▶ 0:17:36Subcommittee will come to order. Without objection, the chair is authorized to declare recess at any time. We welcome everyone to today's hearing on medical residency antirust exemption. Uh I'll now recognize myself for an opening statement. Uh before I do that, I want to wave on. We have one Um Mr. and uh Dr. Ander who will be waving on to today's hearing. Without objection, Mr.
▶ 0:18:04Ander 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.
▶ 0:18:31The 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. uh through mountains of red tape, the AG the ACGME alone decides which programs survive and how they operate.
▶ 0:18:57And because most opportunities are filled through the match, the allegorithm weed wields unrivaled power over resident hiring. 23 years ago, residents tried to challenge this setup under America's antitrust laws. They argued uh that the ACGME and MACH uh and the programs operating under them colluded to restrict slots, limit choice, and keep wages low.
▶ 0:19:23But before the case could be heard, Congress counted to the hospital lobby and slid an antitrust exemption for graduate medical resident matching programs into the unrelated pension bills. Uh as a result uh there's no competition now and it decides the fate of more than 50,000 residents and fellows uh each year. Applicants cannot negotiate pay. They must accept whatever slot the logorithm hands them or whatever terms uh they are given.
▶ 0:19:53Uh the command and control model eliminates competition and flattens salaries. Last year the average firstear resident earned just 66 thou $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 a doctor shortage. Each cycle, thousands of graduates fail to match with the program.
▶ 0:20:22Last 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 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.
▶ 0:20:51The 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.
▶ 0:21:17Instead, 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.
▶ 0:21:45This 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.
▶ 0:22:11Doctors must graduate from an ACGME accredited program to practice medicine. The organization uses that leverage to impose one-sizefits-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.
▶ 0:22:35Two decades after Congress granted the carve out for this system, the market is more conclusive and less competitive than ever, resident wages are completely stagnant. And America is producing fewer practicing doctors even as demand for affordable, highquality 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?
▶ 0:23:03Today's witnesses know this system firsthand. Their testimony will help the committee understand the medical residency market and confront the anti-competitive 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. Thank you, Mr. Chairman. Mr.
▶ 0:23:33Chairman, 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 and 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 health care system is that low-income Americans, people with disabilities, and children have too much health care.
▶ 0:23:59That is the only explanation because of course it couldn't just be a cynical ploy to fund massive tax cuts for billionaires in the backs of the 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.
▶ 0:24:22Under 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 data sets and public health tracking tools, and cut or threaten to cut billions of dollars in grants for scientific research.
▶ 0:24:44At 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.
▶ 0:25:13Meanwhile, Republicans cheer as the administration's immigration policies chase out foreignborn 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 health care research, access to critical health data, and access to care. The impact of these cuts will likely fall most deeply on marginalized communities.
▶ 0:25:43But we will all suffer the consequences. That is why today's hearing on the national residency matching program seems beside the point. The healthcare system is facing an outright assault from the Trump administration. And yet we are being called 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.
▶ 0:26:05Any 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.
▶ 0:26:25But 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.
▶ 0:26:51Before 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 s short fuses.
▶ 0:27:20This 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.
▶ 0:27:49But statistics show that 99% of all US medical school graduates enter residency or full-time practice in the country within six years of graduation. There is simply little evidence to suggest that foreign medical school graduates are taking slots from US 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.
▶ 0:28:17and we have already seen where the Republicans priorities lie. Finally, if the majority wishes to address flaws in the health care 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.
▶ 0:28:46But instead, Republicans want to distract us from their disastrous healthc care 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. Gentleman yields back. Without objection. All other opening statements will be included in the record. We'll now introduce today's witnesses. Dr. James Lynn. Dr.
▶ 0:29:09Lynn is a clinical professor of geriatric medicine at the Lake Erie College of Osteopathic Medicine and the president of the Lake Institute for Successful Living. His practice focuses on geriatrics, internal medicine, and primary care. Mr. Sherman Merik. Mr. Merrick is the founder and principal attorney at Merik Health Law, a Chicago based firm that focuses on representing medical residents in disputes with teaching hospitals through internal appeals.
▶ 0:29:39administrative proceedings, direct negotiations, mediation, and litigation. Over the past 25 years, he and his firm have represented more than 1,000 medical 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 the healthcare re of healthcare reform.
▶ 0:30:09He previously served as a senior health economist with the joint economic committee and as a senior lecturing fellow at the Duke at Duke University School of Law. Dr. Will William Feldman. Dr. Feldman is an assistant professor of medicine at Harvard Medical School and Brighgam and Women's Hospital. Dr. Feldman's research focuses on drug pricing, FDA regulation, and pharmaceutical policy. We welcome our witnesses and thank them for appearing today.
▶ 0:30:39We 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.
▶ 0:31:08Please know that your written testimony will be entered into the record in its entirety. Uh, accordingly, we ask that you summarize your testimony in five minutes. In five minutes, Dr. Lynn, you may begin. 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.
▶ 0:31:32The 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. 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.
▶ 0:32:01Despite 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 policies. ACGME is a sole accrediting body for graduate medical education in the US, influencing over 16 to 18 billion in federal and institutional investment.
▶ 0:32:30Yet its governance is dominated by faculty from major academic centers. As a result, accreditation criteria designed for high resource university hospitals, not for the realities of rural health systems. Programs have closed due to faculty departure tied to vaccination van mandates, a general surgery program in Arnet uh Elmyra, New York. Inflexible geographic limitations on training sites despite affiliation with top tier hospitals.
▶ 0:32:58Lecom Orthopedic program requirement redundancies that ignores consortium models punishing programs for sheer 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 Leecom orthopedic Surgical Residency Program.
▶ 0:33:24Despite 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, disrupt their careers, and stripped Erie County of essential orthopedic care. The Leecom internal medicine residency program.
▶ 0:33:47This 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 gastronurology and pulmonary fellowship, eliminating critical pipeline for specialty care. Since 2020, the number of withdrawn or closed program has increased dramatically, many in rural areas.
▶ 0:34:12The ACGME one-sizefits-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 The loss of residency program directly reduced patient access today and in the future.
▶ 0:34:42Without local training opportunities, DOS's candidates faces increasing exclusion from competitive specialties due to documented disparities in the match. Moreover, rural systems and urban underserved are left with workforce shortages, longer weight times, and higher recruitment costs. Even federal efforts are thwarted.
▶ 0:35:03Despite winning a rural residency planning grant from HERSA, 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 solution. Number one, revise accreditation criteria. Modernize standard to allow flexibility in rural and consortionbased models.
▶ 0:35:30Number two, diversity review committees ensure rural osteopathic educator have a voice in shaping specialty standard. Number three, create an alternative accredit accredititor. Promote innovative training track models specifically designed for rural and urban underserved areas. Streamline administrative burden. Shift focus from bureaucratic checklist to actual outcomes in training and patient care. Protect federal investments.
▶ 0:35:56align ACGME definition with federal and rural health policies to avoid undermining HERSA supported initiative. The current ACGME model while well-intentioned has created systemic barriers that disproportionately harm rural communities, limit innovations and suppress diversity and 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.
▶ 0:36:23We 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 region depends on more inclusive and responsive system. Thank you. Thank you, Dr. Lynn. Uh Mr. Merik, you're now uh recognized for five Here we go.
▶ 0:36:49Good morning, Chairman Fitzgerald, Ranking Member Nadler, and members of the subcommittee. Thank you for the opportunity to testify today. My name is Sherman Merrick, 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.
▶ 0:37:15I 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
▶ 0:37:45contributes 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.
▶ 0:38:09Residents 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.
▶ 0:38:39Residents 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 to $180,000 annually for each one. and the public loses someone who would otherwise help reduce the physician shortage.
▶ 0:39:06That 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.
▶ 0:39:37It 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.
▶ 0:39:55That 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 Junk case did not stand alone in its conclusions.
▶ 0:40:19Independent experts and studies have corroborated our 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.
▶ 0:40:39The 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.
▶ 0:41:07Based 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. Thank you, Mr. Merrick. Mr. Miller, you may begin.
▶ 0:41:33Thank you, Chairman Fitzgerald, Ranking Member Nadler, and members of the subcommittee for the opportunity to testify today on the medical residency antirust 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.
▶ 0:41:57Today'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.
▶ 0:42:27Most 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 and older class action litigation concerning the match program provided evidence of serious problems.
▶ 0:42:46Absent 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.
▶ 0:43:16My 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.
▶ 0:43:40How to fix selection timing problems in a resident market monopsiny 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.
▶ 0:43:59Uh the main drawbacks tied to older legal objections appear to be the vastly unequal bargaining power, the wage suppression and compression, and ownorous working conditions for residents that the program's interrelated rules and practices sustain. Reduced labor market competition reduces the quality, availability, and value of health care services.
▶ 0:44:21I 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.
▶ 0:44:42However, 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 health care 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 health care providers can deliver more accessible, effective, and affordable care.
▶ 0:45:07Most policy interventions aimed at rebalancing competitive forces within physician labor markets face resistance not only from the powerful interest groups benefiting from the long-standing 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 physician licensing as part of their traditional police powers.
▶ 0:45:36But 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.
▶ 0:46:07The 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.
▶ 0:46:37Thank you, Mr. Miller. Dr. Feldman, you may now begin. 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.
▶ 0:47:03For 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 um as they consider potential removal of this long-standing 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.
▶ 0:47:29The goals of this subcommittee as expressed in those letters of increasing physician workforce and ensuring adequate compensation for residents are laudable and ought to be pursued. 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.
▶ 0:47:58The 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 for Medicare and Medicaid and the hospitals themselves. But the match per se is not the bottleneck in the physician shortage.
▶ 0:48:24Beyond 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 US economy from tech to financial services benefit from the infusion of highly skilled workers who train abroad. Why should medicine be different?
▶ 0:48:45On the question of res residency wages, I can tell you firsthand um that living on a residency salary while trying to pay off student loans and start a family was challenging, but it's not clear that eliminating the match would yield higher salaries across the board without disruption. There are certainly other ways of improving wages. Resident unionization, as Chair Nadler mentioned, has accelerated in recent years with 20% of all residents now unionized, including at my own institution.
▶ 0:49:16Through 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. Resid residency programs can and should offer more and Congress could facilitate this in any number of ways beyond actions to eliminate the match.
▶ 0:49:39From 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.
▶ 0:50:07Foundational research funded by the NA 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 wellstaffed FDA for evaluation, and strong public players, including Medicare and Medicaid for access.
▶ 0:50:35Yet, 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.
▶ 0:50:59A large number of which by the way are for clinical trials that uh 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 lowcost generic drugs to keep prices down for patients was terminated.
▶ 0:51:27Proposed 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 cost of uncompensated care. This committee has begun asking hard questions about medical training in the United States, which is good. Chairman, can I have regular order, please? Yeah. Mr. Felman, can you uh wrap up your comments, please? 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. Thank you, Dr. Felman.
▶ 0:51:58Will now proceed under the five-minute rule with questions. I'll recognize gentleman from California, Mr. Isa, for five minutes. Thank you, Mr. Chairman. Dr. Dr. Felman, I I love it. Uh you just had to go for a minute and 25 seconds on a rant against Trump for a 100 days as though what we're hearing about today had anything to do with it or that any real difference has occurred in a 100 days to uh the root causes of not having enough physicians or that they that this didn't happen
▶ 0:52:28during the previous four years. The least you could have done, of course, is is talk about his first four years to give him at least a chance to have had some impact. But you chose not to. I heard you say money, money, money. I I think I'll go to Mr. Merrick. You spend a fortune to become a doctor.
▶ 0:52:49Then you're 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 the federal government already pays more than you receive. Isn't that true if you're a Yes, I agree with that.
▶ 0:53:12The government pays an average between 150 and 180,000 a year per resident and they convey about 65,000 to each resident. Okay. So, we've all heard about, you know, the the rough hours that that doctors go through and uh sort of part of this 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.
▶ 0:53:39What 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. Well, getting a doctor for free who they bill out is somehow the fault of an administration that's been here for 100 days. Mr.
▶ 0:54:08Miller, do can am I am I misunderstanding what I'm hearing? No, but let me add something else to this. 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.
▶ 0:54:36It'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. Dr. Lynn, uh Dr. Feldman seemed to think that unions were the answer while maintaining an antitrust exemption. Uh do you see that as the answer? Do or do you see that a free market or at least a partial free market being restored could help with this problem? Uh I I would say the latter.
▶ 0:55:06Uh Congressman, I think uh union is not an answer for rural community, especially small community hospitals. If you look at the current um financial situation, we have hospitals closing, nursing homes closing because of the financial stress. And if you increase the the the wages artificially like that um with union I think that would be detrimental and that would be a hindrance to uh our future. Now Dr.
▶ 0:55:35Lynn 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 foreignb born doctors some of whom have been US educated who are looking for those uh opportunities when they leave then we allocate slots. It's a quite small number. Correct.
▶ 0:56:05That that's correct. Okay. Uh Mr. Merrick, you uh your case was dismissed because Hillary Clinton and the late uh Senator Ted Kennedy got together and slipped it in there and uh 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?
▶ 0:56:29Well, shortly after we filed the case, I believe that the hospital saw the long dangerous work hours as their Achilles heel. Uh and so they uh supposedly voluntarily adopted 80 80our work. Okay. Well, Mr. Miller, uh let me so I'll take that as some good only 80 hours. Uh Mr.
▶ 0:56:51Miller, 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?
▶ 0:57:13Yeah, it was a very sweeping exemption because basically it also prevented any evidence related to this to be used in in collateral actions. So certainly it should be set as narrowly as possible at at a minimum. Thank you. Thank you Mr. Chairman to yield back. Gentleman yields back. Now recognize the ranking member for five minutes. Thank you Mr. Chairman, uh, Dr.
▶ 0:57:33Feldman, since uh, you've been attacked by several of the other witnesses, is there anything you'd like to say in 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 positions. And the way to do that is is by more funding. Thank you, Dr. Feldman. In an April executive order, the Trump administration once again took aim at institutions of higher education.
▶ 0:58:03This time it was focused on the administration's crusade against DEI. Can you explain whether there is a value in accounting for diversity in in the provision of medical care? I do think there's value in accounting for diversity in the selection of medical students and residents.
▶ 0:58:23I think that having uh classes with a diverse set of interests and backgrounds can help strengthen the medical care that doctors provide and can strengthen residency classes. 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?
▶ 0:58:52The the experience with the match is that you apply to a bunch of programs, interview, you rank the the programs that you like the best and you place into the one that uh also ranks you.
▶ 0:59:08It it is a a the match is not without its its downsides as I've said, but I would worry that eliminating the match would create a a kind of free-for-all that would make it harder for applicants.
▶ 0:59:24this idea that that you mentioned about exploding offers and um being pushed to to commit early to uh one program without actually looking at all of the programs, I think would ultimately be problematic for resident uh for for applicants. Drawing upon your experience, Dr. Dr. Feldman with the FDA and the pharmaceutical industry.
▶ 0:59:49What anti-competitive practices have you encountered that impact most the public's health and well-being? I see lots of anti-competitive practices in the pharmaceutical industry. I'll give you one example that's that's very close to research that that I I've conducted uh with our team at Harvard Medical School.
▶ 1:00:11We see brandname pharmaceutical companies uh obtaining patents that limit generic competition that limit the entrance of lowcost generics onto the market. More competition is the way that we bring down drug prices. I think a patent uh the patent limits the generic. Well, the the the companies list the patents with the FDA in what's called the orange book and and um the generic entrance can't come onto the market until those patents expire or they challenge them in court.
▶ 1:00:38And so, uh, we see anti-competitive practices all of the time, uh, from pharmaceutical companies. We see anti-competitive practices from PBMs throughout the the pharmaceutical supply chain. And I would love for for this subcommittee to to be focused on those issues. 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.
▶ 1:01:05For context, please explain the process by which these grants are made in the first place. Dr. Feldman, the the process by which NIH grants are made. Well, we we uh spend many many hours writing grant applications. We submit them to the NIH. They go to study sections for evaluation, peer review, um and in the grants that have a certain score end up uh end up getting funded. It's an arduous process.
▶ 1:01:30It 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 to to cut um funding from the NIH. 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 researcher choices? I have already seen the chilling effect that these cuts have had.
▶ 1:01:57I've had conversations with colleagues who are in academia and have have thought about uh 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. Uh and I think these cuts are are going to be devastating if they persist for for breakthrough therapies. Thank you.
▶ 1:02:18And finally, um the administration has been uh doing everything it can to deport uh foreign students and uh researchers. Um to what extent do you think what I just said is accurate and to and how will this affect uh medical care? I'll comment on the the the latter question.
▶ 1:02:41I think that that deporting international students that making it hard for international students to to learn in the United States and practice in the United States will only contribute to the physician shortage. Thank you. I yield back. Gentleman yields back. Now recognize a gentleman from Virginia for 5 minutes. Thank you, Dr. Lynn. The ACGME leverages its accreditation monopoly to impose DEI hiring requirements on medical residency programs.
▶ 1:03:08According to ACGME program requirement IC, programs must hire a diverse and inclusive workforce. And we heard m 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 Admission versus Harvard that educational institutions cannot base admission on race either. American healthc care patients suffer when residency programs focus on gender or skin color instead of a resident's competency.
▶ 1:03:38Do you think the ACGME should be in the business of forcing programs to hire residents based on race or gender instead of merit? Uh, Congressman, um, I would tell you that, uh, of course, personally, I I would, uh, think that they should not impose their will on individual program.
▶ 1:03:57Uh some good news as May 9th um the ACGME has suspended their common standard for DEI practices and uh it remain to be seen how they're going to change their standard. Um so we just got the email uh last week. 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 shortage.
▶ 1:04:27Would removing the medical residency antitrust exemption make the market more competitive? 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 antirust exemption. uh I think it could create some opportunities but primarily in terms of improving the overall working conditions and the quality of the health care workforce we produce.
▶ 1:04:56Uh there are a broader set of tools than that alone. There's some ambiguity over exactly what's driving the uh 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. Thank you. As you know, to receive a physician's license, doctors are required to participate in an ACGME accredited residency.
▶ 1:05:21Traditionally, state licensing requirements that facilitate anti-competitive 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? Okay, you're you're opening up a basket. That's okay.
▶ 1:05:41Uh certainly uh many state actions you know that can be there's real state action and then there's kind of sub periphery state action certainly encourage an anti-competitive atmosphere in in in state physician markets. Um in general they are uh being carved back but not as as as much as they should.
▶ 1:06:05We'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 we're moving slower than we should on that front. Uh states certainly could do a better job in this regard and there are as I've suggested other federal levers to uh give them some encouragement to do so.
▶ 1:06:29uh but but any individual state is should be responsible for its medical markets and the results it produces and I think it's the 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 end 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 and we've
▶ 1:06:59got a lot long way to go in order to expand the overall supply of of healthare, not just kind of the newly physicians. 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 andoff switch for billions of dollars in federal funding.
▶ 1:07:21With 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?
▶ 1:07:39There's always room for competition even in 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.
▶ 1:08:04uh 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. Thank you, Mr. Chairman. I yield back. Gentleman yields back. Now recognize a gentleman from Georgia for 5 minutes. 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.
▶ 1:08:30This 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.
▶ 1:08:55I'm proud that the Centers for Disease Control and Prevention is headquartered in my hometown of Atlanta, but the Trump administration already cut 2400 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. Lynn? Yes or no?
▶ 1:09:27Uh, Congressman, okay, 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? Uh, Mr.
▶ 1:09:56Mor, yes or no? I don't have an answer for that. Okay. Well, it's clear. It's abundantly clear. Uh, to, uh, most Americans uh, exempting, of course, MAGA Republicans, I guess, would not understand.
▶ 1:10:13Uh, 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 health care so that they can fund tax breaks for their billionaire buddies. Mr. Miller, that does not make America healthy again, does it? A lot of things don't make America healthy. We could talk about them if you wish to have a wider range of my time. Uh, Dr.
▶ 1:10:42Feldman, 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 non-citizens to come work in the United States. How would it impact care in this country if we lost those international medical graduates? I think it would be devastating.
▶ 1:11:11So, international medical graduates often serve in in rural communities in in primary care roles and they help solve the physician shortage that we're here to talk about today. Yeah. That would not make America healthy again, would it? It would not. Dr. Felman, the Trump administration and Republicans are trying to slash spending to federal health care.
▶ 1:11:32Could 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 uh for for programs? I 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 is more funding.
▶ 1:12:02That's common sense. And Mr. Miller, you're shaking your head. No, I don't understand. But back to Dr. Feldman. Uh, Republicans are floating ideas are floating an idea that would require doctors to work even longer to achieve public interest loan forgiveness because it would not count the years of their residency toward the 10-year requirement.
▶ 1:12:25Can you speak as to how this would impact the availability of care particularly in rural or underserved areas? If you ask the wrong question, you'll get the wrong answer. I'm asking Dr.
▶ 1:12:38So, I I I'll tell you as somebody who who is is is doing public service loan forgiveness uh and and who started paying down my student loans during residency, um I there 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 I think it'd be a bad idea. Yeah.
▶ 1:13:03If Republicans were serious about uh making health care more affordable and more accessible uh to the American people, there are so many things that we could have hearings about other than this uh match. Gentlemen's time is expired and I yield back the remainder of it. Gentleman yields back. Gentlewoman from Wyoming is recognized. Mr. Miller, you seemed as though you had something to say.
▶ 1:13:33Well, there's one view of the world which says simply pour more resources in and everything will work wonderfully. Problems with our health care 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 health care system.
▶ 1:14:02It is not so should not be solely focused on let's just have a lot more physicians and everything will be great. We've tried that approach before. It doesn't produce the results. Now there are barriers to production of physicians which we can talk about but it isn't solved simply by increasing federal funding. Okay. I appreciate that comment. Um, several of you have testified that the match system harms rural hospitals.
▶ 1:14:26I'm from Wyoming, uh, which is a very rural state, dealing with many challenges in its ability to provide health care services and with with barriers related to financing, transportation, and access. Dr. Lynn, is it difficult for rural hospitals to meet ACGME's accreditation requirements? Uh, it is challenging. uh congresswoman uh number one what are those challenges?
▶ 1:14:53Some of the challenges are some of the standards that they put in place that uh for example uh distance radius uh obviously if you look at uh rural America there are 1,300 critical access hospital and by critical access hospital by definition they're less than 25 beds. Um so given that if you're training a physician obviously scope and volume becomes a problem.
▶ 1:15:18So when you're trying to train a rural program uh for residents, you have to send them to distance away for training. And one of the uh barriers to that is that uh 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.
▶ 1:15:40So that creates a barrier where we're trying to increase quality and scope and volume for our residents and they thought that was a a negative. We got cited and that was one of the reasons why they closed down our program. So do you have some ideas of how to fix those kind of accreditation problems? Yeah, absolutely.
▶ 1:15:58the the um if you look at um prior to 2015 the merger of the ACGME and the AOA uh there was an alternative accreditation body which is from the AOA and if you look at uh prior to the merger um we have most of uh osteopathic institutions have a consortium model where we uh have a network of small community hospitals and or community hospitals and we sort of leverage each other's strength anything we put
▶ 1:16:28in the consortium model that we uh have a network of of training sites that we can send our residents and and collaborate and that model has worked out for many many years u Mil Creek Community Hospital which now is coal why was it changed uh it changed because um of the merger of the merger that's correct specifically the issue that this committee addressed to antitrust is is focusing on correct in my opinion yes Okay. Um, Mr.
▶ 1:16:58Miller, 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 uh such as the DEI requirements exacerbates the challenges our nation is facing in terms of providing care for our citizens? Well, the the it sounds like a a euphemism.
▶ 1:17:26You know, the the goal is to have everything based upon competition, quality, and merit. The rest of the distinctions are ancillary and can be distracting from that. I don't want to overstate the magnitude of DEI 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.
▶ 1:17:48But 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. Uh but I think that's going to work itself out through further litigation probably more so than rand random interventions. Okay. Uh Mr. Mary, very quickly, this hearing focuses on the antirust exemption granted by Congress, but you were hired in the 1990s as part of a lawsuit against the match system.
▶ 1:18:18The 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? I think the harm goes all the way back to 1952 frankly from the beginning just created the program itself. They people got their positions by telegrams back in 1952. The problems then have no relevance to today in my view. Gentle. Okay.
▶ 1:18:48Thank you. I yield back. Gentlewoman yields back. Gentleman from Illinois is now recognized for five minutes. Thank you uh Chairman Fitzgerald uh and members uh the witnesses that are here today. Uh we're here today because we're talking about uh 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.
▶ 1:19:16It 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.
▶ 1:19:38But it's also true that repealing the entry entry antitrust exemption outright may be may have unintended consequences that worsen outcomes for medical residents. Dr. Felman, uh, in your opinion, uh, could repealing the exemption actually end up benefiting the most wellresourced hospitals, medical schools, and residency programs.
▶ 1:20:05I I think it could because what 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 thank you.
▶ 1:20:29uh clearly this is a nuanced issue and Congress uh should be taking a nuanced approach to it as well. Our uh 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 uh of internal medicine residents, Congress can act to solve them. Uh Dr. Mr.
▶ 1:20:58Felman, would you agree that federal funding can be used to address these issues? I would agree. Thank you. Uh 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 health care uh more broadly when their policies are actively destroying access to affordable health care. My colleagues have addressed that.
▶ 1:21:25And they've also brought up uh the devastating cuts to the NIH uh and the FDA which will jeopardize the research that residents and physicians rely on to treat their patients. But there are also significant antirust issues in health care that are driving up cost for patients.
▶ 1:21:46If 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. Felman, let me ask you about the last issue since uh your research has focused on it. How is it how is vertical integration in the pharmaceutical industry driving up the cost for consumers?
▶ 1:22:16At the center of the of of vertical integration in the pharmaceutical industry are PBMs, pharmacy benefit managers. And PBMs distort the incentives for lower cost drugs. Um PBMs are after um 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.
▶ 1:22:45And so PBMs um have been in part responsible for for driving uh 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 um can lead to reduced choices at at the pharmacy and and bad outcomes for patients. Thank you.
▶ 1:23:06Uh this uh exchange uh illustrates why we need a serious principled approach to antitrust enforcement and why we need antirust 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. Uh thank you and I yield back. The gentleman yields back.
▶ 1:23:34I'm now going to recognize myself for five minutes and yield my time to the gentleman from Missouri uh for five minutes who waved on to the committee. Thank you, Mr. Chairman, and thanks for all the witnesses here today. Um Dr. Dr.
▶ 1:23:49Lynn, in your testimony, you you touched a little bit on some of the uh residency closures that um were those ones at your institution specifically or around the country or So, in my written testimony, my oral testimony, it's a combination of our uh Leecom uh uh system hospitals. Okay.
▶ 1:24:12And you know I I was reading in your early in your written testimony that there was a general surgery program. Let's see the termination. Oh is of the director due to non-compliance with co 19 vaccination. Yeah. So that was in our uh Almyra campus in our regional campus. Um my understanding of that case is that it was the height of COVID.
▶ 1:24:36Um and the program director uh 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. Oh and the that was my question. The program did end up getting shut down. Yes. Okay.
▶ 1:25:00and and how many do you have an estimate about how many residency programs have been shut down over the years because of ACGME? So I I just have uh general statistics where um uh after the merger of the ACGME and AOA there's approximately 670ome programs that have closed and uh more recently it's an ongoing uh process where you know there are new programs that are trying to get started and then there are programs getting shut down but if
▶ 1:25:30you look at it disproportionately it's always the smaller community program that is not as resourced as a tertiary care center or a universitybased center that can't meet the standards that are getting shut down, 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.
▶ 1:25:52But in rural America, where we have the most acute shortage of primary care doctors and of specialists, you know, with fewer resources, that's where they get shut down. Correct. And and I would I would say that um you know Dr. Filman and my job are probably very different. Uh his environment my environment is very different.
▶ 1:26:14I work in a critical access hospital with with 25 beds in Corey, Pennsylvania where the population is probably less than 6,000 in that town, but there's absolutely no resources. So from that perspective, you know, I um 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 types different types of physicians.
▶ 1:26:40Nor I'm sure are you saying that every residency program in the country is is good that that there isn't right. There has to be a standard. There has to be a standard. But it seems to me that at a time when over 80 8,800 medical school graduates per year go unmatched that it's it's a tragedy that a bureaucratic organization with a monopoly is shutting down shutting down programs. Correct.
▶ 1:27:06Um the and I believe I believe some there was a question earlier in this about about about DEI and and maybe ACGME uh backing away from uh DEI requirements. Did did one of you one of the witnesses address that? Yes, that that was me.
▶ 1:27:25Um, 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 uh program uh requirement for uh every sponsor institution as well as uh programs. And did many of those programs have DEI officers or someone um employed to monitor these mandates? Well, yes, that because using the standards.
▶ 1:27:52So, if you want to maintain the the program, uh the individual program institution would have to expend resources to meet that requirement. 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, uh they the these these same people embedded in the system driven by ACGME requirements over the years will continue to
▶ 1:28:22engage in pernitious discrimination based on race in violation of I think both moral principle and federal law. But that's something I think ACM AC ACGME has given us over the years. Well, thank you for your testimony. I yield back. Gentleman yields back. We now recognize the ranking member of the full committee for five minutes. Thank you very much, Mr. Chairman. Dr. Feldman.
▶ 1:28:46Uh, President Trump and uh, Secretary Kennedy want to cut 18 billion dollars from NIH. They want to cut three and a half billion dollars from CDC. the Centers for Disease Control and they want to cut $4.7 billion from the National Science Foundation.
▶ 1:29:05These uh unprecedented proposed reductions in America's uh healthc care research spending would come at a time when we have overwhelming needs in the American public for uh medical and scientific breakthroughs.
▶ 1:29:24And also they come at a time when we have the opportunity to make big breakthroughs in scientific research related to everything from uh multiple scerosis to cystic fibrosis to breast cancer to malignant narcissistic personality disorder. You name it.
▶ 1:29:46um what would be the direct effects of such drastic budget reductions on health care delivery and on the progress of uh healthcare research. 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.
▶ 1:30:14NIH funding has has contributed to to cures for hepatitis C, to treatments for HIV, to CO 19 vaccines. Um, it cutting NIH funding will absolutely reduce the number of of breakthrough therapies of of uh gamechanging therapies that patients would see in the future. I think it's a bad idea.
▶ 1:30:38So it it sounds like we would be um destroying the wellspring for research across the board. I I think that's right. And what you have to remember is that the NIH is funding the the the highest risk, highest reward research that pharmaceutical companies then uh take to market. So it it's hard to know what's going to work and what doesn't.
▶ 1:31:05And that's why you need broad funding and NIH has been incredibly successful in in funding new cares. So what are some of the next generation breakthroughs that might be lost if uh Robert F. Kennedy Jr. and Donald Trump have their way in dismantling so much scientific health research? I think what's hard about this is that we we can't know until we actually do the research and we can't do the research until the the funding comes.
▶ 1:31:35But 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 for that that treat a variety of different malignancies. uh Alzheimer's, dementia, um there are numerous untreated diseases in my in my area of pulmonology, COPD, asthma.
▶ 1:32:01These are diseases that that um have had some some recent breakthroughs, but I would love to see more therapies available for patients. Um my guest to the joint session of Congress, uh Dr. Lauren McGee, a constituent of mine, was the chief biologist on a pediatric cancer unit at NIH.
▶ 1:32:21And she got sacked on February 14th because she'd made the mistake of being on probation, not because she'd done anything wrong, but because she'd been promoted after serial superior evaluations uh by the people reviewing her. Then we heard uh President Trump at the State of the Union saying that uh attacking childhood cancer was one of his key priorities.
▶ 1:32:43Do 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? The way to make progress on childhood cancer, other diseases of childhood, is through funding the research enterprise that that finds uh new new cures.
▶ 1:33:05Um, the administration's also proposing a massive cut to Medicaid, which the CBO estimates would result in 8 and a half million people losing healthcare access over the next decade. Uh, what population groups in what parts of the country are most affected by these Medicaid cuts? These cuts will affect the most disadvantaged members of society. um in in rural communities, urban communities, and cities.
▶ 1:33:31Um I think it it will be um lead to very bad health outcomes. All right, my time is up, but thank you, Mr. Chairman. Gentleman yields back. We're now going to recognize the gentleman from California for 5 minutes. Thank you, Mr. Chairman. First of all, I want to welcome the witnesses here today. Uh my wife's a medical doc, and this subject brings back a lot of memories.
▶ 1:33:55some 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 uh part of the education process to become a good medical doctor, a good specialist in the area of Um I've spoken to her about this issue and she concurs with me.
▶ 1:34:22a lot of nightmares, a lot of challenges, and a budget. It worked out. So, my question would be, uh, Dr. Felman, 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? I think that the downsides have been spelled out by other witnesses and and to an extent in in my testimony.
▶ 1:34:48I mean it the the current system does not allow individuals to negotiate salaries or benefits directly with institutions. So let me ask you so it's an issue of money so to speak like everything else how much can you pay and and uh we're looking at possible Medicaid cuts. Where do most of the match where is that funded? You got medical schools that are growing.
▶ 1:35:12They got you know we 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 docs expand the match what does it take more money I think we 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
▶ 1:35:43are 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. Inner city, rural areas, farms, Midwest. Is that what you're talking about? All All of what you just mentioned?
▶ 1:36:02because I know that my my spouse usually gets very interesting offers to go work as an OB in the middle of somewhere in this country. And um they're not very lucrative. If it wasn't for the fact that we had, you know, family established in Southern California, we may have taken some of them. But yeah, there's not much money to be made as a dock in the middle of nowhere.
▶ 1:36:30I I would love to see more incentives for primary care doctors in these underserved communities, including rural communities. Give me an example of a of a incentive, higher pay, loan forgiveness. What are we talking about? I 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.
▶ 1:36:56Well, you know, I I remember again Speaking to my spouse, some of her colleagues, the new the new brand spanking new docks 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? Those that those numbers are right.
▶ 1:37:24I can tell you coming out of of residency, I had over $300,000 in in medical school debt. That's just the cost of going to medical school. Now, um there are programs in place. So, we're looking at you just 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 has gone through residency. We we' appreciated your efforts.
▶ 1:37:49But today, here we are, and you're looking at 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 it seems to me it's contradictory here. What am I missing? I don't think you're missing anything. I agree. So, we all got to get on the same page. Need more docs, need more residents, need a better matching program, need more money.
▶ 1:38:18But it seems like the public policy is going the other way. I agree. I think if if the focus is on solving the goals set out by this subcommittee of addressing physician shortages and and improving resident salaries, there are numerous countless ways to do that um that I think are are worth discussing. Thank you very much. And I thank the witnesses all for their time and interest in this issue. Mr. Chairman, I yield.
▶ 1:38:47Gentleman yields back. Recognize Mr. Nadler for some unanimous consent request. Thank you, Mr. Chairman. I ask unanimous consent to submit for the record the this statement from the um Association of American Colleges dated May 14th, 2024. Without objection.
▶ 1:39:04And I ask uh 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. Without objection. Thank you, Mr. Chairman. Uh I ask unanimous consent to enter the record the following statements. A statement from Dr. John Ward, a double board certified dermatologist practicing in Florida. Statement from Dr. Caleb Atkins, current resident practicing family medicine in rural New York.
▶ 1:39:33statement from national board of physicians and surgeons calling for antitrust scrutiny of the medical re residency market and a statement from Dr. Jeffrey Singer senior fellow at the Institute. Uh no objection. Uh at this time uh that would conclude today's hearing. We thank our witnesses for appearing before the committee today without objection.
▶ 1:39:58All members will have five legislative days to submit additional written questions for the witnesses or additional materials for the record. Without objection, the hearing is adjourned.