[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
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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
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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:]
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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:]
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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:]
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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.