Politicization of Graduate Medical Education Antitrust Exemption Obscures Real Workforce Issues and Solutions

Abstract

Visual Abstract.

Although the United States faces a shortage of physicians, efforts to remedy the situation often confront deep ideological divisions. These debates extend to Congress, where recent political considerations of physician workforce development have spread to scrutiny of the antitrust exemption granted to resident matching programs like the National Resident Matching Program (NRMP, The Match). Though seemingly driven by a desire to improve outcomes, the focus on whether training programs should face litigation for participating in a Match is a harmful distraction from genuine challenges to and meaningful reform of physician training and supply. Educators have a responsibility to understand the design and purpose of The Match and to share this context with trainees, fellow faculty, and policymakers.

The Match: Origins and Purpose

The NRMP was incorporated in 1953 to bring order, transparency, and fairness to residency recruitment.^1-3 At that time, hospitals aggressively pursued students with “exploding offers” that required decisions within days if not hours.² Students felt forced to accept positions prior to completing clinical rotations or having adequate time to explore specialties of interest. The Match was a marketplace innovation that reduced these chaotic and coercive practices, gave voice to students’ true preferences for training, standardized recruitment timelines, and optimized placements.

Over the ensuing decades, The Match became a cornerstone of the American training pipeline. Debates and calls for reform occasionally arose, leading to thoughtful discussions and enhancements to its design.^3,4 These have included the addition of couples matching, the prioritization of student preferences above those of programs, and the full incorporation of osteopathic applicants.^3,5-7 Ultimately, when it comes to achieving stable matches that optimize participant preferences and position fill rates, The Match is a proven, mathematically ideal solution.^8,9 Research on the NRMP algorithm led, in part, to the awarding of the 2012 Nobel Prize in Economics.⁹

Recent Congressional Debate

Though The Match has served the field for more than 70 years, on May 14, 2025, the United States House of Representatives Subcommittee on the Administrative State, Regulatory Reform, and Antitrust held a hearing titled The MATCH Monopoly: Evaluating the Medical Residency Antitrust Exemption.¹⁰ The stated intention of this investigation was to “…examine the United States’ medical residency system, which is controlled by a monopoly that reduces competition, suppresses wages, and worsens the doctor shortage…”¹⁰ This investigation reopened an old debate that was previously considered settled after a lawsuit was filed in 2002 by 3 medical trainees who alleged that training programs had suppressed wages and working conditions.¹ To fit these allegations within the form of nationwide class action, plaintiffs argued that programs’ participation in The Match was an unlawful agreement under antitrust laws, and they sought substantial damages from the graduate medical education (GME) community.^1,11,12

While defendants denied liability, Congress intervened to expressly recognize that The Match was a “highly efficient, pro-competitive, and long-standing process” and that participation was not a violation of antitrust laws. A bipartisan amendment to the Pension Funding Equity Act of 2004 (“The Matching Algorithm Exemption”) passed the Senate and was signed into law by President George W. Bush.¹³ In the text, Congress articulated 2 purposes for acting: (1) to “confirm that the antitrust laws do not prohibit sponsoring, conducting, or participating in a graduate medical education residency matching program, or agreeing to do so”; and (2) to “ensure that those who sponsor, conduct, or participate in such matching programs are not subjected to the burden and expense of defending against litigation…”¹³ Given this background, we question whether the subcommittee’s recent efforts to reconsider The Matching Algorithm Exemption may be driven by a misunderstanding of the true purposes of The Match.

The Match in Context

“The Match” is a term often misused to embody the entire transition to residency; when complaints arise with respect to the experiences of young physicians as they enter the workforce, there is often a suggestion that “The Match is broken.” Indeed, legitimate concerns exist regarding costs associated with residency applications, resident salaries, and workplace experiences. However, The Match is neither the source, nor the solution, to such concerns. The NRMP does not dictate terms and conditions of employment, but it does mandate that programs be transparent during recruitment. NRMP policies obligate programs to disclose copies of resident contracts and all institutional policies for appointment, and they never prohibit applicants and programs from engaging in discussions about pay or benefits.

Significant strides have been made in GME working conditions since The Matching Algorithm Exemption was passed in 2004, including the addition of work hour regulations and stronger parental leave policies.^14,15 The quantity of residency training positions has also seen a dramatic expansion, from about 20 000 at the time of the class action lawsuit to more than 40 000 today.¹⁶ In 2025, the NRMP Main Residency Match accommodated more than 50 000 registered applicants and 6626 programs offering 43 237 positions, and it demonstrated an unparalleled capability to scale seamlessly to meet the varying range of supply and demand in the physician workforce, as evidenced by the 2025 overall position fill rate of 99.4%.¹⁶ In contrast to these market efficiencies, consider the struggles teaching hospitals face in consistently filling their attending job openings without a matching system.^17-19

Returning to the subcommittee’s concerns, a more productive approach would be to conceptualize resident issues as spanning 3 interrelated but distinct domains: quantity of applicants and training slots, quality of working conditions and training programs, and market efficiency. Focusing on the antitrust exemption conflates critiques of market efficiency (ie, the NRMP Match) with efforts to improve quantity and quality. In reality, the size of the physician market and the conditions afforded trainees are driven by a variety of factors, including Congressional Medicare funding caps (in place since 1997), state and private grants, specialty boards and professional societies, accreditation bodies, and hospital policies, none of which are the purview of The Match or directly impacted by the antitrust exemption.²⁰ Although a proposed link between the presence of a matching system and suppressed resident salaries is a core argument of the subcommittee’s investigation, this assumption has been empirically discredited by comparing specialties with and without a Match.²¹ Narrowly targeting The Matching Algorithm Exemption to address broader physician workforce issues wrongly perceives the 2 as linked. Examples of more holistic GME reforms proposed in the literature and corresponding action steps for educators are summarized in the Table.

Table.

Examples of Proposed GME Reforms From the Medical Literature With Potential Action Steps for GME Leaders and Faculty

Domain	Target	Actors	Example Levers	Action Steps for Educators	Further Reading
Quantity of training slots and programs	Funding	Federal and state governments	Medicare payment caps Resident Physician Shortage Reduction Act of 2025	Call your representative’s office or partner with your hospital lobbyists for state advocacy Obtain local workforce needs assessments	22, 23
	Geographic maldistribution	Congress, GME leaders	J-1 Visa and Conrad 30 Waiver programs Rural rotation exposure and loan forgiveness	Use IMG-inclusive recruitment approaches Cultivate partnerships with rural and community rotation and elective sites	24, 25
Quality of programs and working conditions	Work hours and burnout	ACGME, GME leaders	Duty hour limits Paid leave policies	Ensure adherence to duty hour rules Normalize the taking of leave in discussions among faculty and leadership to reduce stigma	15, 26
	Salary and benefits	Hospitals	Collective bargaining Housing allowances	Remain educated on developments of resident unionization in your state Ensure transparency about benefits	27, 28
Efficiency, equity, and ease of the marketa	Application process	AAMC, Liaison	Streamlined application with signals Application fees and limits	Set limits on application research listings Provide transparency on interview and ranking decision-making	29, 30
	Matching process	NRMP	Match agreement and policies Consolidation of various matching systems	Set clear post-interview communication norms Participate in NRMP surveys and feedback opportunities	31, 32

^a The 3 E framework for analyzing market design was introduced by Judd Kessler who was a student of Alvin Roth (Nobel Prize winner for work on The Match algorithm).³³

Abbreviations: GME, graduate medical education; IMG, international medical graduate; ACGME, Accreditation Council for Graduate Medical Education; AAMC, Association of American Medical Colleges; NRMP, National Resident Matching Program.

Conclusion

The Match is a mathematically elegant, efficient, and widely trusted feature of American medical education. It is, in fact, one of the few components of our health care system that consistently fulfills its intended purpose. Thoughtful reform and expansion of the physician training pipeline are both necessary and welcome; however, changes in federal regulation and funding are likely more effective levers for expanding the physician pipeline than eliminating Congressional protection for matching programs. Efforts to erode confidence in this marketplace solution have the potential to jeopardize the health and well-being of the American public without directly addressing the pain points of physician selection and training. If policymakers and education leaders are committed to improving GME, we must move beyond misguided scrutiny of The Match and redirect our efforts toward evidence-based policy reforms and expanded funding to strengthen the physician pipeline.