The MATCH Monopoly: Evaluating the Medical Residency Antitrust Exemption

Economic and Commercial Law

2025-05-14

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Source: Congress.gov

Summary

This hearing discussed the medical residency antitrust exemption, examining whether the current system, governed by the Accreditation Council for Graduate Medical Education (ACGME) and the National Resident Matching Program (the match), fosters competition or creates a problematic monopoly in physician training and placement . Witnesses presented contrasting views on the system's effectiveness and its impact on resident welfare, physician shortages, and the broader healthcare landscape [ 00:29:03-00:29:09 ]

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Themes

Impact of the Medical Residency Antitrust Exemption

The 2004 antitrust exemption for medical resident matching programs was introduced into unrelated legislation, preventing residents from challenging the system under antitrust laws . Critics argue this exemption protects market distortions, undermines free market principles, and leads to suppressed wages and limited choice for residents . Before the exemption, a lawsuit by medical residents challenging the match system had won early rounds, highlighting anti-competitive restraints . Proponents of repealing the exemption believe it would allow courts to fully examine the system's merits and potentially lead to reforms, while others worry that repealing it could create chaos or disproportionately benefit well-resourced institutions . Some also suggested that the harm from the Match system goes back to its inception in 1952 .

ACGME's Accreditation Monopoly and Rural Healthcare

The ACGME functions as the sole accrediting body for graduate medical education in the U.S., dictating which programs survive and how they operate, with significant influence over federal funding . This monopoly is criticized for imposing rigid, urban-centric standards that disproportionately harm smaller community hospitals and rural programs, leading to program closures . Examples included programs closing due to vaccination mandates, inflexible geographic limitations, and excessive administrative costs, displacing residents and reducing patient access to care . Recommendations include revising accreditation criteria, diversifying review committees, creating alternative accreditors for rural and underserved areas, and streamlining administrative burdens . The ACGME recently suspended its common standards for DEI practices, which had been a concern for some members [ 01:04:16-01:04:27 ]

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Physician Workforce Shortages and Compensation

The current system is linked to a growing physician shortage, with thousands of graduates failing to match with programs annually, creating a bottleneck for medical licensure . Resident wages are described as stagnant and significantly lower than other healthcare professionals, despite long hours and advanced credentials, with the federal government paying hospitals substantially more per resident than residents receive . This wage disparity, combined with high student debt, discourages doctors from pursuing primary care or working in rural areas [ 01:37:24-01:37:46 ]

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. Proposed solutions include increasing funding for residency positions through Medicare and Medicaid, offering loan forgiveness programs, and supporting resident unionization to negotiate for better wages and working conditions [ 00:55:38 ]

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Broader Healthcare Policy and Political Divisions

The hearing highlighted significant partisan disagreement regarding the overall direction of healthcare policy [ 01:13:24 ]

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. Democratic members criticized proposed federal budget cuts to institutions like the NIH, CDC, and NSF by the Trump administration, arguing these would dismantle public health infrastructure, impede scientific research, and negatively impact healthcare access and innovation . Concerns were also raised about policies affecting foreign-born students and researchers, which could exacerbate physician shortages . These broader policy issues were presented as more critical to the nation's health than the specific focus on the medical residency match .

Tone of the Meeting

The tone of the meeting was largely contentious and politically charged, particularly during the opening statements and questioning segments . While there were attempts to discuss specific issues related to the medical residency system, a significant portion of the dialogue devolved into partisan criticisms regarding broader federal healthcare and research funding policies . Some exchanges were direct and confrontational, with accusations of misdirection and undermining public health .

Participants

Transcript

Subcommittee will come to order without objection.
M
Mr. Thomas Miller
The chair is authorized to declare recess at any time.  Welcome everyone to today's hearing on medical residency antitrust exemption.  I will not recognize myself for an opening statement.  Before I do that, I want to wave on.  We have one member, Mr. Onder, Dr. Onder.   who will be waving onto today's hearing.  Without objection, Mr. Ronder 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, or ACGME, and the centralized hiring system called the match, quote unquote, 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.  And because most opportunities are filled through the match,   The algorithm wields unrivaled power over resident hiring.  23 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.  But before the case could be heard, Congress kowtowed to the hospital lobby and slid an antitrust exemption for graduate medical resident matching programs into the unrelated pension bills.  As a result,
M
Mr. Thomas Miller
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 logarithm 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 $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.  And 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, but 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 of specialized practices like orthopedics, cardiology, and anesthesiology.   According to Medscape 2024 Physician Compensation Report, the average salary for a primary care physician in the United States is $277,000.
M
Mr. Thomas Miller
By contrast, specialists earn an average of over $394,000.  This leaves our communities with fewer family doctors, longer wait times, and a decreased level of care.  A second choke point 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 and 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.
M
Mr. Thomas Miller
Two decades after Congress granted the carve out for this system, the market is more conclusive and less competitive than ever.  Resident wages are completely stagnant.   And 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.

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