The National Residency Matching Program, known as the NRMP or simply the Match, has organized the transition from medical school to residency training in the United States since 1952, and nearly all US medical school graduates now obtain their training positions through it. A new viewpoint article in the Journal of General Internal Medicine argues that this long-standing mechanism, which replaced a chaotic pre-1952 system in which hospitals made offers to students as early as the middle of their third year, now faces converging threats from immigration policy, state licensure reform, federal funding limits and antitrust politics.
The authors, Philip A. Gruppuso, Barak Richman and Eli Y. Adashi, frame the Match as a key component of the US medical education system whose stability cannot be assumed. Their analysis draws on annual NRMP reports and recent legislative and congressional developments, and it describes a system in which several independent pressures could each reduce participation or reshape the labor market for new physicians. The article is a viewpoint, meaning it presents the authors’ interpretation and policy arguments rather than new empirical research findings.
The numbers from the most recent Match illustrate the stakes. In 2025, the Match placed 26,817 US medical school graduates, counting both MD and DO students, into 40,041 available post-graduate year 1 residency positions. Of those positions, 2,374, or 5.9 percent, went unfilled. Positions filled by US international medical graduates numbered 3,108, while non-US international medical graduates filled 6,653. Because non-US IMGs fill a substantial share of PGY-1 positions, the authors argue that a decline in their participation would directly increase the number of unfilled positions.
Immigration policy is the first threat the authors identify. Non-US IMGs most often enter the country on J-1 exchange visitor visas or H-1B temporary work visas. The past year has seen disruptive changes to visa issuance, including a temporary pause in mid-2025, bans on immigration from more than 35 countries, and an attempt to impose a 100,000-dollar H-1B visa application fee. Because residency programs require a full complement of physicians at the start of the training year, any disruption of visa issuance disincentivizes the recruitment of non-US IMGs, the authors write.
Those disruptions may already be visible in match outcomes. The match rate for non-US IMGs fell to 54.4 percent in the 2026 match, compared with 58.0 percent in 2025 and 58.5 percent in 2024. The authors note this as a possible contribution from the visa environment rather than a proven causal effect. A related structural change affects Canadian graduates. Before July 2025, Canadian medical schools were accredited by the Liaison Committee on Medical Education, the body that accredits US medical schools. On July 1, 2025, the Committee on Accreditation of Canadian Medical Schools assumed sole responsibility for accrediting Canadian schools, which means Canadian graduates are now considered IMGs and are subject to the same immigration processes as other IMGs. The authors suggest this change may reduce their participation in the Match.
The second threat comes from medical licensure. In an effort to meet physician workforce needs, states have been modifying licensure requirements so that IMGs can bypass residency training in the United States. As of February 2026, more than 20 states have enacted legislation allowing qualifying IMGs to gain full licensure without accredited post-graduate training in the United States, and another 22 states are considering similar legislation. If physicians can obtain full licenses without completing an American residency, the authors argue, participation of IMGs in the Match will likely decline.
The third pressure concerns the supply of funded training slots. Residency positions depend in large part on Medicare support to hospitals that partially offsets the cost of training, and the number of funded positions has been subject to a cap. The Centers for Medicare and Medicaid Services raised that cap in 2023, allowing 1,000 new resident positions over a five-year period with the goal of supporting primary care and healthcare in rural areas. Those new positions were added to the 40,041 PGY-1 positions available for the 2025 Match, a total that represented a 47 percent increase over the 27,293 positions offered in the 2015 Match. During the same ten-year interval, the number of potential applicants graduating from US allopathic and osteopathic medical schools rose from 24,017 to 30,568, a 27 percent increase. The authors conclude that if US medical school growth continues to lag behind the growth in positions offered, reliance on IMGs can only increase, which ties the funding question back to the immigration and licensure threats.
The final and oldest challenge is antitrust law. When the NRMP became the common mechanism for matching students and programs, critics decried its cartel-like arrangements and argued it undermined the efficiencies of an open labor market. By the mid-1970s, when the number of applicants exceeded the number of residency slots, accusations that the Match was anti-competitive gained force, in large part because rising demand against a stable supply would have predicted a rise in residency compensation that did not occur. A lawsuit filed in May 2002 alleged that the Match violated antitrust laws by, among other things, restricting the number of positions and enabling hospitals to set sub-competitive residency wages. That lawsuit was dismissed after Congress enacted a 2004 bill exempting the Match from federal antitrust laws.
The exemption itself is now under scrutiny. While NRMP procedures and rules do not specifically address resident compensation, the authors note that the Match does prevent programs from making individual salary offers and prevents applicants from bargaining, limitations that would not pertain in a free market environment. A May 2025 hearing before the House Judiciary Subcommittee examined the exemption, and committee chair Scott Fitzgerald, a Republican from Wisconsin, accused the Match of limiting residency compensation, restricting the number of licensed physicians, and exercising a bias against community hospitals. The authors state that the hearing revealed evidence that economic distortions associated with the Match have increased since it acquired antitrust immunity in 2004, while noting that the Match still has supporters in Congress.
The authors close with policy options rather than predictions. Approaches to addressing the anti-competitive aspects of the Match could include opt-out options for both programs and applicants, and carefully designed opportunities for compensation bargaining. Increasing the number of residency positions relies on Congress to raise the current caps, and stabilizing the continued participation of IMGs in the Match also relies on Congress. Protecting the central role of the Match in the transition from undergraduate to graduate medical education, they argue, will require a thoughtful and proactive approach that places the highest priority on sustaining the scope and quality of the US physician workforce, and that will demand a bipartisan strategy built on realistic plans to grow the physician workforce. As a viewpoint, the article does not test these remedies; it identifies the pressures converging on a system that has organized American residency training for more than seven decades.
Subject of Research: Threats to the US National Residency Matching Program from visa policy, licensure reform and antitrust scrutiny
Article Title: The National Residency Matching Program in Uncertain Times
Article References: Gruppuso, P. A., Richman, B., & Adashi, E. Y. (2026). The National Residency Matching Program in Uncertain Times. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10877-7
Image Credits: AI Generated
DOI: 10.1007/s11606-026-10877-7
Keywords: NRMP, residency match, international medical graduates, J-1 visa, H-1B visa, medical licensure, Medicare funding, antitrust exemption, physician workforce, graduate medical education, Journal of General Internal Medicine, National
News Source: Ophelia Keating. (November 6, 2026). US Residency Match Faces Visa Rules, Licensure Shifts and Antitrust Scrutiny. Scienmag.
