Congressional antitrust investigation of medical residency accreditation and matching programs

The medical residency matching system, which has been in place in the United States since the 1950s, is currently being reviewed by the House of Representatives’ Committee on the Judiciary. Specifically, the Judiciary Committee, through its subcommittee on the administrative state, regulatory reform and antitrust, is examining the legitimacy of the antitrust exemption granted to medical residency matching. 

In letters sent on March 14, 2025 to the Accreditation Council for Graduate Medical Education (ACGME), the American Medical Association, the American Osteopathic Association, the Association of American Medical Colleges, the National Resident Matching Program (NRMP) and to various medical schools and academic medical center sponsors of graduate medical education programs (the Judiciary Subcommittee Letters), the Judiciary Subcommittee expressed concern that: “Over the last two decades, this antitrust exemption has distorted the American medical residency market, undermining free-market principles to the detriment of the nation’s doctors and the patients who rely on them.”

The matching program exemption from antitrust laws

Medical residency programs generally fill their slots using the NRMP (and, in limited circumstances applicable to certain particular medical disciplines, another matching program—the SF Match).

In 2002, a group of physicians filed an antitrust class action lawsuit on behalf of all current and former medical residents challenging the NRMP matching program as a violation of Section 1 of the Sherman Act. The litigation continued for the next several years, leading Congress to conclude that the lawsuit could “undermine this highly efficient, pro-competitive and long-standing process.”

As a result, in 2004 Congress passed the Pension Funding Equity Act, Pub. L. No. 108–218, § 207, 118 Stat. 596 (15 U.S.C. §37(b)) (the Act), which provided an exemption from federal and state antitrust enforcement to sponsors and participants in graduate medical education residency matching programs. In the Findings and Purposes section of the Act, Congress stated:

These matching programs developed as an integral part of the educational system that has produced the finest physicians and medical researchers in the world.  .  .  .  Before such matching programs were instituted, medical students often felt pressure, at an unreasonably early stage of their medical education to seek admission to, and accept offers from, residency programs. As a result, medical students often made binding commitments before they were in a position to make an informed decision about a medical specialty or a residency program and before residency programs could make an informed assessment of students’ qualifications. This situation was inefficient, chaotic and unfair and it often led to placements that did not serve the interest of either medical students or residency programs.

The Confirmation of Antitrust Status section of the act set forth a clear exemption from the antitrust laws for graduate medical education matching programs:

It shall not be unlawful under the antitrust laws to sponsor, conduct or participate in a graduate medical education residency matching program, or to agree to sponsor, conduct or participate in such a program. Evidence of any of the conduct described in the preceding sentence shall not be admissible in Federal court to support any claim or action alleging a violation of the antitrust laws.

Congressional oversight of the NRMP

Now, just over 20 years later, Congress is re-examining the issue and considering whether the antitrust exemption “may reduce competition, harming residency applicants and patients.” Indeed, the opinion of the Judiciary Committee, as expressed by the Subcommittee, is direct and unequivocal:

When medical students apply for residency, they enter a closed job market controlled by an accreditation monopoly, the Accreditation Council for Graduate Medical Education (ACGME). Virtually all ACGME-accredited residency positions are filled through the National Resident Matching Program (NRMP), also known as the “MATCH.”

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The ACGME and the MATCH form a bottleneck to the physician workforce, reducing the number of American doctors. Each year, thousands of medical students fail to match with an ACGME-accredited residency through the MATCH process. In 2024, for example, about 20 percent of applicants—8,869 medical students who otherwise would become licensed doctors—failed to match with a residency position. Because participating in an accredited residency is required to receive a physician license or board certification and the ACGME is the sole medical residency accreditor, virtually all medical students who do not receive a placement through the MATCH are excluded from the physician workforce. As a result, the ACGME and the MATCH make the physician shortage in the US much worse.

The Judiciary Subcommittee Letters state that “[b]y controlling every aspect of the hiring process, the MATCH limits the free choice of both applicants and programs within the residency market.” In particular, the Judiciary Subcommittee Letters reference the inability of applicants to negotiate the terms of their employment and the Match Participation Agreement signed by applicants that is binding on the outcomes of the process. The Judiciary Subcommittee Letters also include an assertion that the organizations that govern the ACGME “appear to facilitate the sharing of employment information, including salary information, among residency programs through affiliated information sharing services like the Council of Teaching Hospitals and Health Systems (COTH) surveys and the Fellowship and Residency Electronic Interactive Database (FREIDA).” Notably, the Judiciary Subcommittee Letters represent that but for the statutory exemption provided by the act, the medical residency matching practices would constitute violations of antitrust laws. 

To assess these concerns, the Judiciary Subcommittee has requested, from each of the recipients of its letter, the following:

• All documents and communications referring or relating to the fairness or complaints about the NRMP matching algorithm;
• All documents and communications referring or relating to the exchange of compensation and employment-related information among the ACGME, the NRMP or medical residency programs, including but not limited to COTH and FREIDA;
• All documents and communications referring or relating to the creation and enforcement of rules that require, incentivize or encourage residents or residency programs to participate in the NRMP;
• All documents and communications referring or relating to complaints or concerns from residents or residency programs regarding the NRMP or ACGME;
• All documents and communications referring or relating to resident compensation limits, resident working conditions or resident hiring restrictions;
• All documents and communications referring or relating to the movement of physician residents among residency positions, including transfers, withdrawals or reassignments; and
• All documents and communications referring or relating to the removal or denial of ACGME accreditation.

There is no set timing for the investigation (although the Judiciary Subcommittee Letter calls for responses to its document and information requests to be submitted within a very short timeframe—by 5:00 pm on March 28, 2025), and the outcome is unclear. Ultimately, if Congress decides to repeal the exemption, a new spate of antitrust lawsuits may be filed soon thereafter. Undoubtedly, its repeal will reshape the future of how medical school students are placed as residents throughout the US.

If you have any questions about this development, please contact the authors of this alert. Norton Rose Fulbright has a long history of representing educational associations and institutions, and can help you evaluate the impact of these developments on your organization.