The MATCH Monopoly: Evaluating the Medical Residency Antitrust Exemption

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Subcommittee will come to order. Without objection, the chair is authorized to declare recess at any time. Welcome everyone to today's hearing on medical residency antitrust exemption. I'll 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 onto 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, 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 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, 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 $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. 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 accredited accreditation monopoly. The ACGME is the sole gatekeeper for the residency program approval in the United States. Without it, 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 carve-out for this system, the market is more collusive 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: 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.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you, Mr. Chairman. Mr. Chairman, 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 on 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 that what really ails our healthcare system is that low-income 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. And 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 number one 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. Taken 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 Resident Matching Program seems beside the point. The healthcare system is facing an outright assault from the Trump administration, and yet we are being called upon 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. And as part of that revisiting, we could account for collective bargaining, which has led to approximately 20% of the resident physician workforce becoming unionized. But 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 exploding 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 be 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% of all U.S. medical school graduates enter residency or full-time practice in the country within 6 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. But 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 subcommittee did under Democratic leadership. We examined issues related to consolidation and market concentration across the healthcare industry, and we passed several pieces of legislation addressing the rising cost of prescription drugs. Many of these issues had bipartisan support, and there is much we can do together. But 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, and I yield back the balance of my time.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

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 and principal attorney at Marek Health Law, a Chicago-based firm that focuses on representing medical residents in 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 to 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 research focuses on drug pricing, FDA regulation, and pharmaceutical policy. We welcome our witnesses and thank them for appearing today. We will 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 know that your written testimony will be entered into the record in its entirety. Accordingly, we ask that you summarize your testimony in 5 minutes Dr. Lin, you may begin.

Dr. James LinSPEAKER_02

Thank you, Mr. Chairman and Ranking Member Nadler and members of the committee. Thank you for the opportunity to testify today on a matter of critical national concern, the increasingly detrimental impact of 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 the sole accrediting body for graduate medical education in the U.S., influencing over $16 to $18 billion in federal and institutional investment. Yet its governance is dominated by faculty from major academic centers. As a result, 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, a general surgery program in Arnot, Elmira, New York; inflexible geographic limitations on training sites despite affiliation with top-tier hospitals, the LECOM Orthopedic Program; requirement redundancies that ignores consortium models, punishing programs for shared training infrastructure; excessive administrative costs, 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 Surgery 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 long-standing program that was closed following an unresolved hotline complaint despite an internal and legal review finding of 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 programs has increased dramatically, many in rural areas. The ACGME one-size-fits-all model disproportionately harms smaller institutions and federally qualified health centers. Programs have been denied probationary periods or closed outright, sometimes via 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 programs directly reduces 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 wait 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. Number one, revise accreditation criteria. Modernize standard to allow flexibility in rural and consortium-based models. Number two, diversify review committees. Ensure rural, osteopathic educators have a voice in shaping specialty standards. Number three, 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 in training and patient care. Protect federal investments. Align ACGME definition with federal and rural health policies to avoid undermining HRSA-supported initiative. The current ACGME model, while well-intentioned, has created systemic barriers that disproportionately harm rural communities, limit innovations, and suppress diversity in physician pipeline. 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 depends on a more inclusive and responsive system. Thank you.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Thank you, Dr. Lin. Mr. Marek, you are now recognized for 5 minutes.

Mr. Sherman MarekSPEAKER_10

All right, there we go. Good morning, Chairman Fitzgerald, Ranking Member Nadler, and members of the subcommittee. Thank you for the opportunity to testify today. My name is Sherman Marek, and I support 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 a thousand residents in disputes with their hospitals. I witness 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 resident there in that position for 3 to 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 to $180,000 annually for each one. And 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 anti anti-competitive 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 from 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.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

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

Mr. Thomas MillerSPEAKER_05

Thank you, Chairman 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 anti-competitive aspects of the activities otherwise protected. Early discovery and initial rulings in that 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 assessed 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 program's 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. There's some question about that. Uh, 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 reform match program rather than displace it completely. They might be added as 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 can shape not just the initial supply of new physicians, but also facilitate how all healthcare providers can deliver more accessible, effective, and affordable 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 mismatches 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 medical care. Of physician licensing as part of their traditional police powers. But neither types 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 of them 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 positions 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.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

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

Dr. William FeldmanSPEAKER_13

Chair Fitzgerald, Ranking Member Nadler, members of the committee, 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 consider 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 the physician workforce and ensuring adequate compensation for residents are laudable and ought to be pursued. And the Match certainly has its downsides, but in my view, eliminating the Match would not necessarily accomplish the goals 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% 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. But 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. And there are certainly other ways of improving wages. Resident unionization, as Chair Nadler mentioned, has accelerated in recent years, with 20% 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 to 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 payers, 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% to the NIH and more than 50% 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 8 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.

Rep. Darrell Issa (R-CA)SPEAKER_11

Chairman, can I have regular order, please?

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Yeah. Mr. Feldman, can you wrap up your comments, please?

Dr. William FeldmanSPEAKER_13

Yep. I would encourage you all 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.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Thank you, Dr. Feldman. We'll now proceed under the five-minute rule with questions. I recognize the gentleman from California, Mr. Issa, for five minutes.

Rep. Darrell Issa (R-CA)SPEAKER_11

Thank you, Mr. Chairman. 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 they that this didn't happen during the previous 4 years. The least you could have done, of course, is is talk about his first 4 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 a 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. Sherman MarekSPEAKER_10

Yes, I agree with that. The government pays an average between $150,000 and $180,000 a year per resident. And they convey about 65,000 to

Rep. Darrell Issa (R-CA)SPEAKER_11

Okay, so 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 know, you've got to stay up for a couple of days to prove you could in the future. I'm okay with that. I understand the stressing. 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 that's been here for 100 days. Mr. Miller, am I misunderstanding what I'm hearing?

Mr. Thomas MillerSPEAKER_05

No, but let me add something else to this. I mean, it's worse. I was working on this about 10 years ago. There's no correlation between the federal funding and the supply of physicians. Now, we could 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, it goes to certain favored parties over a period of time. It's not allocated on a need basis. So It's just more sloshing around of funding, which is unrelated to what we say we're trying to accomplish.

Rep. Darrell Issa (R-CA)SPEAKER_11

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. James LinSPEAKER_02

I would say the latter, Congressman. I think a union is not an answer for rural community, especially small community hospitals. If you look at the current financial situation, we have hospitals closing, nursing homes closing because of the financial stress. And if you increase the wages artificially like that with union, I think that would be detrimental and that would be a hindrance to our future.

Rep. Darrell Issa (R-CA)SPEAKER_11

Now, Dr. Lin, I also serve over the years on the Immigration Subcommittee, so one thing I understand is that we have a minuscule allocation to rural of foreigners able to get visas. Is that something that, uh, 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 Uh, opportunities when they leave, then we allocate slots. It's a quite small number, correct?

Dr. James LinSPEAKER_02

That's correct.

Rep. Darrell Issa (R-CA)SPEAKER_11

Okay. 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. Sherman MarekSPEAKER_10

Well, shortly after we filed the case, I believe that the hospital saw the long, dangerous work hours as their Achilles heel. And so they supposedly voluntarily adopted 80-hour work

Rep. Darrell Issa (R-CA)SPEAKER_11

weeks. Okay. Well Mr. Miller, let me—so 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. Thomas MillerSPEAKER_05

Yeah, it was a very sweeping exemption because basically it also prevented any evidence related to this to be used in collateral actions. So certainly it should be set as narrowly as possible at a minimum.

Rep. Darrell Issa (R-CA)SPEAKER_11

Thank you. Thank you, Mr. Chairman. Yield back.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. Now recognize the ranking member for 5 minutes.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you, Mr. Chairman. Dr. Feldman, since you've been attacked by several of the other witnesses, is there anything you'd like to say in response?

Dr. William FeldmanSPEAKER_13

The one thing I would like to say is that my comment about more funding is about funding 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, is by more funding.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

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. William FeldmanSPEAKER_13

I do think there's value in accounting for diversity in the selection of medical students and residents. I think that having classes with a diverse set of interests and backgrounds can help strengthen the medical care that doctors provide and can strengthen residency classes.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

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. William FeldmanSPEAKER_13

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 place into the one that also ranks you. It is— 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 exploding offers and being pushed to commit early to one program without actually looking at all of the programs, I think would ultimately be problematic for resident, for applicants.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Drawing upon your experience, Dr. Feldman, with the FDA and the pharmaceutical industry, what anticompetitive practices have you encountered that impact most the public's health and well-being?

Dr. William FeldmanSPEAKER_13

I see lots of anti-competitive 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

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

prices. How can a patent— the patent limits the generic?

Dr. William FeldmanSPEAKER_13

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. And so we see anti-competitive practices all of the time from pharmaceutical companies. We see anti-competitive practices from PBMs throughout the pharmaceutical supply chain, and I would love for this subcommittee to be focused on those issues.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

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 undiscriminating approach to cost-cutting, for context, please explain the process by which these grants are made in the first place, Dr. Feldman.

Dr. William FeldmanSPEAKER_13

process by which NIH grants are made? 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.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you. As a researcher who receives NIH funding, what are your concerns about how freezing or terminating grants will affect the research enterprise and on researcher choices?

Dr. William FeldmanSPEAKER_13

I have already seen the chilling effect that these cuts have had. I've 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 for breakthrough therapies.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you. And 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. William FeldmanSPEAKER_13

I'll comment on the latter question. I think that deporting international students, that 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.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you. I yield back.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. Now recognize the gentleman from Virginia for 5 minutes.

Rep. Ben Cline (R-VA)SPEAKER_00

Thank you. Dr. Lin, the ACGME leverages its accreditation monopoly to impose DEI hiring requirements on medical residency programs. According to ACGME program requirement I.C., programs must hire a diverse and inclusive workforce. And we heard Dr. Feldman try and justify that, but race-based hiring requirements are against federal law, and 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. James LinSPEAKER_02

Congressman, I would tell you that of course, personally, I would think that they should not impose their will on individual program. 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. So we just got the email last week.

Rep. Ben Cline (R-VA)SPEAKER_00

It'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. Thomas MillerSPEAKER_05

I think we need to parse a couple of different parts to this. Um, the supply line is a little more complex than just removing the antitrust exemption. Uh, I think it could create some opportunities, but primarily in terms of improving the overall working conditions and the quality of the healthcare workforce we produce. Uh, there are a broader set of tools than that alone. There's some ambiguity over exactly what's driving the production line. I'd suggest we need a, a bigger basket than simply this tool alone. It'll help, but I would not exaggerate its effects.

Rep. Ben Cline (R-VA)SPEAKER_00

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 issues do you see with state medical licensing boards rubber-stamping monopolistic conduct like that of the ACGME?

Mr. Thomas MillerSPEAKER_05

Okay, you're opening up a different basket. Yeah, that's okay. Uh, certainly, uh, many state actions— then that can be— there's real state action, and then there's kind of some periphery state action. Certainly encourage an anti-competitive atmosphere in state physician markets. Um, in general, they are, uh, being carved back, but not as much as they should. We've 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 moving 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. But, but any individual state should be responsible for its medical markets and the results it produces. And I think it's the, the process is 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've got to go a lot further on that front in reciprocity. We had to have the extremes of the COVID situation to begin to find out how we could loosen things up when we're really desperate. We should do that more often as a general rule. And we've got a long way to go in order to expand the overall supply of healthcare, not just kind of the newly minted physicians.

Rep. Ben Cline (R-VA)SPEAKER_00

Staying with the ACGME, medical residency programs can only receive federal funding through Medicare and Medicaid if they're 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. Thomas MillerSPEAKER_05

There's always room for competition, even in, uh, government franchises, and certainly there are ways to think of other forms of certification, uh, 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, though, and take more control of that situation, or states also in their own determination of accreditation deciding they need additional sources. Uh, when you have a shortage of supply and you only have one supplier, it suggests time to either, uh, find some alternatives Or say to the person, let's make some adjustments.

Rep. Ben Cline (R-VA)SPEAKER_00

Thank you, Mr. Chairman. I yield back.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. Now recognize the gentleman from Georgia for 5 minutes.

Rep. Hank Johnson (D-GA)SPEAKER_07

Thank you, Mr. Chairman. 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. James LinSPEAKER_02

Congressman— Okay,

Rep. Hank Johnson (D-GA)SPEAKER_07

So, yes or no? I'm running out of time, so 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. Sherman MarekSPEAKER_10

I don't have an answer for that.

Rep. Hank Johnson (D-GA)SPEAKER_07

Okay, 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 8 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. Thomas MillerSPEAKER_05

A lot of things don't make America healthy, and we could talk about them if you wish to have a wider range of

Rep. Hank Johnson (D-GA)SPEAKER_07

In my time, Dr. Feldman, international medical graduates represent a substantial chunk of physicians practicing in the United States. You said 23% in your testimony, but 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. William FeldmanSPEAKER_13

I think it would be devastating. So international medical graduates often serve in, in rural communities and in primary care roles. And they help solve the physician shortage that we're here to talk about today.

Rep. Hank Johnson (D-GA)SPEAKER_07

Yeah, that would not make America healthy again, would it?

Dr. William FeldmanSPEAKER_13

It would not.

Rep. Hank Johnson (D-GA)SPEAKER_07

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 for those programs?

Dr. William FeldmanSPEAKER_13

I think that we need to increase funding because we have a physician shortage, and the way to solve the physician shortage in part is through more positions. The only way to have more positions is more funding.

Rep. Hank Johnson (D-GA)SPEAKER_07

That's common sense. And Mr. Miller, you're shaking your head, No. I don't understand, but back to Dr. Feldman, Republicans are floating ideas, are floating an idea that would require doctors to work even longer to achieve Public Service 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 the availability of care, particularly in rural or underserved areas?

Mr. Thomas MillerSPEAKER_05

If you ask the wrong question, you'll get the wrong answer.

Rep. Hank Johnson (D-GA)SPEAKER_07

I'm asking Dr Cohen. I .

Mr. Thomas MillerSPEAKER_05

thought you were asking

Dr. William FeldmanSPEAKER_13

me. I'll tell you, as somebody who is is, is doing public service loan forgiveness, uh, and, and who started paying down my student loans during residency. Um, there's no reason to, to push that out. And, and I think it's, it's a very good program, and it's a way to get physicians in, into, uh, into the workforce. And, um, I think it'd be a bad idea.

Rep. Hank Johnson (D-GA)SPEAKER_07

Yet 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.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman's time has expired,

Rep. Hank Johnson (D-GA)SPEAKER_07

and I yield back the remainder of it.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back.

Mr. Thomas MillerSPEAKER_05

Gentlewoman from Wyoming is recognized.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Mr. Miller, you seemed as though you had something to say.

Mr. Thomas MillerSPEAKER_05

Well, there's one view of the world which says simply, pour more resources in and everything will work wonderfully. Problems with our healthcare system are what we're getting out of it as well as what we're putting into it. And so 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 in order to get a better healthcare system. It is not— should not be solely focused 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.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Okay, 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 and with barriers related to financing, transportation, and access. Dr. Lin, is it difficult for rural hospitals to meet ACGME's accreditation requirements?

Dr. James LinSPEAKER_02

It is challenging, Congresswoman. Number one—

Rep. Harriet Hageman (R-WY)SPEAKER_12

What are those challenges?

Dr. James LinSPEAKER_02

Some of the challenges are some of the standards that they put in place that, for example, distance radius. Obviously, if you look at rural America, there's 1,300 critical access hospital, and by critical access hospital, by definition, they're less than 25 beds. So given that, if you're training a physician, obviously scope and volume becomes a problem. So when you're trying to train a rural program for residents, you have to send them to distance away for training. And 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 had partnership with them, and that was not acceptable to them. So 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.

Rep. Harriet Hageman (R-WY)SPEAKER_12

So do you have some ideas of how to fix those kind of accreditation problems?

Dr. James LinSPEAKER_02

Yeah, absolutely. If you look at prior to 2015, the merger of the ACGME and the AOA, there was an alternative accreditation body, which is from the AOA. And if you look at prior to the merger, most osteopathic institutions have a consortium model where we have a network of small community hospitals and/or community hospitals, and we sort of 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. And that model has worked out for many, many years. Millcreek Community Hospital, which now is called LECOM

Rep. Harriet Hageman (R-WY)SPEAKER_12

Why was it changed?

Dr. James LinSPEAKER_02

It changed because—

Rep. Harriet Hageman (R-WY)SPEAKER_12

Of the merger?

Dr. James LinSPEAKER_02

Of the merger. That's correct.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Specifically, the issue that this committee addressed, antitrust, is, is focusing on, correct?

Dr. James LinSPEAKER_02

In my opinion, yes.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Okay. Mr. Miller, there is 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. Thomas MillerSPEAKER_05

Well, the— it sounds like a euphemism. You know, the, the goal is to have everything based upon competition, quality, and merit. The rest of these distinctions are ancillary and can be distracting from that. I don't want to overstate the magnitude of DEI, and this is going to fight its way out through the courts. We've got rulings. They're going to be interpreted, and some games are going to be played in the educational system in general, not just for physicians. But 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. But I think that's going to work itself out through further litigation, probably more so than random interventions.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Okay. 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. Sherman MarekSPEAKER_10

I think the harm goes all the way back to 1952, frankly.

Rep. Harriet Hageman (R-WY)SPEAKER_12

From the beginning, just created the program itself.

Mr. Sherman MarekSPEAKER_10

People got their positions by telegrams back in 1952. The problems then have no relevance to today, in my view.

Rep. Harriet Hageman (R-WY)SPEAKER_12

Okay. Thank you. I yield back.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

The gentlewoman yields back. The gentleman from Illinois is now recognized for 5 minutes.

Rep. Chuy Garcia (D-IL)SPEAKER_09

Thank you, Chairman Fitzgerald and members, the witnesses that are here today. We're here today because we're 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. So 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 be 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. William FeldmanSPEAKER_13

I think it could, because what I think I would worry about is a 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, would be lost, I think.

Rep. Chuy Garcia (D-IL)SPEAKER_09

Thank you. Clearly, this is a nuanced issue, and Congress should be taking a nuanced approach to it as well. Our one relevant factor here is that most medical residencies are at least partially funded by federal dollars. So 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. William FeldmanSPEAKER_13

I would agree.

Rep. Chuy Garcia (D-IL)SPEAKER_09

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. But 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. William FeldmanSPEAKER_13

At the center of the— 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, which can, can keep list prices high, and, and patients don't see the benefits of those discounts. In fact, their out-of-pocket costs are tied more to, to list prices. And so PBMs have been in part responsible for, for driving some of the high out-of-pocket costs that we see. In vertical integration, when, when PBMs and pharmacies and payers are all owned by the same company can lead to reduced choices at the pharmacy and, and bad outcomes for patients.

Rep. Chuy Garcia (D-IL)SPEAKER_09

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.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

The gentleman yields back. I'm now going to recognize myself for 5 minutes and yield my time to the gentleman from Missouri for 5 minutes who waved on to the committee.

Rep. Robert Onder (R-MO)SPEAKER_03

Thank you, Mr. Chairman, 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. James LinSPEAKER_02

So, in my written testimony, my oral testimony, it's a combination of our LECOM Health System hospitals.

Rep. Robert Onder (R-MO)SPEAKER_03

Okay. And I was reading in your early— in your written testimony that there was a general surgery program, let's see, the termination—oh, is that of the director due to noncompliance with COVID-19 vaccination?

Dr. James LinSPEAKER_02

Yeah, so that was in our Elmira campus, in 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. So the program director resigned from the position, and because of that, there was no program director and they shut down the program.

Rep. Robert Onder (R-MO)SPEAKER_03

Oh, and that was my question. The program did end up getting shut down?

Dr. James LinSPEAKER_02

Yes.

Rep. Robert Onder (R-MO)SPEAKER_03

Okay. And do you have an estimate about how many residency programs have been shut down over the years because

Dr. James LinSPEAKER_02

of ACGME? So I just have general statistics where after the merger of the ACGME and AOA, there's approximately 670-some programs that have closed. And 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. But if you look at it disproportionately, it's always the smaller community program that is not as resourced as a tertiary care center or university-based center that can't meet the standards that are getting shut down,

Rep. Robert Onder (R-MO)SPEAKER_03

Right? Yeah, that's what it seems to me, that it's a matter of 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. James LinSPEAKER_02

Correct. And I would say that Dr. Feldman and my job are probably very different. His environment, my environment is 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. So from that perspective, I'm not saying ACGME is bad. I'm saying that there needs to be an alternative way to focus on a different venue so we can create different types of physicians.

Rep. Robert Onder (R-MO)SPEAKER_03

Nor, I'm sure, are you saying that every residency program in the country is, is good, that, that there isn't—

Dr. James LinSPEAKER_02

right, there has to be a standard.

Rep. Robert Onder (R-MO)SPEAKER_03

There has to be a standard. But 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 shutting down programs. Correct. And I believe there was a question earlier in this about DEI and maybe ACGME backing away from DEI requirements. Did did one of you one of the witnesses address that?

Dr. James LinSPEAKER_02

Yes, that was me. We did receive an email notifying all the programs that as of May 9th, they're suspending the DEI requirements that used to be an institutional and common program requirement for every sponsoring institution as well as programs.

Rep. Robert Onder (R-MO)SPEAKER_03

And did many of those programs have DEI officers or someone employed to monitor these mandates?

Dr. James LinSPEAKER_02

Well, yes, that— yeah, because using the standards to want to maintain the the program, uh, the individual program institution would have to expend resources to meet that requirement.

Rep. Robert Onder (R-MO)SPEAKER_03

Yeah, my concern there, of course, is that even if the requirement goes away, all of 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, I think, both moral principle and federal law. But that's something I think ACGME has given us over the years. Well, thank you for your testimony. I yield back.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. We now recognize the ranking member of the full committee for 5 minutes.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

Thank you very much, Mr. Chairman. Dr. Feldman, President Trump and Secretary Kennedy want to cut $18 billion from NIH. They want to cut $3.5 billion from CDC, the Centers for Disease Control, and 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. William FeldmanSPEAKER_13

I think 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. NIH funding has contributed to cures for hepatitis C, to treatments for HIV, 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. I think it's a bad idea.

SPEAKER_UNKNOWN

Yeah.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

So it sounds like we would be essentially destroying the wellspring for research across the board.

Dr. William FeldmanSPEAKER_13

I think that's right. And what you have to remember is that the NIH is funding the highest-risk, highest-reward research that pharmaceutical companies then take to market. So it's hard to know what's going to work and what doesn't, and that's why you need broad funding. And the NIH has been incredibly successful in funding new cures.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

So 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. William FeldmanSPEAKER_13

I think what's hard about this is that we can't know until we actually do the research, and we can't do the research until the funding comes. But you mentioned some key disease areas that are vital for public health. Cancer— we've had breakthroughs in cancer therapy over the last 10, 20, 30 years, checkpoint inhibitors that treat a variety of different malignancies. Alzheimer's, dementia— there are numerous untreated diseases. In my, in my area of pulmonology, COPD, asthma, these are diseases that, that have had some, some recent breakthroughs, but I would love to see more therapies available for patients.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

My guest to 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'd done anything wrong, but because she'd 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're dismantling the basic research that's going on at NIH about it?

Dr. William FeldmanSPEAKER_13

The way to make progress on childhood cancer, other diseases of childhood, is through funding the research enterprise that, that finds new cures.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

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, in what parts of the country, are most affected by these Medicaid cuts?

Dr. William FeldmanSPEAKER_13

These cuts will affect the most disadvantaged members of society in rural communities, urban communities, and cities. I think it will lead to very bad health outcomes.

Full Committee Ranking Member Jamie Raskin (D-MD)SPEAKER_01

All right. My time is up, but thank you, Mr. Chairman.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. We're now going to recognize the gentleman from California for 5 minutes.

Rep. Lou Correa (D-CA)SPEAKER_06

Thank you, Mr. Chairman. First of all, I want to welcome the witnesses here today. My wife's a medical doc, and this subject brings back a lot of memories, some kind of nightmarish, residence as an OB resident, putting in all those hours, 90 hours a week. 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, on a tight budget. It worked out. So 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. William FeldmanSPEAKER_13

I think that the downsides have been spelled out by other witnesses and, and to an extent in, in my testimony. I mean, it— the, the current system does not allow individuals to negotiate salaries or benefits directly with institutions.

Rep. Lou Correa (D-CA)SPEAKER_06

So let me ask you, so it's an issue of money, so to speak, like everything else. How much can you pay? And we're looking at possible Medicaid cuts. Where do most of the match— where is that funded? You got medical schools that are growing. You got 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're moving on their own to try to alleviate the challenges they have. So we want to have more docs, expand the match, what does it take? More money?

Dr. William FeldmanSPEAKER_13

I think we need more residency positions. And as you said, the funding for residency positions comes largely from Medicare and Medicaid, so I think 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.

Rep. Lou Correa (D-CA)SPEAKER_06

Inner-city, rural areas, farms, Midwest. Is that what you're talking about?

Dr. William FeldmanSPEAKER_13

All of what you just mentioned.

Rep. Lou Correa (D-CA)SPEAKER_06

Because I know that 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. But, yeah, there's not much money to be made as a doc in the middle of nowhere.

Dr. William FeldmanSPEAKER_13

I, I would love to see more incentives for primary care doctors in these underserved communities, including rural communities.

Rep. Lou Correa (D-CA)SPEAKER_06

Give me an example of a, of an incentive. Higher pay, loan forgiveness— what are we talking about?

Dr. William FeldmanSPEAKER_13

I think, you know, we could debate what incentives would work best. Loan forgiveness, I think, is a good example of, of a way in which um, the system might be able to entice physicians into areas that they might otherwise not be considering?

Rep. Lou Correa (D-CA)SPEAKER_06

Well, you know, I, I remember again speaking to my spouse and her colleagues. The new, the new brand spanking new docs that are hitting the market, half a million dollars in, in debt, something like that. An unbelievable amount of money. So how does a doc like that coming out of medical school residency balance their checkbook.

Dr. William FeldmanSPEAKER_13

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. We're

Rep. Lou Correa (D-CA)SPEAKER_06

Looking at we need more money, and I think 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'd have appreciated your efforts. But today, here we are, and 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. William FeldmanSPEAKER_13

I don't think you're missing anything. I agree.

Rep. Lou Correa (D-CA)SPEAKER_06

So we all 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. William FeldmanSPEAKER_13

I agree. I think if the focus is on solving the goals set out by this subcommittee of addressing physician shortages and improving resident salaries, there are numerous, countless ways to do that, that I think are worth discussing.

Rep. Lou Correa (D-CA)SPEAKER_06

Thank you very much. And I thank the witnesses all for their time and interest in this issue. Mr. Chairman, I yield.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Gentleman yields back. Recognize Mr. Nadler for some unanimous consent requests.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you, Mr. Chairman. I ask unanimous consent to submit for the record this statement from the Association of American Medical Colleges dated May 14th, 2024.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Without objection.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

And 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 4th, 2024.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

Without objection.

Ranking Member Jerrold Nadler (D-NY)SPEAKER_08

Thank you, Mr. Chairman.

Chairman Scott Fitzgerald (R-WI)SPEAKER_04

I ask unanimous consent to enter into the record the following statements: a statement from Dr. John Ward, a double board-certified dermatologist practicing in Florida; a statement from Dr. Caleb Atkins, 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, senior fellow at the Cato Institute. No objection. 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 5 legislative days to submit additional written questions for the witnesses or additional materials for the record. Without objection, the hearing is adjourned.