simple question: Will the next
    generation of physicians train in a free market or under a
    government-sanctioned monopoly? Today's witnesses know this
    system firsthand. Their testimony will help the Committee
    understand the medical residency market and confront the
    anticompetitive fallout of the ACGME and the MATCH and their
    special interest exemption.
        I want to thank each witness for appearing before us today
    and look forward to your insights.
        I'll now recognize the Ranking Member, Mr. Nadler, for an
    opening statement.
        Mr. Nadler. Thank you, Mr. Chair.
        Mr. Chair, it's a little difficult to take seriously a
    hearing that Republicans bill as an effort to improve
    healthcare in this country when their colleagues in other
    Committees are busy gutting Medicaid and other programs, which
    will have a devastating impact on the health of millions of
    Americans.
        Apparently, Republicans think what really ails our
    healthcare system is that lower incomes Americans, people with
    disabilities, and children have too much healthcare. That is
    the only explanation because, of course, it couldn't just be a
    cynical ploy to fund massive tax cuts for billionaires on the
    backs of the most vulnerable among us.
        These same Republicans who claim they want to, quote,
    ``Make America Healthy Again,'' have remained silent while the
    Trump Administration systematically dismantles our entire
    public health infrastructure.
        Under the leadership of America's No. 1 vaccine skeptic and
    conspiracy theory promoter, Robert Kennedy, Jr., the Department
    of Health and Human Services has fired more than 20,000
    experts, eliminated entire agencies, deleted important datasets
    and public health tracking tools, and cut or threatened to cut
    billions of dollars in grants for scientific research.
        At the same time, the administration is waging an
    ideological war on institutions, such as universities and the
    National Institutes of Health, that develop the groundbreaking
    research that underpins most medical advances.
        The NIH alone has suffered a $1.8 billion cut and, by some
    estimates, as much as $2.7 billion. That will undoubtedly set
    back research into cancer treatments, infectious disease
    prevention, and much more by many years.
        Meanwhile, Republicans cheer as the Administration's
    immigration policies chase out foreign-born students and
    researchers and send a clear message to anyone abroad who might
    wish to bring their talents and innovation to our country,
    ``You are not welcome.''
        Taking collectively, these actions represent a dramatic
    effort to undermine, destroy, and limit healthcare research;
    access to critical health data; and access to care. The impact
    of these cuts will likely fall most deeply on marginalized
    communities, but we will all suffer the consequences.
        That is why today's hearing on the National Residency
    Matching Program seems beside the point. The healthcare system
    is facing an outright assault from the Trump Administration,
    and yet we are being called on to examine the Residency
    Matching Program.
        This is not to say that there are no issues related to the
    MATCH worth exploring in due course. Any valid criticisms of
    the program warrant appropriate consideration, whether they
    concern salary, hours, working conditions, or other matters
    that call out for refinement.
        As part of that revisiting, we can account for collectively
    bargaining, which has led to approximately 20 percent of the
    resident physician workforce becoming unionized. We should also
    recognize that the MATCH provides an effective system for
    placing more than 40,000 doctors a year across more than 6,500
    residency programs and tracks throughout every region of the
    country that suits the needs of both students and hospitals
    alike.
        It's important to remember that the MATCH was created in
    1952 to solve problems in the placement process that were
    created by unfettered market competition. Before the MATCH was
    instituted, residency programs competed with each other to make
    offers earlier and earlier so as 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. Attempts to delay the matching process
    by withholding student information until senior year led to
    exploiting offers with extremely short fuses. This system
    served no one, and the MATCH was created to address these
    market breakdowns.
        Over 70 years later, it is still largely working as
    intended, avoiding what would otherwise by chaos even as the
    needs of candidates and residency programs have evolved.
        While no system is perfect, many of the Republicans'
    criticisms simply do not hold up under careful scrutiny. For
    example, Republicans have taken aim at foreign doctors who
    enter the MATCH, arguing that they are displacing American
    students, but statistics show that 99 percent of all U.S.
    medical school graduates enter residency or full-time practice
    in the country within six years of graduation. There is simply
    little evidence to suggest that foreign medical school
    graduates are taking slots from U.S. residents.
        Rather than scapegoating immigrants, Republicans could
    address a real issue, the need for additional residency slots
    overall. That would take an investment in new funding from the
    Federal Government, and we have already seen where the
    Republicans priorities lie.
        Finally, if the majority wishes to address flaws in the
    healthcare system, they need only look at the important work
    this Subcom-
    mittee did under Democratic leadership. We examined issues
    related to consolidation and market concentration across the
    health-care industry, and we passed several pieces of
    legislation addressing the rising cost of prescription drugs.
    Many of these issues had bipartisan support, and there's much
    we can do together. Instead, Republicans want to distract us
    from their disastrous healthcare policies with a hearing on a
    minor issue. We can do better.
        I appreciate our witnesses for appearing today. I look
    forward to hearing from them. I yield back the balance of my
    time.
        Mr. Fitzgerald. The gentleman yields back. Without
    objection, all other opening statements will be included in the
    record.
        We'll now introduce today's witnesses.
        Dr. James Lin. Dr. Lin is a Clinical Professor of geriatric
    medicine at the Lake Erie College of Osteopathic Medicine, and
    the President of the LECOM Institute for Successful Living. His
    practice focuses on geriatrics, internal medicine, and primary
    care.
        Mr. Sherman Marek. Mr. Marek is the Founder of Principal
    Attorney at Marek Health Law, a Chicago-based firm that focuses
    on representing medical residents and disputes with teaching
    hospitals through internal appeals, administrative proceedings,
    direct negotiations, mediation, and litigation. Over the past
    25 years, he and his firm have represented more than 1,000
    medical residents nationwide.
        Mr. Thomas Miller. Mr. Miller is a resident fellow in the
    health policy studies at the American Enterprise Institute
    where he focuses on regulatory barriers through choice and
    competition, market-based alternatives, healthcare litigation,
    and the political economy of healthcare reform. He previously
    served as a senior health economist with the Joint Economic
    Committee and as a senior lecturing fellow at Duke University
    School of Law.
        Dr. William Feldman. Dr. Feldman is an Assistant Professor
    of Medicine at Harvard Medical School and Brigham and Women's
    Hospital. Dr. Feldman's research focuses on drug pricing, FDA
    regulation, and pharmaceutical policy.
        We welcome our witnesses and thank them for appearing
    today. We'll begin by swearing you in. Would you please rise
    and raise your right hand?
        Do you swear or affirm under penalty of perjury that the
    testimony you are about to give is true and correct to the best
    of your knowledge, information, and belief, so help you God?
        Let the record reflect that the witnesses have answered in
    the affirmative.
        Thank you. You can be seated. Please note that your written
    testimony will be entered into the record in its entirety.
    Accordingly, we ask that you summarize your testimony in five
    minutes.
        Dr. Lin, you may begin.

                       STATEMENT OF DR. JAMES LIN

        Dr. Lin. Thank you, Mr. Chair, and Ranking Member Nadler,
    and the Members of the Committee. Thank you for the opportunity
    to testify today on a matter of critical and national concern:
    The increasingly detrimental impact of the Accreditation
    Council for Graduate Medical Education, otherwise known as
    ACGME, standards on the sustainability of medical residency
    fellowship programs in rural and underserved areas.
        LECOM Graduate Medical Education, which has trained over
    693 residents since 1977, stands as a case study in how a rigid
    and monopolistic accreditation system is undermining the health
    infrastructure of America's smaller communities. Despite a
    proven track record of producing competent board-certified
    physicians, 417 of whom remain in practice within a 100-mile
    radius of Erie, Pennsylvania, our programs are being
    dismantled, not due to deficiencies in quality but due to
    arbitrary, urban-centric, inflexible accreditation policies.
        ACGME is a sole accrediting body for graduate medical
    education in the U.S., influencing over 16-18 billion in
    Federal and institutional investment. Yet, its governance is
    dominated by faculty from major academic centers. As a result,
    the accreditation criteria are designed for high-resource
    university hospitals, not for the realities of rural health
    systems.
        Programs have closed due to faculty departure tied to
    vaccination mandates, our general surgery program in Elmira,
    New York; inflexible geographic limitations on training sites
    despite affiliation with top-tier hospitals, LECOM Orthopedic
    Program; requirement of redundancies that ignores consortium
    models, punishing programs for sheer training infrastructure;
    excessive initiative cost, even when programs have no active
    residents. This rigidity stifles innovation, penalizes lean and
    effective community models, and directly contributes to the
    loss of training pathways for future physicians.
        The LECOM Orthopedic Surgical Residency Program, despite
    positive outcomes, premier training partnerships, and high
    board pass rates, the orthopedic surgery program was closed due
    to inflexibility rules about program mix and rotation
    supervision. This displaced residents, disrupted their careers,
    and stripped Erie County of essential orthopedic care.
        The LECOM Internal Medicine Residency Program, this is a
    longstanding program that was closed following an unresolved
    hotline complaint, despite an internal and legal review finding
    no merit. Its closure cascaded into a termination of our
    gastroenterology and pulmonary fellowship, eliminating critical
    pipeline for specialty care.
        Since 2020, the number of withdrawn or closed program has
    increased dramatically, many in rural areas. The ACGME one-
    size-fits-all model disproportionately harms smaller
    institutions and thoroughly qualified health centers. Programs
    have been denied probationary periods or closed outright
    sometimes by Zoom meetings with no room for remediation.
        Critical specialties like psychiatry, cardiology,
    obstetrics, and surgery are being lost in precisely the regions
    that need them most.
        The loss of residency program directly reduced patient
    access today and in the future. Without local training
    opportunities, DO candidates face increasing exclusion from
    competitive specialties due to documented disparities in the
    MATCH.
        Moreover, rural systems and urban underserved are left with
    workforce shortages, longer waiting times, and higher
    recruitment costs. Even Federal efforts are thwarted. Despite
    winning a rural residency planning grant from HRSA, our
    psychiatry program was denied rural track status by ACGME due
    to a rigid and outdated definition of ``rural'' in direct
    conflict with other Federal agencies like CMS and USDA.
        Some proposed solutions: (1) Revise accreditation criteria,
    modernize standard to allow flexibility in rural and
    consortium-based models.
        (2) Diversity review committees ensure rural osteopathic
    educators have a voice in shaping specialty standard.
        (3) Create an alternative accreditor, promote innovative
    training track models specifically designed for rural and urban
    underserved areas. Streamline administrative burden. Shift
    focus from bureaucratic checklists to actual outcomes and
    training and patient care. Protect Federal investments. Align
    ACGME definition with Federal and rural health policy to avoid
    undermining HRSA support initiative.
        The current ACGME model, while well-intentioned, has
    created systemic barriers that disproportionately harm rural
    communities, limit innovations, and suppress diversity in
    physician pipelines.
        We urge Congress and CMS to take action, whether through
    oversight, reform, or the creation of an alternative
    accreditation pathway to ensure rural America is not left
    behind. We can no longer allow bureaucratic rigidity to dictate
    where and how the next generation of doctors are trained. The
    health of millions in rural and urban underserved regions
    depend on a more inclusive and responsive system. Thank you.
        [The prepared statement of Dr. Lin follows:]
      GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

        Mr. Fitzgerald. Thank you, Dr. Lin.
        Mr. Marek, you're now recognized for five minutes.

                       STATEMENT OF SHERMAN MAREK

        Mr. Marek. Thank you. Good morning, Chair Fitzgerald. There
    we go. Good morning, Chair Fitzgerald, Ranking Member Nadler,
    and the Members of the Subcommittee. Thank you for the
    opportunity to testify today.
        My name is Sherman Marek, and I support the repeal of the
    2004 MATCH Antitrust Exemption. It was engineered to stop a
    lawsuit I filed in 2002 on behalf of medical residents. I have
    since represented more than 1,000 residents in disputes with
    their hospitals. I witnessed daily the harm caused by the
    exemption to residents, to patients, to taxpayers, to rural
    hospitals, and to the medically underserved public nationwide.
        In my view, formed now over decades, 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.
        The MATCH is and always has been operated by hospitals for
    hospitals. It assigns each resident to a single program for the
    duration of residency. The system, including an unspoken ban on
    transfers, traps the residents there in that position for 3-5
    years. Residents are not free to leave. Even in cases of unsafe
    working conditions, inadequate pay, incompatible supervisors,
    or a family or medical emergency, or simply changes in personal
    preference. Anyone who leaves or is terminated is blacklisted
    and denied a position anywhere. There are very few second
    chances.
        There is no freedom and no flexibility in the system.
    Residents who leave their program generally lose their entire
    career in medicine--their entire career in medicine.
        Correspondingly, taxpayers generally lose their entire
    investment in that resident. Medicare pays hospitals $150,000-
    $180,000 annually for each one. The public loses someone who
    would otherwise help reduce the physician shortage. That was
    not a sustainable system 20 years ago and is even less
    sustainable now.
        These were the anticompetitive restraints we challenged in
    the 2002 Jung case. We won the opening rounds, and the judge
    ruled our claims viable under the Sherman Act.
        Faced with the loss of lucrative cheap labor, the hospitals
    turned to Congress. In 2004, they were quietly given an
    exemption at the expense of residents. It happened without
    notice, without hearings, without public debate, without
    transparency, and without meaningful consideration of the harm
    that would result.
        The exemption has now perpetuated the MATCH's harm for
    another 20 years. That harm, caused by a lack of competition,
    includes 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.
        The Jung case did not stand alone in its conclusions.
    Independent experts and studies have corroborated our
    conclusions.
        Repealing the 2004 exemption would not dismantle the MATCH
    or decide its legal merits, it would simply restore the
    authority of courts to examine those merits fully and fairly.
    The hospitals may present their justifications in court and
    attempt to prove them, or they may simply reform on their own
    when faced with standard antitrust liability.
        In my view, this is a watershed opportunity for Congress to
    reaffirm core American values of free competition, individual
    opportunity, fiscal responsibility and legal accountability.
    Based on my experience in the Jung litigation, and my daily
    experience with the ongoing harm of the MATCH exemption, I
    strongly support repeal for the benefit of residents, patients,
    taxpayers, rural hospitals, and the general public. Thank you.
    I look forward to any questions you may have.
        [The prepared statement of Mr. Marek follows:]
        GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

        Mr. Fitzgerald. Thank you, Mr. Marek.
        Mr. Miller, you may begin.

                       STATEMENT OF THOMAS MILLER

        Mr. Miller. Thank you, Chair Fitzgerald, Ranking Member
    Nadler, and Members of the Subcommittee for the opportunity to
    testify today on the medical residency antitrust exemption and,
    more generally, on competition policy considerations involving
    physician licensing.
        One version or another of the so-called MATCH mechanism for
    assigning graduating medical students to resident physician
    programs has been around for over 70 years. Today's hearing
    considers whether to thaw what was essentially frozen in
    competition law terms over 20 years ago by virtue of an unusual
    legislative exemption from antitrust liability for the program
    amid ongoing litigation with no debate and little explanation.
        Such exemptions are rarely granted. They are disfavored and
    construed narrowly by the courts. They usually reflect the
    efforts of power and privilege to gain or preserve special
    commercial advantages. Most limited antitrust exemptions also
    presume other regulatory mechanisms to monitor and police
    anticompetitive aspects of the activities otherwise protected.
        Early discovery and initial rulings in an older class
    action litigation concerning the MATCH program provided
    evidence of serious problems. Absent the sweeping statutory
    exemption, further litigation under rule of reason analysis
    would have helped assess the net competitive effects of the
    MATCH program at that time or even later, as its practices
    evolved, and then assess its likelihood--the likelihood of less
    restrictive alternatives.
        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.
        My written testimony recognizes that the likely competition
    problems come not from the mathematical elegance and ingenuity
    of the MATCH algorithm, per se, they derive, rather, from the
    programs related assembly of mutually reinforcing levers of
    market power that attach one-sided conditions to it.
        The MATCH program may do an excellent job in solving the
    wrong problem. How to fix selection timing problems in a
    resident market monopsony that the program only strengthens.
    The matching process delivers efficient sorting of bounded
    preferences, finality, and fewer unfilled positions when it
    operates as described, but there's some question about that.
        The main drawbacks, tied to older legal objections, appear
    to be the vastly unequal bargaining power, the wage suppression
    and compression, and onerous working conditions for residents
    that the program's interrelated rules and practices sustain.
        Reduced labor market competition reduces the quality,
    availability, and value of healthcare services. I suggest an
    initial set of incremental changes, far from original on my
    part, that could improve competition within a reformed MATCH
    program, rather than displace it completely. They might have
    added conditions to retain the current antitrust exemption
    inserted within a newly granted more narrow one or adopted to
    minimize new legal liabilities.
        However, a singular focus on antitrust law will not solve
    all the problems of physician labor markets, let alone the
    larger issues of cost, quality, and access throughout our
    overall healthcare system.
        Policymakers should consider a broader inventory of tools
    and levers that could shape not just the initial supply of new
    physicians, but also facilitate how all healthcare providers
    can deliver more assessable, effective, and affordable care.
        Most policy interventions aimed at rebalancing competitive
    forces within physician labor markets face resistance not only
    from the powerful interest groups benefiting from the
    longstanding status quo; they also can trigger fears of
    disruption and timing mis-matches in any transition toward
    alternative mechanisms.
        A different set of policy conflicts may arise from
    federalism concerns. States have traditionally been viewed as
    the natural constitutional stewards of physician licensing as
    part of their traditional police powers.
        Neither type of concerns are irreconcilable roadblocks to
    reasonable reforms that are calibrated and phased in carefully.
        Although some States have led on this front, not enough
    have done so as rapidly and thoroughly as they might and
    should. Hence, arguments for an increased Federal Government
    role in at least providing stronger incentives to do so.
        The MATCH program's nationwide competition for resident
    physicians was only an early sign of eroding geographical
    boundaries for healthcare labor markets. The issue is not
    whether Congress and the Federal Government have the power to
    be more assertive but whether they decide to do so absent more
    effective State-level actions.
        The potential policy reforms and tools are available if the
    necessary political will to promote and adopt them develops. In
    the meantime, we should expect the more immediate resort of
    recent years: To leaving such matters to litigation,
    regulation, and other administrative actions, not
    coincidentally this Subcommittee's area of jurisdiction. Thank
    you.
        [The prepared statement of Mr. Miller follows:]

        GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

        Mr. Fitzgerald. Thank you, Mr. Miller.
        Dr. Feldman, you may now begin.

                    STATEMENT OF DR. WILLIAM FELDMAN

        Dr. Feldman. Chair Fitzgerald, Ranking Member Nadler, and
    the Members of the Subcommittee, I'm honored to talk with you
    all today about medical training in the United States and, more
    broadly, about ways of strengthening our healthcare system to
    improve outcomes for patients.
        The MATCH, the subject of our hearing today, is the
    mechanism by which residency applicants are paired with
    hospitals for their training after medical school. For the past
    two decades, this mechanism has been protected by an exemption
    from antitrust violations. In March of this year, the
    Subcommittee sent letters to several stakeholders requesting
    information they consider as they considered the potential
    removal of this longstanding exemption.
        The two central arguments of those letters are that the
    residency MATCH has created a bottleneck, resulting in
    physician shortages, and that it has depressed resident
    salaries. The goals of this Subcommittee, as expressed in those
    letters, of increasing physician workforce and ensuring
    adequate compensation for residents are laudable and ought to
    be pursued. The MATCH certainly has its downsides, but in my
    view, eliminating the MATCH would not necessarily accomplish
    the goals as set forth by this Committee.
        Let's start with physician shortages, which are expected to
    increase from 37,000 in 2021 to over 80,000 in 2036. The
    problem is not that a large number of residency spots go
    unfilled each year. In fact, in 2024, 99.6 percent of the more
    than 40,000 advertised positions were filled. Instead, the
    problem is that more residency spots are needed. This, in turn,
    would require additional funding from Medicare and Medicaid and
    the hospitals themselves. The MATCH, per se, is not the
    bottleneck in the physician shortage.
        Beyond creating and funding more positions, lawmakers
    should also identify new ways of bringing international medical
    graduates into our workforce, as many States are now doing.
    Numerous sectors in the U.S. economy, from tech to financial
    services, benefit from the infusion of highly skilled workers
    who train abroad. Why should medicine be different?
        On the question of residency wages, I can tell you
    firsthand that living on a residency salary while trying to pay
    off student loans and start a family was challenging, but it's
    not clear that eliminating the MATCH would yield higher
    salaries across the board without disruption. There are
    certainly other ways of improving wages.
        Resident unionization, Mr. Nadler mentioned, has
    accelerated in recent years, with 20 percent of all residents
    now unionized, including at my own institution. Through
    collective bargaining, residents have successfully negotiated
    wage increases, housing allowances, increased educational time,
    and numerous other benefits that help improve their quality of
    life and educational experience.
        Residency programs can and should offer more, and Congress
    could facilitate this in any number of ways beyond actions to
    eliminate the MATCH, from increasing CMS funding of residency
    programs and supporting the right to unionize setting minimum
    salary floors and implementing more generous loan forgiveness
    programs.
        I want to close by noting that some of the biggest threats
    to medical education and, indeed, to the very practice of
    medicine in the United States come not from the residency MATCH
    but from efforts by the current administration to undermine the
    very fabric of scientific discovery. Foundational research
    funded by the NIH and NSF form the core of what medical
    students and residents learn during their training.
        Future groundbreaking cures that residents of today will
    prescribe to patients of tomorrow depend on a robust NIH and
    NSF for discovery, a well-staffed FDA for evaluation, and
    strong public players, including Medicare and Medicaid, for
    access. Yet, the current administration seems bent on gutting
    these institutions.
        The administration's budget blueprint proposes cuts of 37
    percent to the NIH and more than 50 percent to the NSF. Over
    700 NIH grants, accounting for close to $2 billion in funding,
    have been terminated this year, and more than half of these
    canceled grants are for medical schools and hospitals, a large
    number of which, by the way, are for clinical trials that are
    investigating diseases like cancer, psychiatric illness, HIV,
    and COVID.
        At the FDA, more than 3,500 layoffs have already begun,
    slowing review times of new drugs. An entire office tasked with
    developing product-specific guidance and facilitating entry of
    low-cost generic drugs to keep prices down for patients was
    terminated. Proposed cuts to Medicaid, according to the CBO,
    will leave eight million beneficiaries uninsured, and these
    cuts will have disproportionate effects on hospitals that
    already struggle to cover the costs of uncompensated care.
        This Committee has begun asking hard questions about
    medical training in the United States, which is good--
        Mr. Issa. Mr. Chair, can I have regular order, please?
        Mr. Fitzgerald. Yes. Mr. Feldman, can you wrap up your
    comments, please.
        Dr. Feldman. Yep. I would encourage you to widen the scope
    of assessment and consider an array of tools for addressing
    physician shortages, residency well-being, and larger threats
    to science in our healthcare system.
        [The prepared statement of Dr. Feldman follows:]
        GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

        Dr. Fitzgerald. Thank you, Dr. Feldman.
        We will now proceed under the five-minute rule with
    questions. I'll recognize the gentleman from California, Mr.
    Issa, for five minutes.
        Mr. Issa. Thank you, Mr. Chair.
        Dr. Feldman, I love it. You just had to go for a minute and
    25 seconds on a rant against Trump for 100 days, as though what
    we're hearing about today had anything to do with it or that
    any real difference has occurred in 100 days to the root causes
    of not having enough physicians or that this didn't happen
    during the previous four years.
        The least you could have done, of course, is talk about his
    first four years to give him at least a chance to have had some
    impact, but you chose not to.
        I heard you say money, money, money. I think I'll go to Mr.
    Marek. You spend a fortune to become a doctor. Then, your
    system puts you into slave wages while the Federal Government
    is subsidizing the hospitals so they effectively have you for
    less than free. Is that a fair assessment of how we create
    residents? The Federal Government already pays more than you
    receive, isn't that true, if you're a resident?
        Mr. Marek. I agree with that. Yes, I agree with that. The
    government pays an average between $150,000-$180,000 a year per
    resident, and they convey about $65,000 to each resident.
        Mr. Issa. OK. We've all heard about the rough hours that
    doctors go through and sort of part of this test, sort of like
    Navy SEALs and Rangers; you've got to stay up for a couple of
    days to prove you could in the future. I'm OK with that. I
    understand the stress.
        What I don't understand is how we can have a projected
    shortage under a monopoly that was supposed to allocate and
    guarantee sufficiency, and then Dr. Feldman comes in and tells
    us the problem is that paying more to the hospital than they
    actually spend while getting a doctor for free, who they bill
    out is somehow the fault of an administration who has been here
    for 100 days. Mr. Miller, am I misunderstanding what I'm
    hearing?
        Mr. Miller. No. Let me add something else to this. I was
    wondering about this about 10 years ago. There's no correlation
    between the Federal funding and the supply of physicians. Now,
    we can change the rules and make it more targeted to
    incentivize the expansion of certain types of physicians or
    other areas, but the money goes in, and it goes to certain
    favorite parties over a period of time. It's not allocated on a
    need basis. It's just more sloshing around of funding, which is
    unrelated to what we say we're trying to accomplish.
        Mr. Issa. Dr. Lin, Dr. Feldman seemed to think that unions
    were the answer while maintaining an antitrust exemption. Do
    you see that as the answer, or do you see that a free market,
    or at least a partial free market being restored, could help
    with this problem?
        Dr. Lin. I would say the latter, Congressman. I think union
    is not an answer for rural communities, especially small
    community hospitals. If you look at the current financial
    situation, we have hospitals closing, nursing homes closing
    because of financial stress. If you increase the wages
    artificially like that with union, that would be detrimental,
    and that would be a hindrance to our future.
        Mr. Issa. Now, Dr. Lin, I have also served over the years
    on the Immigration Subcommittee. One thing I understand is that
    we have a minuscule allocation to rural of foreigners able to
    get visas. Is that something that you would also seek to try to
    increase that number, since obviously there are more foreign-
    born doctors, some of whom have been U.S. educated, who are
    looking for those opportunities when they leave than we
    allocate slots? It's a quite small number, correct?
        Dr. Lin. That's correct.
        Mr. Issa. OK.
        Mr. Marek, your case was dismissed because Hillary Clinton
    and the late Senator Ted Kennedy got together and slipped it in
    there, and that's where we are. What, if any, improvement have
    you seen as a result of this antitrust exemption in any part of
    the process?
        Mr. Marek. Well, shortly after we filed the case, I believe
    that the hospitals saw the long, dangerous work hours as their
    Achilles' heel, and so they supposedly voluntarily adopted an
    80-hour work week.
        Mr. Issa. OK. Well, Mr. Miller, let me--I'll take that as
    some good, only 80 hours. Mr. Miller, in my remaining time,
    antitrust exemption for the organization that does this work
    versus the effective antitrust that goes to the hospitals,
    should we make it clear that the selection process enjoys an
    antitrust, but all other aspects of the process should never
    have enjoyed antitrust exemption?
        Mr. Miller. Yes. It was a very sweeping exemption because
    basically it also prevented any evidence related to this from
    being used in collateral actions. Certainly, it should be set
    as narrowly as possible at a minimum.
        Mr. Issa. Thank you, Mr. Chair. I yield back.
        Mr. Fitzgerald. The gentleman yields back. I now recognize
    the Ranking Member for five minutes.
        Mr. Nadler. Thank you, Mr. Chair.
        Dr. Feldman, since you've been attacked by several of the
    witnesses. Is there anything you would like to say in response?
        Dr. Feldman. The one thing I would like to say is that my
    comment about more funding is about funding for more positions.
    If we're concerned about a residency shortage, if we're
    concerned about a physician shortage, we need more physicians,
    and the way to do that is by more funding.
        Mr. Nadler. Thank you.
        Dr. Feldman, in an April Executive Order, the Trump
    Administration once again took aim at institutions of higher
    education. This time it was focused on the administration's
    crusade against DEI. Can you explain whether there is a value
    in accounting for diversity in the provision of medical care?
        Dr. Feldman. I do think there's value in accounting for
    diversity in the selection of medical students and residents.
    Having classes with a diverse set of interests and backgrounds
    can help strengthen the medical care that doctors provide and
    can strengthen residency classes.
        Mr. Nadler. Thank you.
        Dr. Feldman, you've seen the MATCH from both the applicant
    and program sides. What was the experience that you and your
    peers had with the MATCH as applicants, and what concerns you
    about the prospect of eliminating the MATCH?
        Dr. Feldman. The experience with the MATCH is that you
    apply to a bunch of programs. You interview. You rank the
    programs that you like the best, and you're placed into the one
    that also ranks you. The MATCH is not without its downsides, as
    I've said, but I would worry that eliminating the MATCH would
    create a kind of free-for-all that would make it harder for
    applicants.
        This idea that you mentioned about exploiting offers and
    being pushed to commit early to one program without actually
    looking at all the programs would ultimately be problematic for
    residents--for applicants.
        Mr. Nadler. Drawing on your experience, Dr. Feldman, with
    the FDA and pharmaceutical industry, what anticompetitive
    practices have you encountered that impacted most the public's
    health and well-being.
        Dr. Feldman. I see lots of anticompetitive practices in the
    pharmaceutical industry. I'll give you one example that's very
    close to research that I've conducted with our team at Harvard
    Medical School. We see brand-name pharmaceutical companies
    obtaining patents that limit generic competition, that limit
    the entrance of low-cost generics onto the market. More
    competition is the way that we bring down drug prices.
        Mr. Nadler. How could a patent--the patent limits the
    generic?
        Dr. Feldman. Well, the companies list the patents with the
    FDA in what's called the Orange Book, and the generic entrants
    can't come onto the market until those patents expire, or they
    challenge them in court. We see anticompetitive practices all
    the time from pharmaceutical companies. We see anticompetitive
    practices from PBMs throughout the pharmaceutical supply chain.
    I would love for this Subcommittee to be focused on those
    issues.
        Mr. Nadler. Thank you. Research funding is being cut for a
    variety of reasons, including administration concerns about a
    range of issues unrelated to the research itself. Against this
    undis-
    criminating approach to cost-cutting, for context, please
    explain the process by which these grants are made in the first
    place, Dr. Feldman.
        Dr. Feldman. The process by which NIH grants are made?
        Mr. Nadler. Yes.
        Dr. Feldman. Well, we spend many, many hours writing grant
    applications. We submit them to the NIH. They go to study
    sections for evaluation, peer review, and the grants that have
    a certain score end up getting funded. It's an arduous process.
    It makes for good science because you get the best applications
    that are being selected, and I worry a lot about actions that
    are being taken now to cut funding from the NIH.
        Mr. Nadler. Thank you. As a researcher who receives the NIH
    funding, what are your concerns about how freezing or
    terminating grants will affect the research enterprise and
    researcher choices?
        Dr. Feldman. I have already seen the chilling effect that
    these cuts have had. I have had conversations with colleagues
    who are in academia and have thought about going into industry
    because of uncertainties around getting NIH funding. The NIH
    funds some of the riskiest research, also the highest reward
    research, in our country, and I think these cuts are going to
    be devastating if they persist in breakthrough therapies.
        Mr. Nadler. Thank you. Finally, the administration has been
    doing everything it can to deport foreign students and
    researchers. To what extent do you think what I just said is
    accurate, and how will this affect medical care?
        Dr. Feldman. I'll come in on the latter question. I think
    that deporting international students, making it hard for
    international students to learn in the United States and
    practice in the United States will only contribute to the
    physician shortage.
        Mr. Nadler. Thank you, I yield back.
        Mr. Fitzgerald. The gentleman yields back. I now recognize
    the gentleman from Virginia for five minutes.
        Mr. Cline. Thank you. Dr. Lin, the ACGME leverages its
    accreditation monopoly to impose DEI hiring requirements on
    medical residency programs. According to ACGME program
    requirement IC, programs must hire a diverse and inclusive
    workforce. We heard Dr. Feldman try and justify that. Race-
    based hiring requirements are against Federal law. The Supreme
    Court was clear in Students for Fair Admissions v. Harvard that
    educational institutions cannot base admission on race either.
    American healthcare patients suffer when residency programs
    focus on gender or skin color instead of a resident's
    competency.
        Do you think the ACGME should be in the business of forcing
    programs to hire residents based on race or gender instead of
    merit?
        Dr. Lin. Congressman, I would tell you that, of course,
    personally I would think that they should not impose their will
    on individual programs. Some good news, as of May 9th, the
    ACGME has suspended their common standard for DEI practices,
    and--it remains to be seen how they're going to change their
    standard. We just got the email last week.
        Mr. Cline. That's good news.
        Mr. Miller, the medical residency market is stagnant with
    low wages for residents and worse outcomes for patients. It
    also functions as a bottleneck that contributes to America's
    doctor shortage. Would removing the medical residency antitrust
    exemption make the market more competitive?
        Mr. Miller. We need to parse a couple of different parts to
    this. The supply line is a little more complex than just
    removing the antitrust exemption. It could create some
    opportunities, but primarily, in terms of improving the overall
    working conditions and the quality of the healthcare workforce
    we produce, there are a broader set of tools than that alone.
    There's some ambiguity over exactly what's driving the
    production line. I suggest we need a bigger basket than simply
    this tool alone. It will help, but I would not exaggerate its
    effects.
        Mr. Cline. Thank you. As you know, to receive a physician's
    license, doctors are required to participate in an ACGME
    accredited residency. Traditionally State licensing
    requirements that facilitate anticompetitive conduct are
    shielded from antitrust law under the State action immunity
    doctrine.
        What do you see with State medical licensing boards rubber
    stamping monopolistic conduct like that of the ACGME?
        Mr. Miller. You're opening up a different basket. That's
    OK. Certainly, many State actions, there's real State action
    and then there's kind of periphery State action, certainly
    encourage an anticompetitive atmosphere in State physician
    markets.
        In general, they are being clawed back but not as much as
    they should. We have eroded some of the excesses of the State
    action doctrine in terms of having a clear articulation of
    State policy and closer supervision. That's a process in which
    we're removing slower than we should on that front.
        States certainly could do a better job in this regard, and
    there are, as I've suggested, other Federal levers to give them
    some encouragement to do so. Any individual State should be
    responsible for its medical markets and the result it produces.
    It's, the broad sense, fairly disappointing thus far.
        Some States have led the way, but it's a handful. Whether
    it's licensing of foreign physicians, alternative ways to
    expand the workforce, we have to go a lot further on the front
    end there--reciprocity.
        We had to have the extremes of the COVID situation to begin
    to find out how we can loosen things up when we're really
    desperate. We should do that more often as a general rule, and
    we have a long way to go to expand the overall supply of
    healthcare, not just the newly minted physicians.
        Mr. Cline. Staying with the ACGME, medical residency
    programs can only receive Federal funding through Medicare and
    Medicaid if they are accredited by the ACGME. As a result, the
    ACGME essentially controls the on-and-off switch for billions
    of dollars in Federal funding.
        With that power, the ACGME has set accreditation
    requirements that are not consistent with the Federal
    Government's priorities, like radical DEI hiring requirements
    and wasteful administrative burdens.
        How would creating an alternative certification process for
    Medicare and Medicaid funding loosen the ACGME's power over the
    medical residency market?
        Mr. Miller. There's always room for competition, even in
    government franchises, and certainly there are no ways to think
    of other forms of certification, independently driven through
    the private sector, which could be recognized as alternative
    sources of that supply. That would require the Federal
    Government to step forward, take more control of that
    situation, or States, also in their own determination of
    accreditation, decide they need additional sources.
        When you have a shortage of supply and you only have one
    supplier, it suggests time to either find some alternatives or
    say to the person, ``Let's make some adjustments.''
        Mr. Cline. Thank you. Mr. Chair, I yield back.
        Mr. Fitzgerald. The gentleman yields back. I now recognize
    the gentleman from Georgia for five minutes.
        Mr. Johnson. Thank you, Mr. Chair. The medical MATCH is not
    perfect, but let's be honest about why we are having this
    hearing today. For House Republicans, this is a hearing--this
    hearing is an outgrowth of MAGA Republican ongoing attacks on
    science and research. President Trump and the Republican-
    controlled Congress have made massive cuts to medical research
    programs at universities and at the Federal level, including
    research into things like women's health, racial disparities,
    and chronic diseases.
        I'm proud that the Centers for Disease Control and
    Prevention is headquartered in my hometown of Atlanta, but the
    Trump Administration already cut 2,400 jobs from the CDC last
    month and ended programs on lead poisoning, smoking cessation,
    and reproductive health.
        Now, that does not make America healthy again, does it, Dr.
    Lin? Yes or no.
        Dr. Lin. Congressman--
        Mr. Johnson. OK. So, yes or no? I'm running out of time.
    I'm going to move on. You don't want to answer that question.
        President Trump's latest budget calls for cutting CDC's
    funding by half and eliminating its Chronic Disease Center
    entirely, wiping out programs aimed at preventing cancer, heart
    disease, diabetes, epilepsy, and Alzheimer's disease. That
    doesn't make America healthy again, does it, Mr. Marek? Yes or
    no?
        Mr. Marek. I don't have an answer for that.
        Mr. Johnson. OK. Well, it's clear. It's abundantly clear to
    most Americans, exempting, of course, MAGA Republicans, I
    guess, would not understand.
        Now, House Republicans are trying to jam through a spending
    bill that would make massive cuts to research, as well as
    massive cuts to Medicaid, ripping away eight million Americans'
    healthcare so that they can fund tax breaks for their
    billionaire buddies. Mr. Miller, that does not make America
    healthy again, does it?
        Mr. Miller. A lot of things don't make America healthy. We
    can talk about them if you wish to have a wide range--
        Mr. Johnson. I'll reclaim my time.
        Dr. Feldman, international medical graduates represent a
    substantial chunk of physicians practicing in the United
    States. You said 23 percent in your testimony. The Trump
    Administration and House Republicans are trying to make it
    harder for noncitizens to come work in the United States.
        How would it impact care in this country if we lost those
    international medical graduates?
        Dr. Feldman. It would be devastating. International medical
    graduates often serve in rural communities in primary care
    roles, and they help solve the physician shortage that we're
    here to talk about today.
        Mr. Johnson. That would not make America healthy again,
    would it?
        Dr. Feldman. It would not.
        Mr. Johnson. Dr. Feldman, the Trump Administration and
    Republicans are trying to slash spending to Federal healthcare.
    Could you say more about why programs would be impacted if
    Congress increased funding for residency programs through the
    Centers for Medicare and Medicaid Services rather than trying
    to cut funding for those programs?
        Dr. Feldman. We need to increase funding because we have a
    physician shortage, and the way to solve the physician shortage
    in part is through more physicians. The only way to have more
    physicians is more funding.
        Mr. Johnson. That's commonsense. Mr. Miller, you're shaking
    your head no. I don't understand.
        Back to Dr. Feldman, Republicans are floating an idea that
    would require doctors to work even longer to achieve public
    interest loan forgiveness because it would not count the years
    of their residency toward the 10-year requirement. Can you
    speak as to how this would impact on the availability of care,
    particularly in rural or underserved areas?
        Mr. Miller. If you ask the wrong question, you'll get the
    wrong answer.
        Mr. Johnson. I'm asking Dr. Feldman.
        Mr. Miller. I thought you were asking me.
        Dr. Feldman. I'll tell you, as somebody who is doing public
    service loan forgiveness and who started paying down my student
    loans during residency, there's no reason to push that out.
    It's a very good program, and it's a way to get physicians into
    the workforce, and it would be a bad idea.
        Mr. Johnson. If Republicans were serious about making
    healthcare more affordable and more accessible to the American
    people, there are so many things that we could have hearings
    about other than this MATCH.
        Mr. Fitzgerald. The gentleman's time has expired.
        Mr. Johnson. I yield back the remainder of it.
        Mr. Fitzgerald. The gentleman yields back. The gentlewoman
    from Wyoming is recognized.
        Ms. Hageman. Mr. Miller, you seemed as though you had
    something to say.
        Mr. Miller. Well, there's one view of the world which says
    simply, ``Pour more resources in, and everything will work
    wonderfully.'' The problems with our healthcare system are what
    we're getting out of it, as well as what we're putting into it.
    A singular focus on just adding more dollars for more inputs
    says nothing about the quality of the care, its efficiency, its
    alternative delivery. We need to make lots of changes in a lot
    of things to get a better healthcare system. It should not be
    solely focused on ``let's just have a lot more physicians, and
    everything will be great.'' We've tried that approach before;
    it doesn't produce the results.
        Now, there are barriers to production of physicians, which
    we can talk about, but it isn't solved simply by increasing
    Federal funding.
        Ms. Hageman. OK. I appreciate that comment.
        Several of you have testified that the MATCH system harms
    rural hospitals. I'm from Wyoming, which is a very rural State,
    dealing with many challenges in its ability to provide
    healthcare services with barriers related to financing,
    transportation, and access.
        Dr. Lin, is it difficult for rural hospitals to meet
    ACGME's accreditation requirements?
        Dr. Lin. It is challenging, Congresswoman.
        Ms. Hageman. What are those challenges?
        Dr. Lin. Some of the challenges are some of the standards
    that they put in place, for example, distance radius.
    Obviously, if you look at rural America, there are 1,300
    critical access hospitals, and by critical access hospitals, by
    definition, there are less than 25 beds. Given that, if you're
    training a physician, obviously scope and volume become a
    problem. When you're trying to train a rural program for
    residents, you have to send them to a distance away for
    training.
        One of the barriers to that is that, for example, our
    orthopedic program got shut down because we have to send our
    residents to Cincinnati Children's Hospital, and we have a
    consortium model that we have partnership with them, and that
    was not acceptable to them. That creates a barrier where we're
    trying to increase quality and scope and volume for our
    residents, and they thought that was a negative. We got cited,
    and that was one of the reasons why they closed down our
    program.
        Ms. Hageman. Do you have some ideas of how to fix those
    kind of accreditation problems?
        Dr. Lin. Yes. Absolutely. If you look at, prior to 2015,
    the merger of the ACGME and the AOA, there was alternative
    accreditation body, which is from the AOA, and if you look at,
    prior to the merger, we have most osteopathic institutions have
    a consortium model where we have a network of small community
    hospitals and/or community hospitals. We leverage each other's
    strength, and we put in the consortium model that we have a
    network of training sites that we can send our residents and
    collaborate. That model has worked out for many, many years.
    Millcreek Community Hospital, which is now--
        Ms. Hageman. Why was it changed?
        Dr. Lin. It changed because of the merger.
        Ms. Hageman. Of the merger?
        Dr. Lin. That's correct.
        Ms. Hageman. OK. Specifically, the issue that this
    Committee addressed to antitrust is focusing on, correct?
        Dr. Lin. In my opinion, yes.
        Ms. Hageman. OK. Mr. Miller, there is a persistent and
    growing shortage of medical professionals in this country, and,
    again, representing a State like Wyoming, we seem to be hit
    harder than many others. Do you think placing qualifications on
    job positions that are not based on merits, such as the DEI
    requirements, exacerbates the challenges our Nation is facing
    in terms of providing care for our citizens?
        Mr. Miller. Well, it sounds like a euphemism. The goal is
    to have everything based on competition, quality, and merit.
    The rest of the distinctions are ancillary and can be
    distracting from that.
        I don't want to overstate the magnitude of DEI. This is
    going to fight its way out through the courts. We've gotten
    rulings. They are going to be interpreted, and some games are
    going to be played in the educational system in general, not
    just for physicians.
        The more we can focus on what physicians are doing at the
    point of care and what they're producing, that's what we want
    to measure as opposed to any other ancillary considerations.
    That's going to work itself out through further litigation,
    probably more so than random interventions.
        Ms. Hageman. OK. Mr. Marek, very quickly, this hearing
    focuses on the antitrust exemption granted by Congress, but you
    were hired in the 1990s as part of a lawsuit against the MATCH
    system. The National Resident Matching Program, also known as
    MATCH, was founded in 1952. The ACGME was established in 1981.
    How far back does the harm for your clients and other medical
    students go?
        Mr. Marek. The harm goes all the way back to 1952, frankly.
        Ms. Hageman. From the beginning?
        Mr. Marek. Exactly.
        Ms. Hageman. It was created in the program itself?
        Mr. Marek. Exactly.
        Ms. Hageman. All right.
        Mr. Marek. People got their positions by telegrams back in
    1952. The problems then have no relevance to today, in my view.
        Ms. Hageman. OK. Thank you. I yield back.
        Mr. Fitzgerald. The gentlewoman yields back. The gentleman
    from Illinois is now recognized for five minutes.
        Mr. Garcia. Thank you, Chair Fitzgerald, and the Members
    and the witnesses that are here today.
        We are here today because we are talking about the
    possibility of an antitrust exemption for the medical residency
    MATCH program. As a strong proponent of enforcing antitrust
    laws, I approach any exemption with skepticism. It seems to me
    that the exemption for the MATCH has pros and cons. In some
    ways, it does limit choice for candidates who are bound to the
    program they match with and cannot negotiate employment terms
    or benefits since they are matched. There are legitimate
    questions about how the system works and how it can be
    improved, but it's also true that repealing the antitrust
    exemption outright may have unintended consequences that worsen
    outcomes for medical residents.
        Dr. Feldman, in your opinion, could repealing the exemption
    actually end up benefiting the most well-resourced hospitals,
    medical schools, and residency programs?
        Dr. Feldman. It could because--what I would worry about is
    sort of insiderism where, outside of the match, you would have
    well-resourced applicants with well-resourced mentors who are
    connecting with well-resourced institutions, and some of the
    fairness that the MATCH engenders would be lost.
        Mr. Garcia. Thank you. Clearly, this is a nuanced issue,
    and Congress should be taking a nuanced approach to it as well.
        One relevant factor here is that most medical residencies
    are at least partially funded by Federal dollars. If we want to
    fix some of the issues created by the MATCH, like compensation
    and shortages of internal medicine residents, Congress can act
    to solve them.
        Dr. Feldman, would you agree that Federal funding can be
    used to address these issues?
        Dr. Feldman. I would agree.
        Mr. Garcia. Thank you. I also want to join my colleagues
    here in pointing out how absurd it is that Republicans are
    portraying themselves as champions of physicians, patients, and
    healthcare more broadly when their policies are actively
    destroying access to affordable healthcare. My colleagues have
    addressed that, and they've also brought up the devastating
    cuts to the NIH and the FDA, which will jeopardize the research
    that residents and physicians rely on to treat their patients.
        There are also significant antitrust issues in healthcare
    that are driving up costs for patients. If Republicans cared
    about solving the root causes of those problems, we would be
    talking about hospital mergers, price gouging, or consolidation
    in the pharmaceutical industry.
        Dr. Feldman, let me ask you about the last issue, since
    your research has focused on it. How is vertical integration in
    the pharmaceutical industry driving up the cost for consumers?
        Dr. Feldman. At the center of vertical integration in the
    pharmaceutical industry are PBMs, pharmacy benefit managers,
    and PBMs distort the incentives for lower cost drugs. PBMs are
    after large confidential discounts, which can keep list prices
    high, and patients don't see the benefits of those discounts.
    In fact, their out-of-pocket costs are tied more to list
    prices. The PBMs have been in part responsible for driving some
    of the high out-of-pocket costs that we see. Vertical
    integration, when PBMs and pharmacies and payers are all owned
    by the same company, can lead to reduced choices at the
    pharmacy and bad outcomes for patients.
        Mr. Garcia. Thank you. This exchange illustrates why we
    need a serious, principled approach to antitrust enforcement
    and why we need antitrust enforcers at the FTC and the DOJ who
    are willing to fight for workers, for consumers and patients,
    instead of bending the knee to billionaires and corporate
    interests.
        Thank you, and I yield back.
        Mr. Fitzgerald. The gentleman yields back. I'm now going to
    recognize myself for five minutes and yield my time to the
    gentleman from Missouri for five minutes who waived on to the
    Committee.
        Mr. Onder. Thank you, Mr. Chair, and thanks for all the
    witnesses here today.
        Dr. Lin, in your testimony, you touched a little bit on
    some of the residency closures that--were those ones at your
    institution specifically or around the country or--
        Dr. Lin. In my written testimony and my oral testimony,
    it's a combination of our LECOM system hospitals.
        Mr. Onder. OK. I was reading earlier in your written
    testimony that there was a general surgery program--let's see--
    the termination--oh, it was of the director due to
    noncompliance with COVID-19 vaccination--
        Dr. Lin. Yes. That was in our Elmira campus and our
    regional campus. My understanding of that case is that it was
    the height of COVID, and the program director didn't want to
    get a vaccination, and because of that--there was a mandate
    from ACGME that required the program directors to have
    vaccinations. The program director resigned from the position,
    and because of that, there was no program director, and they
    shut down the program.
        Mr. Onder. Oh, that was my question. The program did end up
    getting shut down?
        Dr. Lin. Yes.
        Mr. Onder. OK. Do you have an estimate of how many
    residency programs have been shut down over the years because
    of ACGME?
        Dr. Lin. I just have general statistics where, after the
    merger of the ACGME and the AOA, there are approximately 670-
    some programs that have closed. More recently, it's an ongoing
    process where there are new programs that are trying to get
    started, and then there are programs getting shut down.
        If you look at it, disproportionately, it's always the
    smaller community program that is not as resourced as the
    tertiary care center or university-based center that can't meet
    the standards that are getting shut down.
        Mr. Onder. Right. Yes. That's what it seems to me, that
    it's a matter of resources. You're not going to see a program
    at Harvard Medical School getting shut down, but, in rural
    America, where we have the most acute shortage of primary care
    doctors and of specialists with fewer resources, that's where
    they get shut down.
        Dr. Lin. Correct. I would say that Dr. Feldman and my job
    are probably very different. His environment and my environment
    are very different. I work in a Critical Access Hospital with
    25 beds in Corry, Pennsylvania, where the population is
    probably less than 6,000 in that town, but there's absolutely
    no resources. From that perspective, I'm not saying ACGME is
    bad.
        Mr. Onder. Right.
        Dr. Lin. I'm just saying that there needs to be an
    alternative way to focus on different venues so we can create
    different types of physicians.
        Mr. Onder. Nor, I'm sure, are you saying that every
    residency program in the country is good, that there isn't--
        Dr. Lin. Correct. There has to be a standard.
        Mr. Onder. There has to be a standard.
        Dr. Lin. Absolutely.
        Mr. Onder. It seems to me that, at a time when over 8,800
    medical school graduates per year go unmatched--that it's a
    tragedy that a bureaucratic organization with a monopoly is
    shutting down programs.
        Dr. Lin. Correct.
        Mr. Onder. I believe there was a question earlier in this
    about DEI and maybe ACGME backing away from DEI requirements.
    Did one of the witnesses address that?
        Dr. Lin. Yes. That was me.
        Mr. Onder. That was you.
        Dr. Lin. We did receive an email notifying all the programs
    that, as of May 9th, they are suspending the DEI requirements.
    That used to be an institutional and common program requirement
    for every sponsoring institution as well as programs.
        Mr. Onder. Did many of those programs have DEI officers or
    someone employed to monitor these mandates?
        Dr. Lin. Well, yes.
        Mr. Onder. Yes.
        Dr. Lin. Because it was in the standards.
        Mr. Onder. Right.
        Dr. Lin. If they want to maintain the program, the
    individual program institution would have to suspend resources
    to meet that requirement.
        Mr. Onder. Yes. My concern there, of course, is that, even
    if the requirement goes away, all these institutions have hired
    people to do something. Those people are going to--unless they
    relieve them of their jobs, these same people embedded in the
    system driven by ACGME requirements over the years will
    continue to engage in pernicious discrimination based on race
    in violation of both moral principle and Federal law, but
    that's something ACGME has given us over the years.
        Well, thank you for your testimony. I yield back.
        Mr. Fitzgerald. The gentleman yields back. I now recognize
    the Ranking Member of the Full Committee for five minutes.
        Mr. Raskin. Thank you very much, Mr. Chair.
        Dr. Feldman, President Trump and Secretary Kennedy want to
    cut $18 billion from NIH. They want to cut $3.5 billion dollars
    from CDC, the Centers for Disease Control. They want to cut
    $4.7 billion from the National Science Foundation. These
    unprecedented, proposed reductions in America's healthcare
    research spending would come at a time when we have
    overwhelming needs in the American public for medical and
    scientific breakthroughs, and, also, they come at a time when
    we have the opportunity to make big breakthroughs in scientific
    research related to everything from multiple sclerosis to
    cystic fibrosis to breast cancer to malignant narcissistic
    personality disorder. You name it.
        What would be the direct effects of such drastic budget
    reductions on healthcare delivery and on the progress of
    healthcare research?
        Dr. Feldman. The effects would be dramatic. When you look
    at FDA-approved drugs, nearly every single drug that gets
    approved by the FDA is traced back to some funding through the
    NIH. The NIH funding has contributed to cures for hepatitis C,
    to treatments for HIV, and to COVID-19 vaccines. Cutting NIH
    funding will absolutely reduce the number of breakthrough
    therapies of game-changing therapies that patients would see in
    the future. It's a bad idea.
        Mr. Raskin. It sounds like we would be essentially
    destroying the wellspring for research across the board?
        Dr. Feldman. That's right. What you have to remember is
    that the NIH is funding the highest risk, highest reward
    research that pharmaceutical companies then take to market.
    It's hard to know what's going to work and what doesn't, and
    that's why you need broad funding, and NIH has been incredibly
    successful in funding new cares.
        Mr. Raskin. What are some of the next-generation
    breakthroughs that might be lost if Robert F. Kennedy, Jr. and
    Donald Trump have their way in dismantling so much scientific
    health research?
        Dr. Feldman. What's hard about this is we can't know until
    we actually do the research, and we can't do the research until
    the funding comes.
        You mentioned some key disease areas that are vital for
    public health. Cancer. We've had breakthroughs in cancer
    therapy over the last 10-30 years. Checkpoint inhibitors treat
    a variety of different malignancies, Alzheimer's, dementia.
    There are numerous untreated diseases. In my area of
    pulmonology, COPD, asthma. These are diseases that have had
    some recent breakthroughs, but I would love to see more
    therapies available for patients.
        Mr. Raskin. My guest at the Joint Session of Congress, Dr.
    Lauren McGee, a constituent of mine, was the chief biologist on
    a pediatric cancer unit at NIH, and she got sacked on February
    14th, because she made the mistake of being on probation. Not
    because she had done anything wrong, but because she had been
    promoted after serial superior evaluations by the people
    reviewing her. Then, we heard President Trump at the State of
    the Union saying that attacking childhood cancer was one of his
    key priorities.
        Do we have any chance of making progress on childhood
    cancer if we are dismantling the basic research that's going on
    at NIH about it?
        Dr. Feldman. The way to make progress on childhood cancer
    and other diseases of childhood is through funding the research
    enterprise that finds new cares.
        Mr. Raskin. The administration is also proposing a massive
    cut to Medicaid, which the CBO estimates would result in 8.5
    million people losing healthcare access over the next decade.
    What population groups and what parts of the country are most
    affected by these Medicaid cuts?
        Dr. Feldman. These cuts will affect the most disadvantaged
    members of society in rural communities and urban communities
    in cities. Iit will lead to very bad health outcomes.
        Mr. Raskin. All right. My time is up, but thank you, Mr.
    Chair.
        Mr. Fitzgerald. The gentleman yields back. We're now going
    to recognize the gentleman from California for five minutes.
        Mr. Correa. Thank you, Mr. Chair.
        First, I want to welcome the witnesses here today. My wife
    is a medical doc, and this subject brings back a lot of
    memories of some kind of nightmarish residences, an OB resident
    putting in all those hours, 90 hours a week. The pay was
    challenging, but we all knew it was part of the education
    process to become a good medical doctor, a good specialist in
    the area of practice. I've spoken to her about this issue, and
    she concurs with me. A lot of nightmares, a lot of challenges,
    and a tight budget. It worked out.
        My question would be--Dr. Feldman, I'm going to ask you--if
    it ain't broke, why fix it? What is wrong right now with the
    MATCH system or the program?
        Dr. Feldman. The downsides have been spelled out by other
    witnesses and, to an extent, in my testimony. The current
    system does not allow individuals to negotiate salaries or
    benefits directly with institutions.
        Mr. Correa. So, let me ask you. It's an issue of money, so
    to speak, like everything else. How much can you pay? We're
    looking at possible Medicaid cuts. Where do most of the MATCH--
    where is that funded? You've got medical schools that are
    growing. We have a doctor shortage, and you have people like
    Kaiser Permanente back home in California--they have a doctor
    shortage. They started their own medical school. They are
    moving on their own to try to alleviate the challenges they
    have.
        If you want to have more docs and expand the MATCH, what
    does it take? More money?
        Dr. Feldman. We need more residency positions, and, as you
    said, the funding for residency positions comes largely from
    Medicare and Medicaid. Cuts to Medicaid are counterproductive.
    It's also worth noting that hospitals that serve disadvantaged
    patient populations, including patients with Medicaid, will be
    hurt by these cuts to Medicaid--
        Mr. Correa. Inner city, rural areas, farms, and Midwest? Is
    that what you're talking about?
        Dr. Feldman. All of what you just mentioned.
        Mr. Correa. My spouse usually gets very interesting offers
    to go work as an OB in the middle of somewhere in this country,
    and they're not very lucrative. If it wasn't for the fact that
    we had family established in Southern California, we may have
    taken some of them. There's not much money to be made as a doc
    in the middle of nowhere.
        Dr. Feldman. I would love to see more incentives for
    primary care doctors in these underserved communities,
    including rural communities.
        Mr. Correa. Give me an example of an incentive. Higher pay?
    Loan forgiveness? What are we talking about?
        Dr. Feldman. We could debate what incentives would work
    best. Loan forgiveness is a good example of a way in which the
    system might be able to entice physicians into areas that they
    might otherwise not be considering.
        Mr. Correa. Well, I remember, again, speaking to my spouse
    and some of her colleagues. The new brand-spanking-new docs
    that are hitting the market, half a million dollars in debt or
    something like that. An unbelievable amount of money.
        How does a doc like that coming out of medical school
    residency balance their checkbook?
        Dr. Feldman. Those numbers are right. I can tell you,
    coming out of residency, I had over $300,000 in medical school
    debt. That's just the cost of going to medical school now.
    There are programs in place--
        Mr. Correa. We are looking at we just--we need more money.
    The testimony that we need to pay residents a whole lot more is
    probably correct. I wish you would have been there 40 years ago
    when my wife was going through residency. We would have
    appreciated your efforts. Today, here we are.
        You're looking at some public policies by the
    administration to cut Medicaid, possibly Medicare, when we're
    trying to expand the field of doctors available to take care of
    Americans. It seems to me it's contradictory here. What am I
    missing?
        Dr. Feldman. I don't think you're missing anything. I
    agree.
        Mr. Correa. We all have got to get on the same page. We
    need more docs. We need more residents. We need a better
    matching program. We need more money, but it seems like the
    public policy is going the other way.
        Dr. Feldman. I agree. If the focus is on solving the goals
    set by this Subcommittee of addressing physician shortages and
    improving resident salaries, there are numerous, countless ways
    to do that are worth discussing.
        Mr. Correa. Thank you very much, and I thank the witnesses
    all for their time and interest in this issue.
        Mr. Chair, I yield.
        Mr. Fitzgerald. The gentleman yields back. I recognize Mr.
    Nadler for some unanimous consent requests.
        Mr. Nadler. Thank you, Mr. Chair. I ask unanimous consent
    to submit for the record this statement from the Association of
    American Colleges, dated May 14, 2024.
        I ask unanimous consent to enter into the record an article
    titled ``More Medicare-supported GME slots needed to curb
    doctor shortages,'' from the AMA Journal, dated October 4,
    2024.
        Mr. Fitzgerald. Without objection.
        Mr. Nadler. Thank you, Mr. Chair.
        Mr. Fitzgerald. I ask unanimous consent to enter into the
    record the following statements: A statement from Dr. Jon Ward,
    a double board-certified dermatologist practicing in Florida; a
    statement from Dr. Caleb Atkins, a current resident practicing
    family medicine in rural New York; a statement from National
    Board of Physicians and Surgeons calling for antitrust scrutiny
    of the medical residency market; and a statement from Dr.
    Jeffrey Singer, a Senior Fellow at the Cato Institute.
        With no objection.
        Mr. Fitzgerald. At this time, that would conclude today's
    hearing. We thank our witnesses for appearing before the
    Committee today.
        Without objection, all members will have five legislative
    days to submit additional written questions for the witnesses
    or additional materials for the record.
        [Whereupon, at 11:26 a.m., the Subcommittee was adjourned.]

        All materials submitted for the record by Members of the
    Subcommittee on the Administrative State, Regulatory Reform,
    and Antitrust can be found at: https://docs.house.gov/
    Committee/
    Calendar/ByEvent.aspx?EventID=118236.