The False Choice at the Heart of the Match

A report from the House Judiciary Committee was just released on March 27, 2026, titled Medical Mis-Match: How A Residency Hiring Monopoly Harms Patients, Doctors, And The American Public. The report details the findings of Congress that “The Match” and the NRMP operate as a monopolistic entity.

“Through this oversight, the Committee and Subcommittee have uncovered evidence that the “Match,” a placement system for resident physicians, operated by the National Resident Matching Program (NRMP), exercises monopolistic control over America’s medical residency market, resulting in anticompetitive conduct and burdensome restraints on medical residents.”

It remains to be seen what actions will come from this report, but the discussion surrounding The Match has finally broken beyond the walls of Medtok and reached the general public. And physicians need to be prepared to speak about it.

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The False Binary

We’ve been taught to think of the Match as a kind of necessary protection - a system that prevents backroom deals, bias, and coercion. But those things don’t disappear inside centralized systems. They just become harder to see. Prospective residents are still required to:

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• Network for interviews
• Signal preferences strategically
• Experience institutional bias
• Navigate unequal power dynamics

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The idea that The Match eliminates these forces is not reality. Just because a system is better than what came before it does not make it a perfect system. Frankly, The Match has just enjoyed good branding: “a perfect algorithm,” “applicant-proposing,” etc. As if medical students should be jumping for joy that The Match is here to save medical training. 

But the real issue is that The Match has historically been viewed as a simple coordination tool, when it is in fact a tool used to structure the entire labor market. If a medical student wants to complete residency training and become a board certified physician, they have no other option than to enter The Match.

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The History of NRMP

“[I]n 2004, Congress granted the Match an antitrust exemption that immunized its anticompetitive conduct and barred the use of Match-related evidence in antitrust proceedings. According to Sherman Marek, a health law expert who has challenged the Match’s anticompetitive conduct in court, this antitrust “exemption protects market distortions, undermines free market principles, limits personal freedom and choice, prevents normal employment negotiations, shields wage suppression, and contributes to the nationwide physician shortage.” The documents and testimony received by the Committee and Subcommittee bear this reality out. In over twenty years of real-world experience since this antitrust exemption, it is clear that the medical residency market would benefit from traditional market forces.”

The fact that The Match system is a blatantly monopolistic institution is not a new finding - it was recognized as such during its creation. However, Congress granted NRMP an exemption from antitrust laws to proceed regardless. 

When a labor market is centralized (and residency is a labor market - attempts to paint residents as simply students or trainees is simply incorrect), predictable things happen. Wages flatten. Mobility decreases. Working conditions stagnate. This is not in theory; it has played out repeatedly across industries. Workers can only gain back leverage when they can negotiate and are granted freedom of movement, forcing employers to compete for their services. The current Match system and residency as a whole restricts all three of these. 

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Medicine Isn’t Immune to Labor Dynamics

Healthcare, and specifically the work of physicians, often resists comparison to other industries. In many ways that is fair, but physicians need to understand the cost of this. Repeatedly downplaying labor concerns because “medicine is a calling” or “physicians should be honored to take care of patients” allows market forces to take advantage of their labor. Labor dynamics do not disappear just because the work is “meaningful.”

Resident physicians still participate in the labor market and are subject to incentives and constraints. A resident physician has completed nearly a decade of higher education and job training and is no more of a “student” or “trainee” than a recent graduate of law school who has obtained their first full time job. Per the report, “Residents provide a significant amount of the patient care in teaching hospitals, help to train medical students, and improve access to health services. The quality of residency training, therefore, has major consequences for the future of the physician workforce and for patient care across the United States.” That is not the description of a “learner” by any definition. 

By acting as a bandaid for an increasingly broken healthcare system, the current model for residency helps to bury deeper issues by providing a never ending supply of cheap, highly skilled labor. And when the market is tightly controlled, the consequences ripple outward. 

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The Middle Ground That Is Ignored 

The most limiting part of this conversation is the assumption that reform means completely abandoning structure. It does not. There are countless models between monopoly and free market:

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• Early offer windows with guardrails
• Regional or specialty-based matching systems
• Standardized contracts with negotiable components
• Mobility pathways between programs and specialties
• Transparent salary bands with competition above a floor

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Other industries and countries already use variations of these approaches and they have not collapsed the system.

There is another concern that comes up almost immediately in conversations like this: that changing The Match would somehow lead to worse training or lower standards for physicians. It is an understandable fear, but also a revealing one. The assumption is that the current system is what guarantees quality. But The Match does not set these standards. It doesn’t determine what or how well residents are taught, how programs are evaluated, which institutions maintain excellence, etc. In fact, it almost guarantees that programs will not be incentivized to continually improve and raise the standard of training. If there is no risk of missing out on new residents, or very low risk of current residents leaving, then there are no pressures to improve or even maintain a certain level of training. 

Not to mention that these responsibilities do not even belong to the NRMP. They belong to the accrediting bodies, certification boards, and the culture of medicine itself. Decoupling the two ideas is important. A system can maintain rigorous standards while still allowing for competition, mobility and negotiation. In most industries, competition tends to raise standards. Institutions invest more in training and facilities to attract talent. Programs differentiate themselves based on quality and poor environments are exposed more quickly when people can leave. 

The assumption that residents need to be tightly controlled in order to be well trained says less about the trainees, and more about how much we trust the system to stand on its own.

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What The Match Debate Is Really About

At its core, this is not just a debate about algorithms. It is a question of whether the current system maximizes fairness and the long-term health of applicants and trainees, or optimizes stability for institutions. These goals are often not aligned, but for a long time physicians have assumed that they were. 

The Match may have solved a coordination problem, but over time it has become something else: a system that limits the competition in one of the most important labor markets in healthcare. 

“Resident salaries are also substantially lower than other healthcare providers that did not attend medical school but were hired through more traditional employment negotiations undistorted by the Match, such as nurse practitioners, who make a median wage of $132,050, or physician assistants, who make a median wage of $133,260.” 

The evidence is overwhelming in the face of current conditions experienced by resident physicians. Yes, fair compensation for residents is the most obvious benefit from any potential reform, but the downstream benefits for physicians and society at large are significantly more important. The United States is facing a serious physician shortage, and if we allow conditions to continue to deteriorate, it is almost a guarantee that the solution will be worse than if physicians organize and advocate for a better option themselves.