Congressional Testimony
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Johns Hopkins University Associate Professor Miller Testifies Before House Judiciary Subcommittee
CHARLOTTE, North Carolina, Oct. 1 -- The House Judiciary Subcommittee on the Administrative State, Regulatory Reform and Antitrust released the following testimony by Brian J. Miller, associate professor of medicine and business at the Johns Hopkins University, and a visiting fellow at the Hoover Institution, from a Sept. 14, 2026, field hearing entitled ""Examining Healthcare Markets: Fraud and Competition":
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Chairman Fitzgerald, Ranking Member Nadler, and distinguished members of the Subcommittee:
My name is Brian Miller, and I practice hospital medicine at the Johns Hopkins Hospital. ... Show Full Article CHARLOTTE, North Carolina, Oct. 1 -- The House Judiciary Subcommittee on the Administrative State, Regulatory Reform and Antitrust released the following testimony by Brian J. Miller, associate professor of medicine and business at the Johns Hopkins University, and a visiting fellow at the Hoover Institution, from a Sept. 14, 2026, field hearing entitled ""Examining Healthcare Markets: Fraud and Competition": * * * Chairman Fitzgerald, Ranking Member Nadler, and distinguished members of the Subcommittee: My name is Brian Miller, and I practice hospital medicine at the Johns Hopkins Hospital.As an academic health policy analyst, I serve as an Associate Professor of Medicine and Business (Courtesy) at the Johns Hopkins University School of Medicine and as a Visiting Fellow at the Hoover Institution. My research focuses on how we can build a more competitive and vibrant health sector to make healthcare more efficient, flexible, and personalized for patients. This perspective is based upon my prior regulatory experience at four federal regulatory agencies.
Through my current role as a faculty member, I regularly engage with regulators, policymakers, and businesses in search of solutions to help create a better healthcare system for all. Today I am here in my personal capacity, and the views expressed are my own and do not necessarily reflect those of the Johns Hopkins University, the Johns Hopkins Health System, the Hoover Institution, the North Carolina State Health Plan or the Medicare Payment Advisory Commission.
Monopoly and its younger cousin, consolidation, remain a serious, pressing, persistent concern. Many healthcare markets are highly consolidated, resulting in a loss of price and non-price competition for consumers, employers, workers, and taxpayers. Competition counts. While price competition is critical to a functioning marketplace, the loss of non-price competition often explains many of the additional concerns that consumers and all of us patients experience: the lack of meaningful improvement in medical quality in many service areas, declining consumer experience/convenience, and persistent unsolved basic clinical operational challenges. Monopoly and regulation together protect incumbency and foreclose market-driven incremental improvement and revolutionary change through the removal of incentives to compete.
Through a variety of policy choices, government has at times placed its foot firmly on the accelerator in favor of consolidation. In other circumstances, the government has banned or severely restricted market entry, placing a heavy brake on competition and replacing it with statutory prohibition or regulation. Neither of these is an adequate substitute for competition.
In my testimony today, I will focus on three areas:
1. Hospital consolidation scope and impacts
2. Drivers of hospital consolidation
3. State and federal law and regulatory policy changes to promote competition
1. Hospital Consolidation Scope and Impacts
Scope of Hospital Consolidation
The scope of the problem is significant in scale. With over 2,000 mergers over the past 25 years,1 the share of independent hospitals has declined from 90% in 1970 to 32% in 20192 all amidst the growth of mostly tax-exempt health systems.3 In 2024, in 47% of metropolitan areas, 1 or 2 health systems controlled the entire market for inpatient hospital care while in 83% of markets 1 or 2 health systems controlled more than 75% of the market. To make matters worse, 97% of metro areas were highly concentrated markets (as defined by the Department of Justice Antitrust Division) for inpatient care.4 Locally, according to the Yale Health Care Affordability Lab, 71.2% of North Carolina hospitals are in highly concentrated or monopoly markets, with 25 hospitals operating as pure monopolies.5 Hospital-hospital consolidation is only the beginning. Physician consolidation into hospitals has resulted in increased prices, a loss of non-price competition, and no systematic measurable, durable gains in quality or patient experience. An estimated 82% of physicians are employed by hospitals or corporate entities and 63.9% are owned by the same.6 For hospitals specifically, according to the Government Accountability Office (GAO) an estimated 47% of physicians were consolidated into hospital systems in 2024, up from 30% in 2012./7 Other researchers have found that the most commonly integrated specialties (hematology-oncology, cardiology, and general surgery) are those associated with the delivery of lucrative hospital services.8 The American Medical Association (AMA) physician benchmark survey validates many of these findings of shifting employment models, with physician employment in private practice declining from 60.2% in 2012 to 42.2% in 2024./9
Market ossification from consolidation is a problem worsened in rural markets. Researchers have found that rural hospital system affiliation results in decreased obstetric care, primary care, and on-site imaging all while increasing margins without any accompanying change in patient experience scores or hospital readmissions.10 Further empirical work replicates the decrease in access to obstetric care,11 a concerning finding. Some policy analysts have argued that rural health challenges result purely from financial distress. Empirical research demonstrates otherwise: while financial distress is a predictor of mergers, 77% of unprofitable rural hospitals over an eight-year period continued to operate. This study unintentionally highlights many challenges, including arguably relatively lax financial reporting standards for tax-exempt entities compared to their for-profit counterparts, and the misalignment of booked net income as opposed to cash flow margins from operating activities.
Price Harms of Hospital Consolidation
The loss of competition has both price and non-price impacts: we consider each in turn. Empirical research consistently demonstrates that hospital mergers - including in disparate geographies - result in higher prices and hence higher insurance premiums. Tax status is immaterial in terms of organizational behavior regarding prospective mergers: tax-exempt hospitals also exercise market power in the form of higher prices,12,13 a finding no different than tax-paying, for-profit hospitals. Beyond in-market mergers, cross-market, in-state hospital mergers yield price increases of 7-9%,14 and out-of-market acquisitions result in 17% price increases;15 both types of transaction are becoming more common.16 With hospital spending accounting for 40% of the growth in national health spending from 2022 to 2024,17 scrutiny of hospital consolidation is imperative.
Hospital-physician mergers (frequently viewed as a vertical transaction) also result in higher prices. While not all vertical integration across the healthcare supply chain are uniformly harmful, hospital-physician mergers again have consistent evidence that they produce higher prices and hence higher premiums. Research has found that hospital acquisition of physician practices was associated with price increases of 14.1% post-acquisition, a number that grew when the hospital had a larger share of the inpatient market. Even the integration of primary care physicians increased spending by 4.9%.18 Generally, hospital acquisition of physician practices increased prices, and spending was entirely driven by price increases with little change in utilization.19 Finally, and arguably most critically, although insurance shields consumers from many of these costs directly, consolidation-driven price increases reach them through higher premiums: hospital acquisition of physician practices was associated with a 12% increase in Affordable Care Act (ACA) marketplace premiums20 with another study further supporting the assertion that care delivery consolidation increases health insurance premiums.21 A Medicare Payment Advisory Commission (MedPAC) literature review likewise found that hospital consolidation drives higher prices and that government policy such as the lack of site neutral payment drove hospital acquisition of physician practices.22
Non-Price Harms of Hospital Consolidation
In addition to and equal in importance to the harms of diminishing price competition, the loss of non-price competition harms consumers, purchasers, and workers in a variety of ways. Despite claims to the contrary, hospital mergers do not improve quality, with a study of 246 acquired hospitals compared to controls over a decade demonstrating no change in critical outcomes such as 30-day readmission rates or mortality - and even demonstrating minor decrements in patient experience.23 A subsequent review of 30 years of evidence found no clear pattern that hospital mergers improve quality,24 a finding replicated by a second systematic review.25
Consumer and provider experience also represent significant non-price competition losses from hospital consolidation. Functionally, hospital-hospital and hospital-physician mergers exercise control over and limit or distort patient choice, with research demonstrating that hospital ownership of a physician increased the probability that the patient would select the owning hospital, and more likely a high-cost, low-quality hospital.26 Furthermore, the loss of small providers may make accessing care more difficult for important, vulnerable, high-cost populations.
Small practices may be easier for patients to navigate, especially those with multi-morbidity, and may offer greater care and access customization potentially serving patients with disabilities, special needs, or higher illness acuity.
Non-price competitive losses also encompass provider experience and the loss of choice and oversight over the clinical practice environment. Large health systems offer less flexibility, with a direct loss of clinical independence and externalization of the locus of control over clinical operations and even at times clinical decision-making. The tradeoffs are real, with externalization of the locus of control well-associated with burnout and loss of clinician compassion.27 Burnout is also predictive of physician elective reduction in workload, further constraining supply.28 In 2023, half of all physicians suffered from symptoms of burnout making this a meaningful concern.29 Other workforce impacts are also worth noting, with the marketplace experiencing a move from physicians as small business owners to a largely employed workforce. An estimated 35.5% of physicians were owners in 2024 down from 53.2% in 2012, with 49.2% of private practices as having fewer than five physicians compared to 16.1% for hospitals - with one-third of hospital practices being larger than 50 physicians,30 an assessment largely independently validated by the Physician Advocacy Institute.31 The transition to a hospital-employed physician workforce results in a world akin to "Severance," with a new generation of employed physicians experiencing deep feelings of depersonalization, alienation, and disempowerment through dehumanization and excessive administrative control.
Non-price competition impacts are not limited to physicians. The hospital industry is a textbook example of employers using market power to reduce nurse wages. Recent work in the American Economic Review found that when hospital mergers increase local employer concentration, wages go down. For mergers in the top quartile of concentration increases, researchers estimated that wages for nursing and pharmacy workers were 6.8% lower four years after the merger than they otherwise would have been.32 Other researchers replicated this, finding that increased hospital-system concentration in smaller metropolitan statistical areas is associated with slower real nursing wage growth with a 0.10 increase in market concentration associated with about a $0.70 reduction in real hourly nurse wage growth in smaller metropolitan areas.33
2. Policy drivers of hospital consolidation
Federal Policy Incentivizes Consolidation
Hospital consolidation results primarily from policy incentivizing consolidation and additional policy blocking market entry.
Federal policy unfortunately incentivizes and at times directly drives consolidation. On a first principles basis, payers should fund the right service for the right patient at the right time in the right setting by the right person. This also means that payers should not pay differential rates for the same service for non-clinical reasons - that is, if a colonoscopy has a defined cost and a patient chooses to undergo it in an ambulatory surgery center setting or a hospital outpatient department (HOPD), it should cost the same. The same argument applies to many other outpatient services, when comparing their completion in an HOPD versus a physician office. Unfortunately, the lack of site neutral payment in the Medicare program creates an opportunity for regulatory arbitrage to drive both increased payment and increased market power.34 Because HOPDs are paid under a distinct payment system than freestanding clinics that results in higher rates for the same clinical service, hospitals have an economic rationale to acquire clinics and bill at the higher rate.
Congress recognized this and, in the Bipartisan Budget Act of 2015, mandated that new off-campus (>250 yards) HOPDs be paid at a lower rate. Grandfathered off-campus HOPDs and on-campus HOPDs remained unaffected.
Fully closing this loophole by implementing site neutral payment would, per the Congressional Budget Office (CBO), generate $170 billion in savings.35 The lack of site neutral payment also drives physician-hospital consolidation, as noted by prior MedPAC Chair Chernew36 and noted as far back as 2015 by the GAO.37 Critically, research has demonstrated minimal impact on rural facilities if site neutral policy were implemented.38
In this setting, it is no surprise that a significant portion of hospital corporate strategy is to seek additional state and federal subsidies directly or undertake mergers to access or amplify regulatory-driven arbitrage opportunities.
Consequently, clinical innovation and improvement are disincentivized. Incentives therefore need to be realigned to ensure that affordable products and services flow to the patients who need them, and that hospitals that need subsidies should access them directly.
State and Federal Policy Disfavors and Even Bans Competitor Entry
Certificate of Need (CON) laws at the state level disfavor entry. Briefly, a state health planning agency, the department of health, or another entity reviews and approves the creation of new health care facilities, facility expansion, or purchase of capital equipment. An estimated 35 states and the District of Columbia operate CON programs,39 a marketplace spurred by the 1974 National Health Planning and Resources Development Act. This Act required states to adopt CON or federal health funding would be withheld, with policymakers positing that CON would ensure adequate care for rural and underserved areas and prevent overuse in other areas. In contrast, outcomes are the opposite, representing a failure of central planning, with the 1974 Act repealed as part of the 1986 Comprehensive Mental Health Services Act. Robust evidence has demonstrated the harms of CON, suggesting that they raise rather than restrain spending.40,41 Quality impacts are also negative, with the presence of CON laws associated with greater Medicare spending, more ED visits, and hospital readmissions.42 Access is also restricted, with evidence demonstrating that CON law restricts access to hospitals and ASCs including in rural areas,43 in addition to decreasing access to imaging services such as MRI/CT/PET while simultaneously favoring hospital over nonhospital providers.44 In this way, CON hurts rural states the most45 and is thankfully widely recognized as anticompetitive, including by FTC Commissioners46 and U.S. Department of Justice Antitrust Division frequently commenting on their anticompetitive nature and advocating for repeal.47
Stark Law, or physician self-referral law, was initially enacted in 1989 and expanded in subsequent years through statute and rulemaking. Stark Law prohibits self-referral for physician-owned enterprises to 12 designated services when billing Medicare or Medicaid.48 There were valid concerns about physician self-referral in a fee-for-service setting, dating back to research from the 1980s regarding induced demand for imaging and lab services.49 At the time as part of Stark Law, a specifically crafted "whole hospital exception" previously allowed self-referral to a hospital with physician ownership, with the conception that the physician owned an interest in an entity that provided a wide range of services, as opposed to an individual service. This exception was subsequently closed as part of the 2010 Patient Protection and Affordable Care Act (ACA) as a consequence of hospital industry lobbying.
Interestingly, no such self-referral ban in statute or rulemaking exists for tax-exempt and for-profit corporate entities, which frequently require self-referral as a condition of clinical practice and employment. Presupposing that one corporate form engages in self-referral for malignant reasons while other corporate forms with the same incentives engage in self-referral for only good reasons is a policy failure, substituting a need for regulation of all market participants with a statutory ban on a single market participant. Self-referral is a complex issue: self-referral for integrated care delivery sometimes has strong clinical value and in other settings it only has financial value. As a complex issue involving taxpayer-funded health benefits, oversight is critical. Yet, patients and practice patterns are unique and likely need some loco-regional flexibility. Recognizing this reality, utilization management practices are needed for all market participants. This would be best executed in the marketplace a dynamic tool that allows patients to have access to the benefits of integrated care delivery while ensuring against fraud, waste, and abuse.
Impacts of the Stark self-referral ban are real and include price and non-price competition impacts. Stark foreclosed the entire market for physician-owned and -operated integrated care delivery as Medicare and Medicaid often comprise half or more of patients for a care delivery organization. In contrast, tax-exempt health systems could employ an orthopedic surgeon and require internal system referral for imaging, physical therapy, and surgical services for a Medicare or Medicaid patient. Meanwhile, a physician-owned practice could not, as doing so would be statutorily illegal. In foreclosing the market for physician-owned and -operated care delivery, Stark Law decreased non-price competition in terms of medical quality, consumer experience and the clinician experience through the loss of service delivery innovation from front-line clinician owner-operators. This is the deterioration in quality that all of us, or those close to us, have experienced but that goes unmeasured. Critically, the loss of small business in care delivery sectors is an acute problem in rural areas where integrated care delivery is needed at smaller scale, and larger corporations may not have an incentive to invest without significant subsidy. Policy has made owning and operating small business illegal in many care delivery markets.
Finally, the physician-owned hospital (POH) ban directly discourages entry. A provision pushed by the hospital trade association,50 Section 6001 of the 2010 ACA51 closed the "whole hospital exception" portion of Stark Law.52 Around 200 POHs remain in existence but as clinical enterprises are prohibited from growing. Approximately half of the marketplace is community POHs (i.e. general acute care hospitals) and half are surgical specialty POHs, largely represented by cardiac and orthopedic POHs.53 In the setting of the POH ban, patients lose price competition from community POHs and surgical specialty POHs, while physicians and nurses lose labor price and nonprice competition. Payers have fewer facilities to construct networks from, resulting in decreased bargaining power and higher prices for the insured. Quality impacts are real: a loss of service delivery innovation, and an absence of growth of focused factories.
A systematic review of 30 years of research demonstrated that patients experience higher quality of care in physician-owned hospitals even when accounting for patient differences:
* Orthopedic surgical specialty hospitals take a focused factory approach to procedures. For total knee and total hip arthroplasty, research demonstrated higher patient satisfaction from MD-RN communication, staff responsiveness along with lower length of stay (LOS) and expected v. observed LOS. These facilities also deploy nonsurgical therapy: POHs tried other interventions prior to surgery more frequently. (e.g. NSAIDs 93.0 vs 83.9%, PT 72.2 vs 67.1%). With respect to outcomes, there was a lower inpatient and 30-day mortality along with lower risk-adjusted readmission for joint replacements while there were lower complications: cardiac, sepsis, deep venous thrombosis, and renal complications for some spinal surgeries.
* Cardiac specialty hospitals take a focused factory approach to procedures exhibiting a lower LOS, lower inpatient and 30-day mortality rates such as in the setting of percutaneous coronary intervention. Highly morbid procedures such as abdominal aortic aneurysm repair had lower mortality as did coronary artery bypass graft surgery, carotid endarterectomy, and acute myocardial infarction treatment. Patients also exhibited a lower risk of severe complications such as post-op hemorrhage, post-op pulmonary embolus and death.
Access impacts from the POH ban on participation in Medicare were real. With the law's passage a statutory deadline of December 31, 2010 resulted in cessation of 45 hospital expansion projects and loss of access to focused factory, a model flourishing in other countries such as Narayana Health (focused factory for cardiac care)54 and the Shouldice hospital (hernia repair).55 Patients also lost access to owner-operated businesses run by the front-line clinicians who best understand clinical operations, and with them the service-delivery innovation those clinicians generate; the voice of the clinician became subsumed by administrators. Taxpayers also faced a revenue loss: POHs pay taxes, tax-exempt hospitals do not. Finally, the loss of price competition results in high costs in suburban and urban markets while the loss of non-price competition reduces quality, convenience/access. In contrast, in rural markets with loss of competition you may even lose market participation, an even more stark outcome that is not well-assessed.
3. State and federal law and regulatory policy changes to promote competition Employer options
Policymakers have state and federal actions that can be taken to combat consolidation and promote competition.
First, state health plans offer an opportunity to implement market-based solutions. The North Carolina State Health Plan (NC SHP), of which I serve as Vice Chairman of the Board of Trustees, is a 750,000-member, $4.8 billion self-insured health plan that recently undertook a fiscal turnaround56 in partnership with employees and providers. The NC SHP worked with employees to set a target share of income for premiums, serving to create income-adjusted premiums and begin to create a budgetary framework for health expenditures. This forced the plan to make decisions about tradeoffs as a team - instead of seeking disproportionately greater subsidies from taxpayers and employees year over year. Instead of electing traditional choices of significant double-digit premium increases or cuts to benefits, this fiscal structure and discipline empowered the plan in partnership with members to creatively use the tools of network strategy and benefit design to drive provider competition.
In this setting, the plan elected to build a preferred provider network through volume-based purchasing with a minimum quality threshold to achieve significant price discounts. Preferred providers were aligned with favorable benefit design to drive volume (see Figure 1). Using a first principles approach, the member wins first on reduced cost-sharing and then the plan wins on savings thus ensuring the members and the plan both benefit (albeit sequentially, not in parallel) from price competition.
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Figure 1: Abbreviated table of updated benefit design57
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The preferred provider strategy also facilitates - for the first time in NC SHP history - for the member to undertake "time travel" in benefit design back to the richness of the 2011/2012 benefit design despite generally concentrated markets if one uses preferred providers (see Figure 2). This is an unheard-of occurrence in health insurance markets.
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Figure 2: Case example and side-by-side comparison of old/new benefit design58
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With a 3-tiered benefit design, the Access tier serves as functionally an "any-willing-provider" in rural areas, whereas in concentrated urban markets through partnership with preferred health systems and robust independent physician networks, plan members can still benefit from price competition (see Figure 3). Geographically, deploying basic insurance design principles in partnership with employees allowed the plan to act as a prudent fiduciary and avoid persistent double-digit year over year rate increases.
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Figure 3: Geography of hospitals by network tier59
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For elective surgeries, the NC SHP partnered with a vendor, Lantern, to construct a no-cost elective surgical benefit for spine, orthopedic, cardiac and other procedures. Recognizing that robust price competition to drive member and plan savings would result in a subset of provider options, the no-cost elective surgical benefit is optional, and members can still access care through the standard benefit design. Rather, the no-cost elective surgical benefit offers just that: no cost to the member. With a wide state and dispersed population, the plan also funds travel with the potential for mileage or even airfare and hotel to support member access to cost savings.60 In this setting independent practices have an equal opportunity to compete as do large health systems, with OrthoCarolina, a Lantern partner, as an example.61
By deploying the principles of competition, steerage, and benefit design, self-insured employers in North Carolina and other states can design their health benefits along these principles to drive competition, as can other state employee health plans. Employers purchasing plan products can also demand - as customers - that health plans undertake a similar contracting strategy. Competition counts.
Options for State Policymakers
State policymakers have multiple options to combat consolidation. With 35 states and the District of Columbia operating CON programs of varying scope and scale,62 state policymakers could undertake a full repeal.
Recognizing that in many circumstances that is not a viable first step, policymakers could consider a phased repeal, with some combination of the following:63,64
1. Repeal service line by service line to help vulnerable populations (e.g. psychiatric facilities, Labor & Delivery units, substance use facilities).
2. Eliminate CONs for low-cost services (e.g. ambulatory surgery centers, home care).
3. Eliminate CONs for services that are not likely to be overprescribed (e.g. neonatal intensive care unit, dialysis, radiation treatment).
4. Exempt physician-owned enterprise from CON to promote competition.
5. Exempt private-equity-backed entities from CON to promote competition.
6. Exempt from CON geographic and service markets that meet the DOJ Antitrust Division's highly concentrated definition (HHI of 1,800).65
7. Sunset CON over time.
Recently, North Carolina has made progress in this direction, with CON long a target of meaningful reform.66,67 With the current state of CON in NC still encompassing a wide range of facilities,68 many opportunities remain.
Phased repeal by service or facility type is a viable option, as with the recent repeal of CON for inpatient rehabilitation facilities.69 Still, other venues such as constitutional challenges remain an option for either phased or ideally wholesale repeal, with ophthalmologist Jay Singleton M.D.70 challenging the constitutionality of CON law, an effort supported by North Carolina Treasurer Brad Briner and the State Employees Association of North Carolina, the latter of which represents over 45,000 state employees.71,72
State policymakers could also prohibit anti-tiering and anti-steering provisions. Functionally, market dominant or monopoly health systems insert these provisions into managed care contracts, preventing plans from using financial incentives to direct patients to other systems or placing the health system in a lower tier compared to other providers (or alternatively requiring placement in the highest tier). The Department of Justice Antitrust Division successfully sued Atrium Health73 over anti-competitive steering provisions and won, and recently sued OhioHealth74 and New York Presbyterian (2026).75 A White House Council of Economic Advisers report76 estimates savings of 4-9% in impacted markets from preventing the use of anti-tiering and anti-steering provisions, with Texas' recently passed HB71177 serving as an early success and example.
Finally, in the context of a rising policy effort to ban private equity investment in healthcare, state policymakers should do no harm. While private equity has risks and benefits, it is a potential positive force for competition.
Banning one ownership model in favor of another replaces competition with a statutory prohibition, favoring one corporate form over another. In the case of physician-owned enterprise, Stark Law and the physician-owned hospital ban fundamentally destroyed independent practice, driving clinicians towards a large-corporation, fully employed model with many untoward side effects on patient care and workforce sustainability.
Options for Federal Policymakers
In addition to state action, federal policymakers have a litany of options to combat consolidation. First, federal policymakers can work to eliminate CON. Policymakers can deploy federal fiscal incentives and regulations to remove a barnacle-like entry barrier that persists in state law. Medicaid policy, a recent source of policy disagreement, offers an opportunity for bipartisan efforts. The Federal Medical Assistance Percentage or FMAP78 is the share of Medicaid funds that the federal government pays. Policymakers could undertake a carrot and stick approach to FMAP adjusting FMAP upward by, for example, 1% for states that repeal CON within three years and downward by 2% for states that do not. There are multiple dials, including the size of the carrot, the size of the stick, and the timeline for a cutoff. Policymakers could undertake a similar exercise with Medicare Advantage benchmark policy, 79 adjusting benchmarks for the presence or absence of CON. Finally, policymakers could undertake the same exercise by reducing hospital payment (IPPS,80 OPPS)81 through a deflator when CON is present to account for increased market power and self-referral, and increase the rates when CON is absent.
Federal policymakers also have a wide range of potential solutions to implement site neutral policy either piecemeal or in whole and remove the consolidation accelerator in Medicare. Site neutral policy in hospital outpatient department markets has a wide range of supporters including experts at the American Enterprise Institute,82 the America First Policy Institute,83,84 the Brookings Institution,85 the Committee for a Responsible Federal Budget,86 the Heritage Foundation,87 and the Paragon Health Institute.88 MedPAC's proposed site-neutral service list includes 57 Ambulatory Payment Classifications (APCs).89 Additionally, CMS90 has specifically proposed site neutral drug administration while Congress has taken steps with the Lower Costs, More Transparency Act which passed the House in the prior session by a vote of 320 - 7191 and has been reintroduced.92 Finally, policymakers could work to implement an acuity adjuster that ties payment to patient acuity to ensure appropriate placement in a clinic, ASC, or hospital outpatient department. This would ensure that the right patient gets the care in the right setting at the right time. Other options include addressing grandfathered off-campus HOPDs and all on-campus HOPDs.
Repeal of the physician self-referral law (Stark Law) and of the POH ban would remove entry bans and work to reverse both hospital consolidation93 and physician-hospital consolidation. The evidence for repeal is strong: the Section 6001 Medicare participation ban has foreclosed the nationwide hospital market to new POHs and expansion of existing POHs,94 a systematic review of 30 years of research shows both price and non-price (medical quality) competition gains from POHs, and other work shows that general acute-care POHs have lower prices.95 Repeal options are numerous and include repeal by:
1. Service market (e.g. specialty vs community or general acute care POHs)
2. Geography (rural, suburban, urban) noting that proposed H.R. 2191 narrowly does this for rural settings with a specific drive-time distance from other hospitals96
3. Site neutrality for all new on-campus and off-campus HOPDs for POHs
4. A 2% Medicare cut
5. Some combination
Policymakers should also consider adding a statutory exception to Stark Law in the setting of managed care, or a so-called "managed care exception." Both Medicare Advantage and Medicaid Managed Care Organizations are paid on a risk-adjusted, capitated basis and deploy network design and utilization management practices to manage costs.
Stark could be preserved in the setting of Fee-for-Service Medicare and waived in the setting of managed Medicare and managed Medicaid, with utilization management oversight of referral patterns.97 This would allow physician-owned businesses to serve the roughly 53% of Medicare and 72% of the Medicaid market and restore competition, removing a ban on market entry and replacing it with a dynamic market oversight model.
Additional federal policy options exist, including ERISA prudent fiduciary guidance to drive employers to transition from passive to active purchasers. Defining a prudent fiduciary and setting a target share of employee income for premium and additionally a target employee/employer financing split would force meaningful consideration of tradeoffs with networks, utilization management and costs in the employer-sponsored insurance market serving over 130 million Americans.
Finally, policymakers could work to support the already successful FTC competition advocacy program98 by directing the agency to comment on competition impacts of Medicare and Medicaid regulations. Medicare rules occur on an annual cycle including IPPS/LTC Hospital, OPPS/PFS/ESRD,99 MA Advance Notice and Rate Notice, MA-Part D rule, and others. In contrast, the Medicaid program has rules with competitive impacts including the Medicaid/CHIP managed care rules (most recently in 2020 and 2024) amongst others that are issued with less regularity. This would allow the FTC to have early input on the structure and functioning of public payer markets, driving competition.
Conclusions
Policy analysts of a variety of backgrounds, training and belief systems fundamentally agree that hospital markets are consolidated and that this results in significant price and non-price harms. A careful analysis reveals that government intervention through law and regulation has fundamentally distorted or eliminated market competition, through poor incentive structures or outright banning competition or specific categories of market participants.
Instead of promoting more regulation and government control, a better answer is to recognize the need for dynamism, creativity, and innovation in the clinical setting and in policy and restore competition, as competition counts.
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References
1 Levinson Z, Godwin J, Hulver S, Neuman T. Ten things to know about consolidation in health care provider markets. KFF. April 19, 2024. https://www.kff.org/health-costs/ten-things-to-know-about-consolidation-in-health-care-provider-markets/
2 Patzman A, Neeck M. Health care provider consolidation. Bipartisan Policy Center. January 29, 2026. https://bipartisanpolicy.org/issuebrief/health-care-provider-consolidation/
3 Levinson Z, Godwin J, Hulver S, Neuman T. Ten things to know about consolidation in health care provider markets. KFF. April 19, 2024. https://www.kff.org/health-costs/ten-things-to-know-about-consolidation-in-health-care-provider-markets/
4 Godwin J, Levinson Z, Neuman T. One or two health systems controlled the entire market for inpatient hospital care in nearly half of metropolitan areas in 2024. KFF. March 27, 2026. https://www.kff.org/health-costs/one-or-two-health-systems-controlled-the-entire-market-forinpatient-hospital-care-in-nearly-half-of-metropolitan-areas/
5 Cooper Z, Harris A, Hill M. A ranking of all 50 states by hospital consolidation. Health Care Affordability Lab at Yale. March 9, 2026. https://www.healthcareaffordabilitylab.org/commentary-press-release-posts/a-ranking-of-all-50-states-by-hospital-consolidation
6 Physicians Advocacy Institute, Avalere Health. Escalating Consolidation: The Rapid Expansion of Hospital and Corporate Control Over Physician Practices and Employment 2018-2026. April 2026. https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAIResearch/20260424_PAI%20Physician%20Employment%20Practice%20Acquisition%20Trends_vFINAL.pptx
7 US Government Accountability Office. Health Care Consolidation: Published Estimates of the Extent and Effects of Physician Consolidation. GAO-25-107450. September 22, 2025. https://www.gao.gov/products/gao-25-107450
8 Machta RM, D Reschovsky J, Jones DJ, Kimmey L, Furukawa MF, Rich EC. Health system integration with physician specialties varies across markets and system types. Health Serv Res. 2020;55 Suppl 3(Suppl 3):1062-1072. doi:10.1111/1475-6773.13584
9 Kane CK. Physician Practice Characteristics in 2024: Private Practices Account for Less Than Half of Physicians in Most Specialties. American Medical Association; 2025. Policy Research Perspective 2025-39. https://www.ama-assn.org/system/files/2024-prp-pp-characteristics.pdf
10 O'Hanlon CE, Kranz AM, DeYoreo M, Mahmud A, Damberg CL, Timbie J. Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation. Health Aff (Millwood). 2019;38(12):2095-2104. doi:10.1377/hlthaff.2019.00918
11 Dranove D, Gaynor M, Geddes E. Expecting Harm? The Impact of Rural Hospital Acquisitions on Maternal Health Care. National Bureau of Economic Research; 2025. NBER Working Paper 34159. doi:10.3386/w34159
12 Simpson J, Shin R. Do Nonprofit Hospitals Exercise Market Power? Federal Trade Commission, Bureau of Economics; November 1996. Working Paper 214. https://www.ftc.gov/reports/do-nonprofit-hospitals-exercise-market-power
13 Vita MG, Sacher S. The competitive effects of not-for-profit hospital mergers: a case study. J Ind Econ. 2001;49(1):63-84. doi:10.1111/14676451.00138
14 Dafny L, Ho K, Lee RS. The Price Effects of Cross-Market Hospital Mergers. National Bureau of Economic Research; March 2016. Revised October 2018. NBER Working Paper 22106. https://www.nber.org/system/files/working_papers/w22106/w22106.pdf
15 Lewis MS, Pflum KE. Hospital systems and bargaining power: evidence from out-of-market acquisitions. RAND J Econ. 2017;48(3):579-610. doi:10.1111/1756-2171.12186
16 Godwin J, Levinson Z, Hulver S. Understanding mergers between hospitals and health systems in different markets. KFF. August 23, 2023. https://www.kff.org/health-costs/understanding-mergers-between-hospitals-and-health-systems-in-different-markets/
17 Godwin J, Levinson Z, Neuman T. Hospital spending accounted for 40% of the growth in national health spending between 2022 and 2024. KFF. February 11, 2026. https://www.kff.org/health-costs/hospital-spending-accounted-for-40-of-the-growth-in-national-health-spendingbetween-2022-and-2024/
18 Capps C, Dranove D, Ody C. The effect of hospital acquisitions of physician practices on prices and spending. J Health Econ. 2018;59:139152. doi:10.1016/j.jhealeco.2018.04.001
19 Neprash HT, Chernew ME, Hicks AL, Gibson T, McWilliams JM. Association of Financial Integration Between Physicians and Hospitals With Commercial Health Care Prices. JAMA Intern Med. 2015;175(12):1932-1939. doi:10.1001/jamainternmed.2015.4610
20 Scheffler RM, Arnold DR, Whaley CM. Consolidation trends in California's health care system: impacts on ACA premiums and outpatient visit prices. Health Aff (Millwood). 2018;37(9):1409-1416. doi:10.1377/hlthaff.2018.0472
21 Boozary AS, Feyman Y, Reinhardt UE, Jha AK. The association between hospital concentration and insurance premiums in ACA Marketplaces. Health Aff (Millwood). 2019;38(4):668-674. doi:10.1377/hlthaff.2018.05491
22 Medicare Payment Advisory Commission. Congressional request on health care provider consolidation. In: Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; March 2020:457-510. https://www.medpac.gov/wpcontent/uploads/import_data/scrape_files/docs/default-source/reports/mar20_medpac_ch15_sec.pdf
23 Beaulieu ND, Dafny LS, Landon BE, Dalton JB, Kuye I, McWilliams JM. Changes in quality of care after hospital mergers and acquisitions. N Engl J Med. 2020;382(1):51-59. doi:10.1056/NEJMsa1901383
24 Pauly MV, Burns LR, Benitez A, Sielski M. Hospital consolidation and quality: opening the behavioral black box. Soc Sci Med. 2025;386:118593. doi:10.1016/j.socscimed.2025.118593
25 Satiani B, Way DP, Hoyt DB, Ellison EC. Systematic review of integration strategies across the US healthcare system: assessment of price, cost, and quality of care. J Am Coll Surg. 2025;240(5):758-773. doi:10.1097/XCS.0000000000001229
26 Baker LC, Bundorf MK, Kessler DP. The effect of hospital/physician integration on hospital choice. J Health Econ. 2016;50:1-8. doi:10.1016/j.jhealeco.2016.08.006
27 Braun M, Naor L, Hasson-Ohayon I, Goldzweig G. Oncologists' Locus of Control, Compassion Fatigue, Compassion Satisfaction, and the Mediating Role of Helplessness. Curr Oncol. 2022;29(3):1634-1644. Published 2022 Mar 4. doi:10.3390/curroncol29030137
28 Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clin Proc. 2016;91(4):422-431. doi:10.1016/j.mayocp.2016.02.001
29 Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2023. Mayo Clin Proc. 2025;100(7):1142-1158. doi:10.1016/j.mayocp.2024.11.031
30 Kane CK. Physician Practice Characteristics in 2024: Private Practices Account for Less Than Half of Physicians in Most Specialties. American Medical Association; 2025. Policy Research Perspective 2025-39. https://www.ama-assn.org/system/files/2024-prp-pp-characteristics.pdf
31 Physicians Advocacy Institute, Avalere Health. Updated Report: Hospital and Corporate Acquisition of Physician Practices and Physician Employment 2019-2023. April 2024. https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/PAIAvalere%20Physician%20Employment%20Trends%20Study%202019-2023%20Final.pdf
32 Prager E, Schmitt M. Employer consolidation and wages: evidence from hospitals. Am Econ Rev. 2021;111(2):397-427. doi:10.1257/aer.20190690
33 Allegretto SA, Graham-Squire D. Monopsony in Professional Labor Markets: Hospital System Concentration and Nurse Wages. Institute for New Economic Thinking; January 2023. Working Paper 197. doi:10.36687/inetwp197
34 Levinson Z, Neuman T, Hulver S. Five things to know about Medicare site-neutral payment reforms. KFF. June 14, 2024. https://www.kff.org/medicare/five-things-to-know-about-medicare-site-neutral-payment-reforms/
35 Congressional Budget Office. Reduce payments for hospital outpatient departments. In: Options for Reducing the Deficit: 2025 to 2034. December 12, 2024. https://www.cbo.gov/budget-options/60908
36 Chernew ME. Disparities in payment across sites encourage consolidation. Health Serv Res. 2021;56(1):5-6. doi:10.1111/1475-6773.13612
37 US Government Accountability Office. Medicare: Increasing Hospital-Physician Consolidation Highlights Need for Payment Reform. GAO16-189. December 2015. https://www.gao.gov/assets/gao-16-189.pdf
38 Lou KK, Linehan KE, da Fonte LN, Lai P, Buntin MB. Medicare site-neutral payment policies: effects of proposals on hospitals and beneficiary groups. Health Aff (Millwood). 2025;44(6):668-676. doi:10.1377/hlthaff.2024.01501
39 National Conference of State Legislatures. Certificate of need state laws. April 29, 2025. https://www.ncsl.org/health/certificate-of-need-statelaws
40 Bailey J. Can Health Spending Be Reined In Through Supply Constraints? An Evaluation of Certificate-of-Need Laws. Mercatus Center at George Mason University; August 2016. Mercatus Working Paper. https://www.mercatus.org/research/working-papers/can-health-spending-bereined-through-supply-constraints-evaluation
41 Mitchell MD. Do Certificate-of-Need Laws Limit Spending? Mercatus Center at George Mason University; September 2016. Mercatus Working Paper. https://www.mercatus.org/system/files/mercatus-mitchell-con-healthcare-spending-v1a.pdf
42 Stratmann T, Baker MC. Examining Certificate-of-Need Laws in the Context of the Rural Health Crisis. Mercatus Center at George Mason University; July 29, 2020. Mercatus Working Paper. https://www.mercatus.org/research/working-papers/examining-certificate-need-laws-contextrural-health-crisis
43 Stratmann T, Koopman C. Entry Regulation and Rural Health Care: Certificate-of-Need Laws, Ambulatory Surgical Centers, and Community Hospitals. Mercatus Center at George Mason University; February 18, 2016. Mercatus Working Paper. https://www.mercatus.org/research/working-papers/entry-regulation-and-rural-health-care-certificate-need-laws-ambulatory
44 Stratmann T, Baker MC. Are Certificate-of-Need Laws Barriers to Entry? How They Affect Access to MRI, CT, and PET Scans. Mercatus Center at George Mason University; January 12, 2016. Mercatus Working Paper. https://www.mercatus.org/research/working-papers/arecertificate-need-laws-barriers-entry-how-they-affect-access-mri-ct-and
45 Slivinski S, Mitchell MD. Certificate of Need: The Regulation Blocking Greater Access to Higher-Quality and Lower-Cost Care. Cato Institute; August 11, 2026. Briefing Paper 204. https://www.cato.org/briefing-paper/certificate-need-regulation-blocking-greater-access-higher-qualitylower-cost-care
46 Ohlhausen MK. Certificate of need laws: a prescription for higher costs. Antitrust. 2015;30(1):50-54. https://www.ftc.gov/system/files/documents/public_statements/896453/1512fall15-ohlhausenc.pdf
47 Federal Trade Commission, Antitrust Division, US Department of Justice. Joint Statement of the Federal Trade Commission and the Antitrust Division of the U.S. Department of Justice on Certificate-of-Need Laws and South Carolina House Bill 3250. January 11, 2016. https://www.ftc.gov/legal-library/browse/advocacy-filings/joint-statement-federal-trade-commission-antitrust-division-us-department-justicecertificate-need
48 Centers for Medicare & Medicaid Services. Physician self-referral. Updated February 9, 2026. https://www.cms.gov/medicare/regulationsguidance/physician-self-referral
49 Zimmerman M. Medicare: Referring Physicians' Ownership of Laboratories and Imaging Centers. Testimony before the Subcommittee on Health, Committee on Ways and Means, House of Representatives. US General Accounting Office; June 1, 1989. GAO/T-HRD-89-24. https://www.gao.gov/assets/t-hrd-89-24.pdf
50 Larsen E. "If we hadn't been there, history might have been different": Chip Kahn on two decades helming the Federation of American Hospitals. Advisory Board. June 1, 2021. https://www.advisory.com/blog/2021/06/two-decades
51 Miller BJ, Moffit RE, Ficke J, Marine J, Ehrenfeld J. Reversing hospital consolidation: the promise of physician-owned hospitals. Health Affairs Forefront. April 12, 2021. doi:10.1377/forefront.20210408.980640
52 Cole CM. Physician-owned hospitals and self-referral. Virtual Mentor. 2013;15(2):150-155. doi:10.1001/virtualmentor.2013.15.2.hlaw1-1302
53 Blumenthal DM, Orav EJ, Jena AB, Dudzinski DM, Le ST, Jha AK. Access, quality, and costs of care at physician owned hospitals in the United States: observational study. BMJ. 2015;351:h4466. doi:10.1136/bmj.h4466
54 Taylor A, Escobar E, Udayakumar K. Expanding Access to Low-Cost, High-Quality Tertiary Care: Spreading the Narayana Health Model Beyond India. The Commonwealth Fund; November 2017. https://www.commonwealthfund.org/publications/case-study/2017/nov/expandingaccess-low-cost-high-quality-tertiary-care
55 Heskett JL, Hallowell RH. Shouldice Hospital Limited (Abridged). Harvard Business School Case 805-002. July 2004. Revised January 2005. https://www.hbs.edu/faculty/Pages/item.aspx?num=31326
56 Briner B, Miller BJ, Friedman T, Turner E. Solving the challenges of employee health benefits: the North Carolina State Health Plan story. Health Affairs Forefront. October 23, 2025. doi:10.1377/forefront.20251021.733866
57 North Carolina State Health Plan. 2027 State Health Plan Comparison: Active and Non-Medicare Subscribers. https://www.shpnc.gov/documents/open-enrollment-documents/2027-active-non-medicare-plan-comparison/open
58 North Carolina State Health Plan. State Health Plan Board of Trustees Meeting. July 10, 2026. https://www.shpnc.gov/documents/boardtrustees/state-health-plan-board-trustees-presentation-7102026/download?attachment
59 North Carolina State Health Plan. Preferred Provider Regional Maps. September 10, 2026. https://www.shpnc.gov/documents/open-enrollmentdocuments/preferred-provider-regional-maps/download?attachment
60 North Carolina State Health Plan. Lantern surgical benefit. https://www.shpnc.gov/employee-benefits/lantern-surgical-benefit
61 North Carolina Department of State Treasurer. NC State Health Plan and OrthoCarolina announce no cost Lantern surgery benefit for members. Press release. June 16, 2026. https://www.nctreasurer.gov/news/press-releases/2026/06/16/nc-state-health-plan-and-orthocarolina-announce-nocost-lantern-surgery-benefit-members
62 National Conference of State Legislatures. Certificate of need state laws. April 29, 2025. https://www.ncsl.org/health/certificate-of-need-statelaws
63 Mitchell MD. Certificate of Need Laws in Health Care: Past, Present, and Future. Inquiry. 2024;61:469580241251937. doi:10.1177/00469580241251937
64 Mitchell MD, Amez-Droz E, Miller A. Phasing Out Certificate-of-Need Laws: A Menu of Options. Mercatus Center at George Mason University; February 25, 2020. Mercatus Policy Brief. https://www.mercatus.org/research/policy-briefs/phasing-out-certificate-need-laws-menuoptions
65 US Department of Justice, Antitrust Division. Herfindahl-Hirschman Index. Updated January 17, 2024. https://www.justice.gov/atr/herfindahlhirschman-index
66 Sanders J. Certified: The Need to Repeal CON; Counter to Their Intent, Certificate of Need Laws Raise Health Care Costs. John Locke Foundation; October 23, 2013. https://www.johnlocke.org/research/certified-the-need-to-repeal-con-counter-to-their-intent-certificate-of-needlaws-raise-health-care-costs/
67 Bailey J. Certificate of Need in North Carolina: Cost, Access, Treatment. John Locke Foundation; January 2021. https://www.johnlocke.org/wp-content/uploads/2021/01/Certificate-of-Need-2-digital.pdf
68 North Carolina Department of Health and Human Services, Division of Health Service Regulation. Overview of Certificate of Need (CON). Updated December 17, 2024. https://info.ncdhhs.gov/dhsr/coneed/overview.html
69 Tierney C. NC budget repeals CON for inpatient rehabilitation care. Carolina Journal. July 6, 2026. https://www.carolinajournal.com/ncbudget-repeals-con-for-inpatient-rehabilitation-care/
70 CJ Staff. New Bern eye surgeon cites three reasons to reverse CON dispute ruling. Carolina Journal. July 13, 2026. https://www.carolinajournal.com/new-bern-eye-surgeon-cites-three-reasons-to-reverse-con-dispute-ruling/
71 Carolina Journal. Treasurer, state employees group back challenge to NC CON law. Carolina Coast Online. November 9, 2025. https://www.carolinacoastonline.com/regional/article_185f6a1d-cbff-4a5d-a624-6c266b4c7f78.html
72 CJ Staff. Briner, SEANC support state Supreme Court review of CON dispute. Carolina Journal. April 2, 2026. https://www.carolinajournal.com/briner-seanc-support-state-supreme-court-review-of-con-dispute/
73 US Department of Justice. Atrium Health agrees to settle antitrust lawsuit and eliminate anticompetitive steering restrictions. Press release 181509. November 15, 2018. https://www.justice.gov/archives/opa/pr/atrium-health-agrees-settle-antitrust-lawsuit-and-eliminate-anticompetitivesteering
74 US Department of Justice. Justice Department requires OhioHealth to stop using anticompetitive healthcare contract terms that raise costs for Ohio patients. Press release 26-663. June 16, 2026. https://www.justice.gov/opa/pr/justice-department-requires-ohiohealth-stop-usinganticompetitive-healthcare-contract-terms
75 US Department of Justice. Justice Department sues New York-Presbyterian Hospital for anticompetitive contracts that increase healthcare costs for New Yorkers. Press release 26-290. March 26, 2026. https://www.justice.gov/opa/pr/justice-department-sues-new-york-presbyterian-hospitalanticompetitive-contracts-increase
76 The White House. Effects of Banning Anti-Competitive Hospital Contracts. June 18, 2026. https://www.whitehouse.gov/research/2026/06/effects-of-banning-anti-competitive-hospital-contracts/
77 Relating to Certain Contract Provisions and Conduct Affecting Health Care Provider Networks, HB 711, 88th Leg (Tex 2023). https://legiscan.com/TX/text/HB711/id/2791115
78 Mitchell A. Medicaid's Federal Medical Assistance Percentage (FMAP). Congressional Research Service; April 2, 2025. CRS Report R43847. https://www.congress.gov/crs-product/R43847
79 Medicare Payment Advisory Commission. Payment Basics: Medicare Advantage Program Payment System. Revised November 2025. https://www.medpac.gov/wp-content/uploads/2024/10/MedPAC_Payment_Basics_25_MA_FINAL_SEC.pdf
80 Medicare Payment Advisory Commission. Payment Basics: Hospital Acute Inpatient Services Payment System. Revised November 2025. https://www.medpac.gov/wp-content/uploads/2024/10/MedPAC_Payment_Basics_25_hospital_FINAL_SEC.pdf
81 Medicare Payment Advisory Commission. Payment Basics: Outpatient Hospital Services Payment System. Revised November 2025. https://www.medpac.gov/wp-content/uploads/2024/10/MedPAC_Payment_Basics_25_OPD_FINAL_SEC.pdf
82 Capretta JC. Chairman Smith is right about the need for a site-neutral policy in Medicare. AEIdeas, American Enterprise Institute. April 29, 2026. https://www.aei.org/health-care/chairman-smith-is-right-about-the-need-for-a-site-neutral-policy-in-medicare/
83 Katebi C. America First Policy Institute supports Centers for Medicare and Medicaid Services' final rule. America First Policy Institute. December 8, 2025. https://www.americafirstpolicy.com/issues/afpi-supports-centers-for-medicare-and-medicaid-services-final-rule
84 Katebi C. Ending Medicare's hospital markup: a site-neutral path to lower costs for seniors. America First Policy Institute. August 18, 2026. https://www.americafirstpolicy.com/issues/ending-medicares-hospital-markup-a-site-neutral-path-to-lower-costs-for-seniors
85 Ippolito B, Fiedler M, Adler L. Weighing policy options for returning savings from site-neutral payment reforms to hospitals. Brookings Institution. May 26, 2023. https://www.brookings.edu/articles/weighing-policy-options-for-returning-savings-from-site-neutral-payment-reformsto-hospitals/
86 Committee for a Responsible Federal Budget. Equalizing Medicare payments regardless of site-of-care. February 23, 2021. https://www.crfb.org/papers/equalizing-medicare-payments-regardless-site-care
87 Moffit RE. Time for action to reverse hospital consolidation. The Heritage Foundation. January 3, 2023. https://www.heritage.org/health-carereform/commentary/time-action-reverse-hospital-consolidation
88 Albanese J. Opportunities for Medicare site neutrality in 2025. Paragon Health Institute. January 8, 2025. https://paragoninstitute.org/medicare/opportunities-for-medicare-site-neutrality-in-2025/
89 Medicare Payment Advisory Commission. Aligning fee-for-service payment rates across ambulatory settings. In: Report to the Congress: Medicare and the Health Care Delivery System. Medicare Payment Advisory Commission; June 2023:chap 8. https://www.medpac.gov/wpcontent/uploads/2023/06/Jun23_Ch8_MedPAC_Report_To_Congress_SEC.pdf
90 Levinson Z. The Trump administration continues to advance incremental site-neutral payment reforms. KFF. July 6, 2026. https://www.kff.org/quick-insights/the-trump-administration-continues-to-advance-incremental-site-neutral-payment-reforms/
91 Lower Costs, More Transparency Act, HR 5378, 118th Cong (2023). https://www.congress.gov/bill/118th-congress/house-bill/5378/all-actions
92 Lower Costs, More Transparency Act of 2026, HR 9393, 119th Cong (2026). https://www.congress.gov/bill/119th-congress/housebill/9393/titles
93 Miller BJ, Moffit RE, Ficke J, Marine J, Ehrenfeld J. Reversing hospital consolidation: the promise of physician-owned hospitals. Health Affairs Forefront. April 12, 2021. doi:10.1377/forefront.20210408.980640
94 Plummer E, Wempe W. The Affordable Care Act's Effects On The Formation, Expansion, And Operation Of Physician-Owned Hospitals. Health Aff (Millwood). 2016;35(8):1452-1460. doi:10.1377/hlthaff.2015.1342
95 Wang Y, Plummer E, Wang Y, Cram P, Bai G. Comparison of commercial negotiated price and cash price between physician-owned hospitals and other hospitals in the same hospital referral region. JAMA Netw Open. 2023;6(6):e2319980. doi:10.1001/jamanetworkopen.2023.19980
96 Physician Led and Rural Access to Quality Care Act, HR 2191, 119th Cong (2025). https://www.congress.gov/bill/119th-congress/housebill/2191
97 Miller BJ, Ehrenfeld JM, Wu AW. Competition or conflict of interest--Stark choices. JAMA Health Forum. 2021;2(2):e210150. doi:10.1001/jamahealthforum.2021.0150
98 Federal Trade Commission. Legal library: advocacy filings. https://www.ftc.gov/legal-library/browse/advocacy-filings
99 Centers for Medicare & Medicaid Services. General schedule of rulemaking for Medicare payment systems. In: CMS Guide for Medical Technology Companies and Other Interested Parties. Updated March 10, 2026. https://www.cms.gov/cms-guide-medical-technology-companiesand-other-interested-parties/payment/rulemaking-schedule
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Original text here: https://judiciary.house.gov/sites/evo-subsites/republicans-judiciary.house.gov/files/evo-media-document/miller-testimony_0.pdf
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Chairman Fitzgerald, Ranking Member Nadler, and distinguished members of the Subcommittee:
My name is Brian Miller, and I practice hospital medicine at the Johns Hopkins Hospital. ... Show Full Article CHARLOTTE, North Carolina, Oct. 1 -- The House Judiciary Subcommittee on the Administrative State, Regulatory Reform and Antitrust released the following testimony by Brian J. Miller, associate professor of medicine and business at the Johns Hopkins University, and a visiting fellow at the Hoover Institution, from a Sept. 14, 2026, field hearing entitled ""Examining Healthcare Markets: Fraud and Competition": * * * Chairman Fitzgerald, Ranking Member Nadler, and distinguished members of the Subcommittee: My name is Brian Miller, and I practice hospital medicine at the Johns Hopkins Hospital.As an academic health policy analyst, I serve as an Associate Professor of Medicine and Business (Courtesy) at the Johns Hopkins University School of Medicine and as a Visiting Fellow at the Hoover Institution. My research focuses on how we can build a more competitive and vibrant health sector to make healthcare more efficient, flexible, and personalized for patients. This perspective is based upon my prior regulatory experience at four federal regulatory agencies.
Through my current role as a faculty member, I regularly engage with regulators, policymakers, and businesses in search of solutions to help create a better healthcare system for all. Today I am here in my personal capacity, and the views expressed are my own and do not necessarily reflect those of the Johns Hopkins University, the Johns Hopkins Health System, the Hoover Institution, the North Carolina State Health Plan or the Medicare Payment Advisory Commission.
Monopoly and its younger cousin, consolidation, remain a serious, pressing, persistent concern. Many healthcare markets are highly consolidated, resulting in a loss of price and non-price competition for consumers, employers, workers, and taxpayers. Competition counts. While price competition is critical to a functioning marketplace, the loss of non-price competition often explains many of the additional concerns that consumers and all of us patients experience: the lack of meaningful improvement in medical quality in many service areas, declining consumer experience/convenience, and persistent unsolved basic clinical operational challenges. Monopoly and regulation together protect incumbency and foreclose market-driven incremental improvement and revolutionary change through the removal of incentives to compete.
Through a variety of policy choices, government has at times placed its foot firmly on the accelerator in favor of consolidation. In other circumstances, the government has banned or severely restricted market entry, placing a heavy brake on competition and replacing it with statutory prohibition or regulation. Neither of these is an adequate substitute for competition.
In my testimony today, I will focus on three areas:
1. Hospital consolidation scope and impacts
2. Drivers of hospital consolidation
3. State and federal law and regulatory policy changes to promote competition
1. Hospital Consolidation Scope and Impacts
Scope of Hospital Consolidation
The scope of the problem is significant in scale. With over 2,000 mergers over the past 25 years,1 the share of independent hospitals has declined from 90% in 1970 to 32% in 20192 all amidst the growth of mostly tax-exempt health systems.3 In 2024, in 47% of metropolitan areas, 1 or 2 health systems controlled the entire market for inpatient hospital care while in 83% of markets 1 or 2 health systems controlled more than 75% of the market. To make matters worse, 97% of metro areas were highly concentrated markets (as defined by the Department of Justice Antitrust Division) for inpatient care.4 Locally, according to the Yale Health Care Affordability Lab, 71.2% of North Carolina hospitals are in highly concentrated or monopoly markets, with 25 hospitals operating as pure monopolies.5 Hospital-hospital consolidation is only the beginning. Physician consolidation into hospitals has resulted in increased prices, a loss of non-price competition, and no systematic measurable, durable gains in quality or patient experience. An estimated 82% of physicians are employed by hospitals or corporate entities and 63.9% are owned by the same.6 For hospitals specifically, according to the Government Accountability Office (GAO) an estimated 47% of physicians were consolidated into hospital systems in 2024, up from 30% in 2012./7 Other researchers have found that the most commonly integrated specialties (hematology-oncology, cardiology, and general surgery) are those associated with the delivery of lucrative hospital services.8 The American Medical Association (AMA) physician benchmark survey validates many of these findings of shifting employment models, with physician employment in private practice declining from 60.2% in 2012 to 42.2% in 2024./9
Market ossification from consolidation is a problem worsened in rural markets. Researchers have found that rural hospital system affiliation results in decreased obstetric care, primary care, and on-site imaging all while increasing margins without any accompanying change in patient experience scores or hospital readmissions.10 Further empirical work replicates the decrease in access to obstetric care,11 a concerning finding. Some policy analysts have argued that rural health challenges result purely from financial distress. Empirical research demonstrates otherwise: while financial distress is a predictor of mergers, 77% of unprofitable rural hospitals over an eight-year period continued to operate. This study unintentionally highlights many challenges, including arguably relatively lax financial reporting standards for tax-exempt entities compared to their for-profit counterparts, and the misalignment of booked net income as opposed to cash flow margins from operating activities.
Price Harms of Hospital Consolidation
The loss of competition has both price and non-price impacts: we consider each in turn. Empirical research consistently demonstrates that hospital mergers - including in disparate geographies - result in higher prices and hence higher insurance premiums. Tax status is immaterial in terms of organizational behavior regarding prospective mergers: tax-exempt hospitals also exercise market power in the form of higher prices,12,13 a finding no different than tax-paying, for-profit hospitals. Beyond in-market mergers, cross-market, in-state hospital mergers yield price increases of 7-9%,14 and out-of-market acquisitions result in 17% price increases;15 both types of transaction are becoming more common.16 With hospital spending accounting for 40% of the growth in national health spending from 2022 to 2024,17 scrutiny of hospital consolidation is imperative.
Hospital-physician mergers (frequently viewed as a vertical transaction) also result in higher prices. While not all vertical integration across the healthcare supply chain are uniformly harmful, hospital-physician mergers again have consistent evidence that they produce higher prices and hence higher premiums. Research has found that hospital acquisition of physician practices was associated with price increases of 14.1% post-acquisition, a number that grew when the hospital had a larger share of the inpatient market. Even the integration of primary care physicians increased spending by 4.9%.18 Generally, hospital acquisition of physician practices increased prices, and spending was entirely driven by price increases with little change in utilization.19 Finally, and arguably most critically, although insurance shields consumers from many of these costs directly, consolidation-driven price increases reach them through higher premiums: hospital acquisition of physician practices was associated with a 12% increase in Affordable Care Act (ACA) marketplace premiums20 with another study further supporting the assertion that care delivery consolidation increases health insurance premiums.21 A Medicare Payment Advisory Commission (MedPAC) literature review likewise found that hospital consolidation drives higher prices and that government policy such as the lack of site neutral payment drove hospital acquisition of physician practices.22
Non-Price Harms of Hospital Consolidation
In addition to and equal in importance to the harms of diminishing price competition, the loss of non-price competition harms consumers, purchasers, and workers in a variety of ways. Despite claims to the contrary, hospital mergers do not improve quality, with a study of 246 acquired hospitals compared to controls over a decade demonstrating no change in critical outcomes such as 30-day readmission rates or mortality - and even demonstrating minor decrements in patient experience.23 A subsequent review of 30 years of evidence found no clear pattern that hospital mergers improve quality,24 a finding replicated by a second systematic review.25
Consumer and provider experience also represent significant non-price competition losses from hospital consolidation. Functionally, hospital-hospital and hospital-physician mergers exercise control over and limit or distort patient choice, with research demonstrating that hospital ownership of a physician increased the probability that the patient would select the owning hospital, and more likely a high-cost, low-quality hospital.26 Furthermore, the loss of small providers may make accessing care more difficult for important, vulnerable, high-cost populations.
Small practices may be easier for patients to navigate, especially those with multi-morbidity, and may offer greater care and access customization potentially serving patients with disabilities, special needs, or higher illness acuity.
Non-price competitive losses also encompass provider experience and the loss of choice and oversight over the clinical practice environment. Large health systems offer less flexibility, with a direct loss of clinical independence and externalization of the locus of control over clinical operations and even at times clinical decision-making. The tradeoffs are real, with externalization of the locus of control well-associated with burnout and loss of clinician compassion.27 Burnout is also predictive of physician elective reduction in workload, further constraining supply.28 In 2023, half of all physicians suffered from symptoms of burnout making this a meaningful concern.29 Other workforce impacts are also worth noting, with the marketplace experiencing a move from physicians as small business owners to a largely employed workforce. An estimated 35.5% of physicians were owners in 2024 down from 53.2% in 2012, with 49.2% of private practices as having fewer than five physicians compared to 16.1% for hospitals - with one-third of hospital practices being larger than 50 physicians,30 an assessment largely independently validated by the Physician Advocacy Institute.31 The transition to a hospital-employed physician workforce results in a world akin to "Severance," with a new generation of employed physicians experiencing deep feelings of depersonalization, alienation, and disempowerment through dehumanization and excessive administrative control.
Non-price competition impacts are not limited to physicians. The hospital industry is a textbook example of employers using market power to reduce nurse wages. Recent work in the American Economic Review found that when hospital mergers increase local employer concentration, wages go down. For mergers in the top quartile of concentration increases, researchers estimated that wages for nursing and pharmacy workers were 6.8% lower four years after the merger than they otherwise would have been.32 Other researchers replicated this, finding that increased hospital-system concentration in smaller metropolitan statistical areas is associated with slower real nursing wage growth with a 0.10 increase in market concentration associated with about a $0.70 reduction in real hourly nurse wage growth in smaller metropolitan areas.33
2. Policy drivers of hospital consolidation
Federal Policy Incentivizes Consolidation
Hospital consolidation results primarily from policy incentivizing consolidation and additional policy blocking market entry.
Federal policy unfortunately incentivizes and at times directly drives consolidation. On a first principles basis, payers should fund the right service for the right patient at the right time in the right setting by the right person. This also means that payers should not pay differential rates for the same service for non-clinical reasons - that is, if a colonoscopy has a defined cost and a patient chooses to undergo it in an ambulatory surgery center setting or a hospital outpatient department (HOPD), it should cost the same. The same argument applies to many other outpatient services, when comparing their completion in an HOPD versus a physician office. Unfortunately, the lack of site neutral payment in the Medicare program creates an opportunity for regulatory arbitrage to drive both increased payment and increased market power.34 Because HOPDs are paid under a distinct payment system than freestanding clinics that results in higher rates for the same clinical service, hospitals have an economic rationale to acquire clinics and bill at the higher rate.
Congress recognized this and, in the Bipartisan Budget Act of 2015, mandated that new off-campus (>250 yards) HOPDs be paid at a lower rate. Grandfathered off-campus HOPDs and on-campus HOPDs remained unaffected.
Fully closing this loophole by implementing site neutral payment would, per the Congressional Budget Office (CBO), generate $170 billion in savings.35 The lack of site neutral payment also drives physician-hospital consolidation, as noted by prior MedPAC Chair Chernew36 and noted as far back as 2015 by the GAO.37 Critically, research has demonstrated minimal impact on rural facilities if site neutral policy were implemented.38
In this setting, it is no surprise that a significant portion of hospital corporate strategy is to seek additional state and federal subsidies directly or undertake mergers to access or amplify regulatory-driven arbitrage opportunities.
Consequently, clinical innovation and improvement are disincentivized. Incentives therefore need to be realigned to ensure that affordable products and services flow to the patients who need them, and that hospitals that need subsidies should access them directly.
State and Federal Policy Disfavors and Even Bans Competitor Entry
Certificate of Need (CON) laws at the state level disfavor entry. Briefly, a state health planning agency, the department of health, or another entity reviews and approves the creation of new health care facilities, facility expansion, or purchase of capital equipment. An estimated 35 states and the District of Columbia operate CON programs,39 a marketplace spurred by the 1974 National Health Planning and Resources Development Act. This Act required states to adopt CON or federal health funding would be withheld, with policymakers positing that CON would ensure adequate care for rural and underserved areas and prevent overuse in other areas. In contrast, outcomes are the opposite, representing a failure of central planning, with the 1974 Act repealed as part of the 1986 Comprehensive Mental Health Services Act. Robust evidence has demonstrated the harms of CON, suggesting that they raise rather than restrain spending.40,41 Quality impacts are also negative, with the presence of CON laws associated with greater Medicare spending, more ED visits, and hospital readmissions.42 Access is also restricted, with evidence demonstrating that CON law restricts access to hospitals and ASCs including in rural areas,43 in addition to decreasing access to imaging services such as MRI/CT/PET while simultaneously favoring hospital over nonhospital providers.44 In this way, CON hurts rural states the most45 and is thankfully widely recognized as anticompetitive, including by FTC Commissioners46 and U.S. Department of Justice Antitrust Division frequently commenting on their anticompetitive nature and advocating for repeal.47
Stark Law, or physician self-referral law, was initially enacted in 1989 and expanded in subsequent years through statute and rulemaking. Stark Law prohibits self-referral for physician-owned enterprises to 12 designated services when billing Medicare or Medicaid.48 There were valid concerns about physician self-referral in a fee-for-service setting, dating back to research from the 1980s regarding induced demand for imaging and lab services.49 At the time as part of Stark Law, a specifically crafted "whole hospital exception" previously allowed self-referral to a hospital with physician ownership, with the conception that the physician owned an interest in an entity that provided a wide range of services, as opposed to an individual service. This exception was subsequently closed as part of the 2010 Patient Protection and Affordable Care Act (ACA) as a consequence of hospital industry lobbying.
Interestingly, no such self-referral ban in statute or rulemaking exists for tax-exempt and for-profit corporate entities, which frequently require self-referral as a condition of clinical practice and employment. Presupposing that one corporate form engages in self-referral for malignant reasons while other corporate forms with the same incentives engage in self-referral for only good reasons is a policy failure, substituting a need for regulation of all market participants with a statutory ban on a single market participant. Self-referral is a complex issue: self-referral for integrated care delivery sometimes has strong clinical value and in other settings it only has financial value. As a complex issue involving taxpayer-funded health benefits, oversight is critical. Yet, patients and practice patterns are unique and likely need some loco-regional flexibility. Recognizing this reality, utilization management practices are needed for all market participants. This would be best executed in the marketplace a dynamic tool that allows patients to have access to the benefits of integrated care delivery while ensuring against fraud, waste, and abuse.
Impacts of the Stark self-referral ban are real and include price and non-price competition impacts. Stark foreclosed the entire market for physician-owned and -operated integrated care delivery as Medicare and Medicaid often comprise half or more of patients for a care delivery organization. In contrast, tax-exempt health systems could employ an orthopedic surgeon and require internal system referral for imaging, physical therapy, and surgical services for a Medicare or Medicaid patient. Meanwhile, a physician-owned practice could not, as doing so would be statutorily illegal. In foreclosing the market for physician-owned and -operated care delivery, Stark Law decreased non-price competition in terms of medical quality, consumer experience and the clinician experience through the loss of service delivery innovation from front-line clinician owner-operators. This is the deterioration in quality that all of us, or those close to us, have experienced but that goes unmeasured. Critically, the loss of small business in care delivery sectors is an acute problem in rural areas where integrated care delivery is needed at smaller scale, and larger corporations may not have an incentive to invest without significant subsidy. Policy has made owning and operating small business illegal in many care delivery markets.
Finally, the physician-owned hospital (POH) ban directly discourages entry. A provision pushed by the hospital trade association,50 Section 6001 of the 2010 ACA51 closed the "whole hospital exception" portion of Stark Law.52 Around 200 POHs remain in existence but as clinical enterprises are prohibited from growing. Approximately half of the marketplace is community POHs (i.e. general acute care hospitals) and half are surgical specialty POHs, largely represented by cardiac and orthopedic POHs.53 In the setting of the POH ban, patients lose price competition from community POHs and surgical specialty POHs, while physicians and nurses lose labor price and nonprice competition. Payers have fewer facilities to construct networks from, resulting in decreased bargaining power and higher prices for the insured. Quality impacts are real: a loss of service delivery innovation, and an absence of growth of focused factories.
A systematic review of 30 years of research demonstrated that patients experience higher quality of care in physician-owned hospitals even when accounting for patient differences:
* Orthopedic surgical specialty hospitals take a focused factory approach to procedures. For total knee and total hip arthroplasty, research demonstrated higher patient satisfaction from MD-RN communication, staff responsiveness along with lower length of stay (LOS) and expected v. observed LOS. These facilities also deploy nonsurgical therapy: POHs tried other interventions prior to surgery more frequently. (e.g. NSAIDs 93.0 vs 83.9%, PT 72.2 vs 67.1%). With respect to outcomes, there was a lower inpatient and 30-day mortality along with lower risk-adjusted readmission for joint replacements while there were lower complications: cardiac, sepsis, deep venous thrombosis, and renal complications for some spinal surgeries.
* Cardiac specialty hospitals take a focused factory approach to procedures exhibiting a lower LOS, lower inpatient and 30-day mortality rates such as in the setting of percutaneous coronary intervention. Highly morbid procedures such as abdominal aortic aneurysm repair had lower mortality as did coronary artery bypass graft surgery, carotid endarterectomy, and acute myocardial infarction treatment. Patients also exhibited a lower risk of severe complications such as post-op hemorrhage, post-op pulmonary embolus and death.
Access impacts from the POH ban on participation in Medicare were real. With the law's passage a statutory deadline of December 31, 2010 resulted in cessation of 45 hospital expansion projects and loss of access to focused factory, a model flourishing in other countries such as Narayana Health (focused factory for cardiac care)54 and the Shouldice hospital (hernia repair).55 Patients also lost access to owner-operated businesses run by the front-line clinicians who best understand clinical operations, and with them the service-delivery innovation those clinicians generate; the voice of the clinician became subsumed by administrators. Taxpayers also faced a revenue loss: POHs pay taxes, tax-exempt hospitals do not. Finally, the loss of price competition results in high costs in suburban and urban markets while the loss of non-price competition reduces quality, convenience/access. In contrast, in rural markets with loss of competition you may even lose market participation, an even more stark outcome that is not well-assessed.
3. State and federal law and regulatory policy changes to promote competition Employer options
Policymakers have state and federal actions that can be taken to combat consolidation and promote competition.
First, state health plans offer an opportunity to implement market-based solutions. The North Carolina State Health Plan (NC SHP), of which I serve as Vice Chairman of the Board of Trustees, is a 750,000-member, $4.8 billion self-insured health plan that recently undertook a fiscal turnaround56 in partnership with employees and providers. The NC SHP worked with employees to set a target share of income for premiums, serving to create income-adjusted premiums and begin to create a budgetary framework for health expenditures. This forced the plan to make decisions about tradeoffs as a team - instead of seeking disproportionately greater subsidies from taxpayers and employees year over year. Instead of electing traditional choices of significant double-digit premium increases or cuts to benefits, this fiscal structure and discipline empowered the plan in partnership with members to creatively use the tools of network strategy and benefit design to drive provider competition.
In this setting, the plan elected to build a preferred provider network through volume-based purchasing with a minimum quality threshold to achieve significant price discounts. Preferred providers were aligned with favorable benefit design to drive volume (see Figure 1). Using a first principles approach, the member wins first on reduced cost-sharing and then the plan wins on savings thus ensuring the members and the plan both benefit (albeit sequentially, not in parallel) from price competition.
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Figure 1: Abbreviated table of updated benefit design57
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The preferred provider strategy also facilitates - for the first time in NC SHP history - for the member to undertake "time travel" in benefit design back to the richness of the 2011/2012 benefit design despite generally concentrated markets if one uses preferred providers (see Figure 2). This is an unheard-of occurrence in health insurance markets.
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Figure 2: Case example and side-by-side comparison of old/new benefit design58
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With a 3-tiered benefit design, the Access tier serves as functionally an "any-willing-provider" in rural areas, whereas in concentrated urban markets through partnership with preferred health systems and robust independent physician networks, plan members can still benefit from price competition (see Figure 3). Geographically, deploying basic insurance design principles in partnership with employees allowed the plan to act as a prudent fiduciary and avoid persistent double-digit year over year rate increases.
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Figure 3: Geography of hospitals by network tier59
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For elective surgeries, the NC SHP partnered with a vendor, Lantern, to construct a no-cost elective surgical benefit for spine, orthopedic, cardiac and other procedures. Recognizing that robust price competition to drive member and plan savings would result in a subset of provider options, the no-cost elective surgical benefit is optional, and members can still access care through the standard benefit design. Rather, the no-cost elective surgical benefit offers just that: no cost to the member. With a wide state and dispersed population, the plan also funds travel with the potential for mileage or even airfare and hotel to support member access to cost savings.60 In this setting independent practices have an equal opportunity to compete as do large health systems, with OrthoCarolina, a Lantern partner, as an example.61
By deploying the principles of competition, steerage, and benefit design, self-insured employers in North Carolina and other states can design their health benefits along these principles to drive competition, as can other state employee health plans. Employers purchasing plan products can also demand - as customers - that health plans undertake a similar contracting strategy. Competition counts.
Options for State Policymakers
State policymakers have multiple options to combat consolidation. With 35 states and the District of Columbia operating CON programs of varying scope and scale,62 state policymakers could undertake a full repeal.
Recognizing that in many circumstances that is not a viable first step, policymakers could consider a phased repeal, with some combination of the following:63,64
1. Repeal service line by service line to help vulnerable populations (e.g. psychiatric facilities, Labor & Delivery units, substance use facilities).
2. Eliminate CONs for low-cost services (e.g. ambulatory surgery centers, home care).
3. Eliminate CONs for services that are not likely to be overprescribed (e.g. neonatal intensive care unit, dialysis, radiation treatment).
4. Exempt physician-owned enterprise from CON to promote competition.
5. Exempt private-equity-backed entities from CON to promote competition.
6. Exempt from CON geographic and service markets that meet the DOJ Antitrust Division's highly concentrated definition (HHI of 1,800).65
7. Sunset CON over time.
Recently, North Carolina has made progress in this direction, with CON long a target of meaningful reform.66,67 With the current state of CON in NC still encompassing a wide range of facilities,68 many opportunities remain.
Phased repeal by service or facility type is a viable option, as with the recent repeal of CON for inpatient rehabilitation facilities.69 Still, other venues such as constitutional challenges remain an option for either phased or ideally wholesale repeal, with ophthalmologist Jay Singleton M.D.70 challenging the constitutionality of CON law, an effort supported by North Carolina Treasurer Brad Briner and the State Employees Association of North Carolina, the latter of which represents over 45,000 state employees.71,72
State policymakers could also prohibit anti-tiering and anti-steering provisions. Functionally, market dominant or monopoly health systems insert these provisions into managed care contracts, preventing plans from using financial incentives to direct patients to other systems or placing the health system in a lower tier compared to other providers (or alternatively requiring placement in the highest tier). The Department of Justice Antitrust Division successfully sued Atrium Health73 over anti-competitive steering provisions and won, and recently sued OhioHealth74 and New York Presbyterian (2026).75 A White House Council of Economic Advisers report76 estimates savings of 4-9% in impacted markets from preventing the use of anti-tiering and anti-steering provisions, with Texas' recently passed HB71177 serving as an early success and example.
Finally, in the context of a rising policy effort to ban private equity investment in healthcare, state policymakers should do no harm. While private equity has risks and benefits, it is a potential positive force for competition.
Banning one ownership model in favor of another replaces competition with a statutory prohibition, favoring one corporate form over another. In the case of physician-owned enterprise, Stark Law and the physician-owned hospital ban fundamentally destroyed independent practice, driving clinicians towards a large-corporation, fully employed model with many untoward side effects on patient care and workforce sustainability.
Options for Federal Policymakers
In addition to state action, federal policymakers have a litany of options to combat consolidation. First, federal policymakers can work to eliminate CON. Policymakers can deploy federal fiscal incentives and regulations to remove a barnacle-like entry barrier that persists in state law. Medicaid policy, a recent source of policy disagreement, offers an opportunity for bipartisan efforts. The Federal Medical Assistance Percentage or FMAP78 is the share of Medicaid funds that the federal government pays. Policymakers could undertake a carrot and stick approach to FMAP adjusting FMAP upward by, for example, 1% for states that repeal CON within three years and downward by 2% for states that do not. There are multiple dials, including the size of the carrot, the size of the stick, and the timeline for a cutoff. Policymakers could undertake a similar exercise with Medicare Advantage benchmark policy, 79 adjusting benchmarks for the presence or absence of CON. Finally, policymakers could undertake the same exercise by reducing hospital payment (IPPS,80 OPPS)81 through a deflator when CON is present to account for increased market power and self-referral, and increase the rates when CON is absent.
Federal policymakers also have a wide range of potential solutions to implement site neutral policy either piecemeal or in whole and remove the consolidation accelerator in Medicare. Site neutral policy in hospital outpatient department markets has a wide range of supporters including experts at the American Enterprise Institute,82 the America First Policy Institute,83,84 the Brookings Institution,85 the Committee for a Responsible Federal Budget,86 the Heritage Foundation,87 and the Paragon Health Institute.88 MedPAC's proposed site-neutral service list includes 57 Ambulatory Payment Classifications (APCs).89 Additionally, CMS90 has specifically proposed site neutral drug administration while Congress has taken steps with the Lower Costs, More Transparency Act which passed the House in the prior session by a vote of 320 - 7191 and has been reintroduced.92 Finally, policymakers could work to implement an acuity adjuster that ties payment to patient acuity to ensure appropriate placement in a clinic, ASC, or hospital outpatient department. This would ensure that the right patient gets the care in the right setting at the right time. Other options include addressing grandfathered off-campus HOPDs and all on-campus HOPDs.
Repeal of the physician self-referral law (Stark Law) and of the POH ban would remove entry bans and work to reverse both hospital consolidation93 and physician-hospital consolidation. The evidence for repeal is strong: the Section 6001 Medicare participation ban has foreclosed the nationwide hospital market to new POHs and expansion of existing POHs,94 a systematic review of 30 years of research shows both price and non-price (medical quality) competition gains from POHs, and other work shows that general acute-care POHs have lower prices.95 Repeal options are numerous and include repeal by:
1. Service market (e.g. specialty vs community or general acute care POHs)
2. Geography (rural, suburban, urban) noting that proposed H.R. 2191 narrowly does this for rural settings with a specific drive-time distance from other hospitals96
3. Site neutrality for all new on-campus and off-campus HOPDs for POHs
4. A 2% Medicare cut
5. Some combination
Policymakers should also consider adding a statutory exception to Stark Law in the setting of managed care, or a so-called "managed care exception." Both Medicare Advantage and Medicaid Managed Care Organizations are paid on a risk-adjusted, capitated basis and deploy network design and utilization management practices to manage costs.
Stark could be preserved in the setting of Fee-for-Service Medicare and waived in the setting of managed Medicare and managed Medicaid, with utilization management oversight of referral patterns.97 This would allow physician-owned businesses to serve the roughly 53% of Medicare and 72% of the Medicaid market and restore competition, removing a ban on market entry and replacing it with a dynamic market oversight model.
Additional federal policy options exist, including ERISA prudent fiduciary guidance to drive employers to transition from passive to active purchasers. Defining a prudent fiduciary and setting a target share of employee income for premium and additionally a target employee/employer financing split would force meaningful consideration of tradeoffs with networks, utilization management and costs in the employer-sponsored insurance market serving over 130 million Americans.
Finally, policymakers could work to support the already successful FTC competition advocacy program98 by directing the agency to comment on competition impacts of Medicare and Medicaid regulations. Medicare rules occur on an annual cycle including IPPS/LTC Hospital, OPPS/PFS/ESRD,99 MA Advance Notice and Rate Notice, MA-Part D rule, and others. In contrast, the Medicaid program has rules with competitive impacts including the Medicaid/CHIP managed care rules (most recently in 2020 and 2024) amongst others that are issued with less regularity. This would allow the FTC to have early input on the structure and functioning of public payer markets, driving competition.
Conclusions
Policy analysts of a variety of backgrounds, training and belief systems fundamentally agree that hospital markets are consolidated and that this results in significant price and non-price harms. A careful analysis reveals that government intervention through law and regulation has fundamentally distorted or eliminated market competition, through poor incentive structures or outright banning competition or specific categories of market participants.
Instead of promoting more regulation and government control, a better answer is to recognize the need for dynamism, creativity, and innovation in the clinical setting and in policy and restore competition, as competition counts.
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References
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Original text here: https://judiciary.house.gov/sites/evo-subsites/republicans-judiciary.house.gov/files/evo-media-document/miller-testimony_0.pdf
Buchalter LLP Special Counsel DePeppe Testifies Before House Education & Workforce Subcommittee
WASHINGTON, Sept. 30 -- The House Education and Workforce Subcommittee on Higher Education and Workforce Development released the following written testimony by Douglas M. DePeppe, special counsel at Buchalter LLP, from a Sept. 16, 2026, hearing entitled "Who Gets the Scholarship? How the Global Shift in College Sports Affects Americans":
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I. Introduction and Purpose of Testimony
Chairman Owens, Ranking Member Adams, and Members of the Subcommittee:
Thank you for the opportunity to testify regarding athlete pathways into college sports and the growing internationalization of collegiate ... Show Full Article WASHINGTON, Sept. 30 -- The House Education and Workforce Subcommittee on Higher Education and Workforce Development released the following written testimony by Douglas M. DePeppe, special counsel at Buchalter LLP, from a Sept. 16, 2026, hearing entitled "Who Gets the Scholarship? How the Global Shift in College Sports Affects Americans": * * * I. Introduction and Purpose of Testimony Chairman Owens, Ranking Member Adams, and Members of the Subcommittee: Thank you for the opportunity to testify regarding athlete pathways into college sports and the growing internationalization of collegiatesoccer.
My name is Douglas M. DePeppe. I am an attorney, a retired U.S. Army Judge Advocate, a former Division I college soccer player, and a volunteer youth boys' soccer coach of more than twenty years.
I am also the father of three sons, and I assisted across a seven-year period to help them pursue their respective pathways from youth soccer through college soccer. I have also advised youth players, families, and soccer clubs concerning player pathways, including U.S. college soccer and international gap-year programs.
I am the author of a recent Sportico article and a linked self-published Medium.com study that examined international participation in college soccer. As a researcher, I conducted an analysis of every team competing in the 2025 men's soccer national championship tournaments across NCAA Divisions I, II, and III, the National Association of Intercollegiate Athletics (NAIA), and the National Junior College Athletic Association (NJCAA). My interest in this subject grew directly from watching, over those seven years, the pathway change under my own sons' feet -- and under the feet of the boys I coached alongside them. Each of my sons ultimately found his way to college soccer, and I am grateful for that. But the path became noticeably more difficult to navigate with each passing year, and I began to notice the same growing concern among the coaches, parents, and players around me: that the pathway connecting American youth soccer to college soccer was changing in ways that were poorly understood and rarely measured. My research and this testimony focus on boys' and men's soccer specifically, because that is the pathway I have lived and coached for two decades, and the one in which I am best positioned to identify what has changed and why.
Before describing what I found, I want to be clear about what my testimony is, and is not, offered to show. My purpose is not to criticize international student-athletes, who come to our colleges seeking educational and athletic opportunities much as American students do. Nor do I suggest that international recruiting is the sole driver of the changes occurring in college sports. My purpose is to provide data demonstrating the scale of a transformation that many athletes, families, coaches, and administrators have observed, and to explain why understanding that transformation matters if Congress wishes to preserve meaningful pathways for future generations of American student-athletes.
Until recently, no one appeared to have comprehensively examined who was filling the rosters of championship-participating men's college soccer programs across the principal collegiate associations and divisions. To better understand what was occurring, I assembled and analyzed roster data from all 216 men's soccer teams that qualified for the 2025 national championship tournaments across NCAA, NAIA, and junior college soccer, encompassing 7,183 players. The purpose was straightforward: to determine whether the increasing presence of international players was anecdotal, isolated to a handful of elite programs, or part of a broader systemic pattern.
The results show that this pattern is neither isolated nor confined to any single division, association, or level of competition. International recruitment has become a significant and widespread presence throughout championship-level college soccer, cutting across every level of the collegiate system I examined. The findings raise important questions about athlete pathways, opportunity allocation, and the future relationship between American youth soccer and American college soccer.
It is also important to recognize that the internationalization of college soccer is occurring within a broader realignment of non-revenue college athletics. Related pressures include a shrinking number of roster positions relative to the athletes competing for them, tuition and enrollment economics that may influence roster construction, and a widening gap between what American families invest in athletic development and what the collegiate pathway may deliver in return.
These pressures can reinforce one another. Some institutions may construct rosters for purposes extending beyond immediate competitive need. American families may pay more and wait longer to reach collegiate sports. Recruited athletes may also lack reliable information about whether the offered opportunity will materialize as expected. Taken together, these conditions can produce a pathway that appears open on paper but functions differently in practice. My testimony addresses the roster data first because those data are the headline. I then describe the related factors only to the extent necessary to assess a durable response.
II. The Data: Internationalization of Championship-Level College Soccer
A. Research Methodology
This analysis covers all 216 teams that competed in the 2025 men's soccer national championship tournaments across NCAA Divisions I, II, and III, the NAIA, and NJCAA Divisions I and II, encompassing 7,183 players. Roster data were drawn from official team rosters published for the 2025 championship tournaments. Players were classified as international or domestic based on their listed hometown and prior playing background.
I want to be transparent about how this analysis was conducted. To manage a dataset of this size accurately, I used multiple AI platforms -- Claude, Gemini, and ChatGPT -- to compile and crosscheck the roster data, supplemented by manual review. This approach allowed me to catch and correct errors that would be difficult to identify using a single method alone. I have a reasonably high level of confidence in the accuracy of this data, though I do not claim it is free of every error, and I welcome independent verification.
Three limitations bear directly on how this data should be read. First, this study covers men's collegiate soccer only; I have not conducted a parallel study of the women's game, and I would caution against extrapolating these findings to women's college soccer without independent data. Second, this is a single-season snapshot of the 2025 championship tournaments; it does not itself establish a multi-year trend, though I am familiar with prior years' championship data and can speak to that history if the Committee has questions. Third, NJCAA Division III was not included in this study.
B. Principal Findings
Across the 216 teams and 7,183 players studied, the aggregate composition varies depending on how NCAA Division III -- the only division studied that does not offer athletic scholarships -- is treated.
Including Division III, the overall roster composition is 56.8 percent American players to 43.2 percent international players. Viewed separately from Division III, because it operates under a fundamentally different scholarship model from the other divisions and associations studied, the composition reverses: 55.0 percent international players to 45.0 percent American players. I present both figures because each is accurate and each tells the Committee something different -- the first describes the full landscape of championship-level college soccer as currently structured, and the second describes what that landscape looks like among the programs competing for scholarship-based rosters.
Only two of the five divisions and associations studied -- NCAA Division I and NCAA Division III -- had majority-American rosters at the national championship level. Every other tier studied was majority international:
C. Internationalization Is Systemic
The pattern is not confined to NCAA Division I. International players constituted 50.5 percent of NCAA Division II championship rosters, 70.7 percent of NAIA championship rosters, and 61.5 percent of the combined NJCAA Division I and II championship rosters. NCAA Division III differed sharply, with championship rosters that were 83.5 percent American.
The study also found wide variation among individual programs and successful teams. Predominantly domestic and heavily international teams both won championships or advanced deep into their tournaments. It is worth noting that a single year's championship outcome should not be read as evidence for or against the broader trend documented here. Championship results vary from year to year for reasons specific to each program and season, independent of the overall composition of the tournament field. My study is limited to the 2025 championship data presented in this testimony and its appendix, and I do not offer year-over-year comparisons in this written testimony. But those data -- the composition of the full 216-team field, not the identity of any single champion -- are the relevant evidence for the question before this Committee.
Appendix A reproduces the detailed findings from my study published on Medium.com, "Crunching 2025 College Soccer Championships Player Demographic Data," including its detailed divisional and program-level findings, and including the highest - and lowest-international - percentage programs at each level. I incorporate that appendix as the fuller presentation of the underlying study.
D. Why This Matters
Each of the 7,183 roster positions examined in this study represents an individual athlete's pathway: an educational opportunity, in many cases a scholarship, and a competitive and developmental opportunity that shapes that athlete's options after college. Viewed in aggregate, these numbers describe not a series of isolated recruiting decisions but a system-wide allocation pattern across every level of American men's collegiate soccer -- from the most prominent Division I programs to community colleges that receive virtually no public attention. Any policy response that considers only the most visible tier of this system will miss most of where the pattern actually occurs.
III. Responding to the Pending Legislation
In preparing for this testimony, committee staff advised me that, in addition to other pending legislation, Representative Walberg has introduced a bill, the Training and Education for American Members in University Sports and Athletics Act, or TEAM USA Act, which would generally limit international student-athletes to 20 percent of each varsity team's official roster. I offer the following in response.
I support the concept of a reasonable formula to help restore balance for American athletes who have lost access to college sport opportunities. I do not offer a view on the specific percentage; setting that number is a legislative judgment, and doing so myself would exceed what my data can responsibly support. I will note, however, that a 20 percent threshold is not without precedent: it can be placed in comparative context alongside restrictions and locally trained-player mechanisms used in several major European football markets.
For brief comparative context, several European countries and top leagues limit non-EU player registrations or use locally trained-player requirements. While the rules sometimes have exceptions, such as for players from former colonies and the like, rules affecting non-EU player registrations operate in La Liga in Spain, Serie A in Italy, and Ligue 1 in France, although their scope, exceptions, and operation differ. European football systems use several mechanisms to balance open recruitment and local development. Their legal and institutional settings differ materially from American higher education. I offer them only as evidence that leading football markets have recognized a policy interest in domestic development alongside international mobility, not as a direct regulatory template. A 20 percent cap for college soccer is not a material deviation from international player restriction caps found in many European football markets.
Beyond soccer, I believe Congress should also consider whether similar access and fairness concerns are affecting other non-revenue, Olympic-pathway sports.
IV. Beyond Soccer: Access and Fairness Across Non-Revenue Sports
My concern for athlete pathways did not begin with the international-recruiting question, and it does not end with soccer. In December 2024, before the House v. NCAA settlement was finalized, I coauthored an analysis for Sports Illustrated, with Attorney Brandon Leopoldus, examining the projected effect of the settlement's proposed roster caps on non-revenue college sports. That analysis estimated that as many as 25,000 Division I roster spots -- spread across sports that produced roughly threequarters of Team USA's roster and more than four-fifths of its medalists at the 2024 Paris Olympics -- were at risk of elimination, predominantly in non-revenue, Olympic-pathway sports.
I raise this history for two reasons. First, it illustrates that the pressures reshaping college soccer are part of a larger pattern affecting non-revenue sports broadly, not a phenomenon unique to soccer or to international recruiting. Second, it reflects a distinction I believe is important for the Committee to keep in view throughout this hearing: there are at least three related but distinct pathway questions before Congress. Who receives the roster spots that exist is the question most directly raised by international recruiting. How many roster spots exist in the first place is the question raised by the House v. NCAA settlement and its roster caps. And what the quality and reliability of a roster opportunity actually is, once granted, is a third question -- one I return to later in this testimony in the context of athlete information and protection.
V. What the Data Suggests About Athlete Pathways
A. The Traditional Pathway
For generations, the pathway for an American soccer player has followed a recognizable sequence: youth club soccer, often high school soccer next, and college soccer, with the possibility of continued play or coaching beyond graduation.
B. The Emerging Pathway
The data presented above suggest this pathway is changing. Increasing international competition for roster spots, growing demand from coaches for athletes who are competitively ready upon arrival, and the resulting pressure on domestic recruits to seek additional development time before college are reshaping what were once standard expectations for an American player and family. In many cases, graduating high school players are pursuing a gap year abroad, incurring substantial costs, in order to physically develop to better compete against older college players, and to improve their talent level for college soccer.
C. The Policy Question
These findings raise a question that is squarely within this Committee's jurisdiction: who is the American collegiate soccer system intended to develop, and how should the opportunities it offers be balanced between American and international athletes?
VI. Broader Policy Questions: Athlete Protection and Transparency
A. Lessons from House v. NCAA and the Sports Illustrated Analysis
My perspective on today's student-athlete experience is informed not only by coaching and research, but also by my representation of NCAA athletes objecting to roster limits in the House v. NCAA litigation. I was subsequently appointed by Chief Judge Claudia Wilken to participate in the court-ordered final settlement mediation, where I advocated on behalf of affected athletes and supported consideration of athlete-protection mechanisms, including my recommendation for an ombuds program to protect athlete rights and to address unfairness in the modern college sport landscape.
That experience, together with the roster-cap analysis I co-authored in December 2024, showed me directly how information and power imbalances affect athletes during periods of roster transition -- imbalances that persist regardless of an athlete's nationality, and regardless of how Congress ultimately resolves the international-participation question.
B. Voices from Continued Representation
Since the final settlement in House v. NCAA, I have continued to represent college athletes navigating its aftermath. These athletes have competed in soccer, golf, swimming, tennis, and track and field.
Nearly all are Division I athletes; several hold the equivalent of four-star national recruiting rankings and hold other impressive accolades and championship accomplishments in their respective sports, and several presently compete for Power Four Conference sport programs. Across sports and programs, I have heard a common refrain from them, centered on a single word: fairness. The examples below are drawn from separate athlete experiences, presented without identifying details. These experiences raise questions that extend beyond playing time or disappointment with a coach's competitive decisions.
While maintaining client confidences and privacy, I present now the voices of elite college athletes with their common questions, compiled and paraphrased:
Is it fair for a college to market a varsity opportunity to an American athlete without disclosing that the recruited class is already highly concentrated with older, professionally-groomed international players, or that the full roster is so oversized that the entire team cannot even be accommodated in its own locker room?
Is it fair to accept that athlete's commitment and tuition payment without disclosing that the program has recruited more players than it can realistically train, develop, take to competitions, or play at the varsity level?
Is it fair for the athlete to discover those material facts only after enrolling, when transferring or withdrawing may mean interrupted education, lost development, additional expense, and the loss of a year within the athlete's eligibility period?
And if the athlete's enrollment helps subsidize the athletic program or institution, is it fair for the financial benefit to flow to the college while the athlete and family bear the consequences, including a diminished athletic opportunity and substantial student-loan debt?
These are not hypothetical concerns. They come from highly recruited athletes who did what was asked of them -- earned recognition, received offers, and signed agreements -- and still found that the opportunity they were recruited for differed materially from the opportunity they received.
Additionally, these questions are not objections to international student-athletes, nor do they ask Congress to guarantee playing time or second-guess legitimate coaching decisions. They concern the institutional practices surrounding recruitment. This is the human reality behind the economics and pressures that prevail in college sports today. When international concentration and oversized rosters materially narrow the opportunities realistically available to American athletes, colleges should disclose those conditions before accepting an athlete's commitment, tuition payment, and use of collegiate eligibility.
These concerns raise more than questions of abstract fairness. As an attorney who addressed unfair and deceptive practices during the House v. NCAA fairness hearing, I question whether a college should be permitted to market and financially benefit from a varsity opportunity while withholding material information about roster size, international concentration, overflow roster practices, and the realistic structure of the marketed (i.e., recruited) opportunity. Congress should examine whether existing laws adequately reach such conduct or whether recruited college athletes require more specific disclosure and protection.
C. Collegiate Athletics: A Holistic View
This hearing is not solely focused on NCAA Division I sports. Intercollegiate athletics includes all levels of collegiate sport. As my data illustrates, the international athlete participation question affects all levels. But additionally, as my clients' concerns illustrate, there are also other issues with intercollegiate athletics that warrant attention from Congress.
VII. Problems a Participation Cap Alone May Not Solve
A nationality-based participation cap regulates the allocation of existing roster positions. It does not, by itself:
* Prevent institutions from eliminating non-revenue sports programs
* Limit the practice of recruiting athletes for reasons unrelated to sport and which go undisclosed
* Require disclosure of recruited class size
* Afford student-athletes with governance mechanisms to redress violations of specified athlete rights
A. Over-Recruiting and Roster Inflation
Several incentives may contribute to recruiting more athletes than a roster can realistically place on the field. A larger roster provides competitive depth and insurance against injury and transfer-portal attrition. At tuition-dependent institutions, each additional recruited athlete -- especially for non-scholarship athletes -- also represents additional net tuition revenue. And in the post-NIL, post-House settlement environment, many non-revenue programs face new budget pressure as institutional resources shift toward revenue-sharing obligations in football and basketball, which can push coaches toward recruiting larger classes to sustain program visibility and results on a constrained budget.
The consequence is a widening gap between the number of athletes recruited and the number who receive meaningful playing time or developmental attention. This dynamic affects domestic and international athletes alike, and it operates independently of any nationality-based roster rule Congress might adopt.
B. Athlete Debt and Financial Exposure
For nonrevenue sports, recruited athletes often pay their way to school, as well as receive student loans.
My championship dataset includes college soccer rosters exceeding 40 or 50 players. Roster size alone does not prove improper over-recruiting, but it warrants inquiry into whether recruited athletes receive meaningful competitive and developmental opportunities. Materially incomplete or misleading recruiting information can expose athletes and families to educational, financial, and eligibility consequences that are difficult to reverse after enrollment. For the athlete, in addition to a lost year of athletic eligibility, significant student debt can accrue without receiving any athletic benefits from paying tuition at the school.
VIII. Policy Considerations
A. Ombudsman and Athlete-Advocacy Concepts
Congress need not reproduce Olympic governance to draw from an existing American framework. The Team USA Athlete Ombuds provides independent, confidential, and impartial assistance; supports fact-finding, facilitated communication, and mediation; and promotes fair, transparent, timely, and equitably administered processes. The reference points for college athletics are the underlying principles: independence, confidentiality, impartiality, retaliation protection, and the ability to identify recurring concerns and recommend systemic improvements. I offer that model as a reference for congressional consideration, not as a complete proposal or the centerpiece of this testimony.
The Aspen Institute's Children's Bill of Rights in Sports supplies a related youth-sport reference, emphasizing access, development, athlete voice, equal opportunity, dignity, and safe environments.
Together, these models suggest a limited collegiate framework centered on access, transparency, independent assistance, fair process, development, and dignity. Congress could use those principles to evaluate an ombudsman pilot or a focused college-athlete bill of rights.
These principles would require adaptation to the collegiate setting. They should not be understood to guarantee selection, playing time, or a particular competitive role. Rather, they would support accurate information, independent guidance, fair administration of established rules, and protection against retaliation for raising concerns.
B. International Participation and Domestic Pathways
Consistent with Section III, I support the concept of a reasonable formula to restore balance for American athletes, without endorsing a specific percentage. I encourage the Committee to consider any such formula alongside the additional measures below, since a nationality-based rule addresses only one of the three pathway questions this testimony has described.
C. Recruiting and Roster Transparency
I recommend that Congress consider requiring institutions to disclose the following to a recruited athlete and their family before a commitment is signed:
* The program's historical roster size and year-over-year attrition rate for the preceding three seasons
* The number of fully funded, partially funded, and unfunded roster positions on the team
* A de-identified and aggregated scholarship profile for the preceding three seasons that depicts the ratio of scholarships between international and US student-athletes
* Any additional material disclosures Congress determines necessary after consultation with athletes, institutions, associations, and recruiting experts
A standardized, plain-language disclosure form -- comparable to consumer financial disclosure requirements in other contexts -- would allow families to compare offers on a consistent basis and make an informed decision before committing to a program.
D. Athlete Protection Mechanisms
I recommend that Congress consider directing or funding a pilot athlete-ombudsman program, modeled on the principles of the Team USA Athlete Ombuds described above, at a defined set of institutions or conferences. Such a pilot should be structured so that the ombudsman:
* Operates independently of the athletic department's own reporting lines, perhaps operating at the conference level
* Receives inquiries and complaints on a confidential basis
* Has authority to recommend redress for any retaliation related to a complaint to the ombudsman
* Is authorized to identify systemic patterns across multiple complaints and report aggregate findings to institutional leadership and, where appropriate, to NCAA or NAIA governance bodies
I would recommend that Congress ask the NCAA, NAIA, and affected institutions to help define the pilot's scope and funding mechanism as a next step, rather than legislating a fully specified program at this stage.
IX. Conclusion
The central question before this Committee is not whether international athletes should participate in American college sports. The question is whether the pathway from American youth soccer to college soccer -- and, more broadly, from American youth sports to collegiate opportunity across non-revenue programs -- remains meaningful, accessible, and sustainable for future generations of American athletes.
Understanding the scale of internationalization is a necessary first step toward answering that question, but it is not the last step. My own path through this sport -- as a player, as a coach, and as a father who watched three sons navigate a pathway that grew more difficult with each passing year -- is what brought me to this data. I hope it can help bring the Committee to a more complete understanding of what is at stake, and of what Congress can do about it.
Thank you for the opportunity to testify. I am happy to answer the Committee's questions.
* * *
Appendix A
CRUNCHING 2025 COLLEGE SOCCER CHAMPIONSHIPS PLAYER DEMOGRAPHIC DATA
Douglas DePeppe | Originally published December 21, 2025 on Medium
Purpose and Background
What follows is an AI-supported analysis of the roster make-up for the men's college soccer teams that participated in their respective 2025 national championship playoffs for NCAA Divisions I, II, and III, the NAIA, and NJCAA Divisions I and II. The objective is to enumerate and compare the U.S. and international player make-up of college soccer. The original analysis was made available under a Creative Commons Attribution license.
The project grew from my life-long soccer interest; twenty years of youth coaching and player-pathway mentoring; sports-law work involving FIFA player-status and transfer rules and European work-permit requirements; the October 2025 U.S. Soccer and Next Gen College Soccer Committee white paper; and the 2026 World Cup. It also followed Representative Tim Walberg's December 16, 2025 remarks concerning international student-athlete recruiting and lost American scholarship or participation opportunities.
Summary of Overall Findings
NCAA Division III had the highest concentration of U.S. players, at 83.5 percent. Across all levels studied, the roster population was approximately 56.8 percent U.S. and 43.2 percent international.
Excluding Division III, the remaining championship-roster population was approximately 55.0 percent international and 45.0 percent U.S. players. International players constituted a majority in NCAA Division II, the NAIA, and NJCAA Divisions I and II.
NCAA Division I
48 teams; 1,433 players; 59.1% U.S.; 40.9% international. The 2025 College Cup was 84% U.S. National Champion Washington listed one international player and nineteen players from Washington State.
Highest: Marshall 93.1%; UCF 77.8%; Syracuse 76.0%; Hofstra 65.6%; Kansas City 65.5%.
Lowest: Princeton 3.4%; Washington 3.4%; Notre Dame 7.1%; Stanford 7.4%; Denver 9.4%.
NCAA Division II
40 teams; 1,420 players; 49.5% U.S.; 50.5% international; average roster 35.5. National Champion Midwestern State listed nine international players, below the tournament average.
Highest: Palm Beach Atlantic 79.3%; Wilmington (DE) 76.7%; Bridgeport 75.0%; Mississippi College 70.0%; Fort Hays State 68.8%.
Lowest: Seattle Pacific 0%; CSUSB 5.7%; Bentley 13.5%; Rockhurst 17.9%; UCCS 21.2%.
NCAA Division III
64 teams; 2,203 players; 83.5% U.S.; 16.5% international; average roster 34.4. National Champion Tufts listed no international players.
Highest: NC Wesleyan 90.9%; Lyon College 60.8%; Luther 59.5%; Wisconsin-Superior 57.1%; Penn State Harrisburg 27.3%.
Lowest: Tufts, Christopher Newport, Scranton, Catholic, and Stevens each 0%.
NAIA
40 teams; 1,369 players; 29.3% U.S.; 70.7% international; average roster 34.2. National Champion Cumberlands listed 32 international players; WVU Tech listed 40 on a 49-player roster.
Highest: William Penn 100%; Keiser 96.9%; Dalton State 96.8%; Bethel 94.3%; Campbellsville 91.4%.
Lowest: Warner Pacific 1.8%; Indiana East 11.5%; Carroll 39.0%; Concordia 42.9%; Baker 46.0%.
NJCAA Divisions I and II
24 teams; 758 players; 38.5% U.S.; 61.5% international; average roster 31.6. Reported champions illustrated opposite models: Indian Hills fully international (100%) and Phoenix College 96.7% U.S.
Highest: Indian Hills 100%; Iowa Lakes 90.0%; Murray State College 89.3%; Northeast CC 85.7%; St. Clair County CC 84.6%.
Lowest: Phoenix College 3.3%; Mississippi Gulf Coast CC 16.0%; Pima CC 17.1%; Mohave College 18.2%; Pearl River CC 20.0%.
Study Limitations and Notes
A single season's champion should not be treated as proof for or against a broader recruiting pattern.
The relevant evidence is the composition of the full 216-team championship field and the differences among levels and programs. The study covers men's soccer only, is a 2025 championship snapshot, excludes NJCAA Division III, and does not measure age, academy tenure, prior senior competition, scholarship value, playing time, retention, or causation.
* * *
Original text here: https://edworkforce.house.gov/uploadedfiles/depeppe_written_testimony_9-16.pdf
* * *
I. Introduction and Purpose of Testimony
Chairman Owens, Ranking Member Adams, and Members of the Subcommittee:
Thank you for the opportunity to testify regarding athlete pathways into college sports and the growing internationalization of collegiate ... Show Full Article WASHINGTON, Sept. 30 -- The House Education and Workforce Subcommittee on Higher Education and Workforce Development released the following written testimony by Douglas M. DePeppe, special counsel at Buchalter LLP, from a Sept. 16, 2026, hearing entitled "Who Gets the Scholarship? How the Global Shift in College Sports Affects Americans": * * * I. Introduction and Purpose of Testimony Chairman Owens, Ranking Member Adams, and Members of the Subcommittee: Thank you for the opportunity to testify regarding athlete pathways into college sports and the growing internationalization of collegiatesoccer.
My name is Douglas M. DePeppe. I am an attorney, a retired U.S. Army Judge Advocate, a former Division I college soccer player, and a volunteer youth boys' soccer coach of more than twenty years.
I am also the father of three sons, and I assisted across a seven-year period to help them pursue their respective pathways from youth soccer through college soccer. I have also advised youth players, families, and soccer clubs concerning player pathways, including U.S. college soccer and international gap-year programs.
I am the author of a recent Sportico article and a linked self-published Medium.com study that examined international participation in college soccer. As a researcher, I conducted an analysis of every team competing in the 2025 men's soccer national championship tournaments across NCAA Divisions I, II, and III, the National Association of Intercollegiate Athletics (NAIA), and the National Junior College Athletic Association (NJCAA). My interest in this subject grew directly from watching, over those seven years, the pathway change under my own sons' feet -- and under the feet of the boys I coached alongside them. Each of my sons ultimately found his way to college soccer, and I am grateful for that. But the path became noticeably more difficult to navigate with each passing year, and I began to notice the same growing concern among the coaches, parents, and players around me: that the pathway connecting American youth soccer to college soccer was changing in ways that were poorly understood and rarely measured. My research and this testimony focus on boys' and men's soccer specifically, because that is the pathway I have lived and coached for two decades, and the one in which I am best positioned to identify what has changed and why.
Before describing what I found, I want to be clear about what my testimony is, and is not, offered to show. My purpose is not to criticize international student-athletes, who come to our colleges seeking educational and athletic opportunities much as American students do. Nor do I suggest that international recruiting is the sole driver of the changes occurring in college sports. My purpose is to provide data demonstrating the scale of a transformation that many athletes, families, coaches, and administrators have observed, and to explain why understanding that transformation matters if Congress wishes to preserve meaningful pathways for future generations of American student-athletes.
Until recently, no one appeared to have comprehensively examined who was filling the rosters of championship-participating men's college soccer programs across the principal collegiate associations and divisions. To better understand what was occurring, I assembled and analyzed roster data from all 216 men's soccer teams that qualified for the 2025 national championship tournaments across NCAA, NAIA, and junior college soccer, encompassing 7,183 players. The purpose was straightforward: to determine whether the increasing presence of international players was anecdotal, isolated to a handful of elite programs, or part of a broader systemic pattern.
The results show that this pattern is neither isolated nor confined to any single division, association, or level of competition. International recruitment has become a significant and widespread presence throughout championship-level college soccer, cutting across every level of the collegiate system I examined. The findings raise important questions about athlete pathways, opportunity allocation, and the future relationship between American youth soccer and American college soccer.
It is also important to recognize that the internationalization of college soccer is occurring within a broader realignment of non-revenue college athletics. Related pressures include a shrinking number of roster positions relative to the athletes competing for them, tuition and enrollment economics that may influence roster construction, and a widening gap between what American families invest in athletic development and what the collegiate pathway may deliver in return.
These pressures can reinforce one another. Some institutions may construct rosters for purposes extending beyond immediate competitive need. American families may pay more and wait longer to reach collegiate sports. Recruited athletes may also lack reliable information about whether the offered opportunity will materialize as expected. Taken together, these conditions can produce a pathway that appears open on paper but functions differently in practice. My testimony addresses the roster data first because those data are the headline. I then describe the related factors only to the extent necessary to assess a durable response.
II. The Data: Internationalization of Championship-Level College Soccer
A. Research Methodology
This analysis covers all 216 teams that competed in the 2025 men's soccer national championship tournaments across NCAA Divisions I, II, and III, the NAIA, and NJCAA Divisions I and II, encompassing 7,183 players. Roster data were drawn from official team rosters published for the 2025 championship tournaments. Players were classified as international or domestic based on their listed hometown and prior playing background.
I want to be transparent about how this analysis was conducted. To manage a dataset of this size accurately, I used multiple AI platforms -- Claude, Gemini, and ChatGPT -- to compile and crosscheck the roster data, supplemented by manual review. This approach allowed me to catch and correct errors that would be difficult to identify using a single method alone. I have a reasonably high level of confidence in the accuracy of this data, though I do not claim it is free of every error, and I welcome independent verification.
Three limitations bear directly on how this data should be read. First, this study covers men's collegiate soccer only; I have not conducted a parallel study of the women's game, and I would caution against extrapolating these findings to women's college soccer without independent data. Second, this is a single-season snapshot of the 2025 championship tournaments; it does not itself establish a multi-year trend, though I am familiar with prior years' championship data and can speak to that history if the Committee has questions. Third, NJCAA Division III was not included in this study.
B. Principal Findings
Across the 216 teams and 7,183 players studied, the aggregate composition varies depending on how NCAA Division III -- the only division studied that does not offer athletic scholarships -- is treated.
Including Division III, the overall roster composition is 56.8 percent American players to 43.2 percent international players. Viewed separately from Division III, because it operates under a fundamentally different scholarship model from the other divisions and associations studied, the composition reverses: 55.0 percent international players to 45.0 percent American players. I present both figures because each is accurate and each tells the Committee something different -- the first describes the full landscape of championship-level college soccer as currently structured, and the second describes what that landscape looks like among the programs competing for scholarship-based rosters.
Only two of the five divisions and associations studied -- NCAA Division I and NCAA Division III -- had majority-American rosters at the national championship level. Every other tier studied was majority international:
C. Internationalization Is Systemic
The pattern is not confined to NCAA Division I. International players constituted 50.5 percent of NCAA Division II championship rosters, 70.7 percent of NAIA championship rosters, and 61.5 percent of the combined NJCAA Division I and II championship rosters. NCAA Division III differed sharply, with championship rosters that were 83.5 percent American.
The study also found wide variation among individual programs and successful teams. Predominantly domestic and heavily international teams both won championships or advanced deep into their tournaments. It is worth noting that a single year's championship outcome should not be read as evidence for or against the broader trend documented here. Championship results vary from year to year for reasons specific to each program and season, independent of the overall composition of the tournament field. My study is limited to the 2025 championship data presented in this testimony and its appendix, and I do not offer year-over-year comparisons in this written testimony. But those data -- the composition of the full 216-team field, not the identity of any single champion -- are the relevant evidence for the question before this Committee.
Appendix A reproduces the detailed findings from my study published on Medium.com, "Crunching 2025 College Soccer Championships Player Demographic Data," including its detailed divisional and program-level findings, and including the highest - and lowest-international - percentage programs at each level. I incorporate that appendix as the fuller presentation of the underlying study.
D. Why This Matters
Each of the 7,183 roster positions examined in this study represents an individual athlete's pathway: an educational opportunity, in many cases a scholarship, and a competitive and developmental opportunity that shapes that athlete's options after college. Viewed in aggregate, these numbers describe not a series of isolated recruiting decisions but a system-wide allocation pattern across every level of American men's collegiate soccer -- from the most prominent Division I programs to community colleges that receive virtually no public attention. Any policy response that considers only the most visible tier of this system will miss most of where the pattern actually occurs.
III. Responding to the Pending Legislation
In preparing for this testimony, committee staff advised me that, in addition to other pending legislation, Representative Walberg has introduced a bill, the Training and Education for American Members in University Sports and Athletics Act, or TEAM USA Act, which would generally limit international student-athletes to 20 percent of each varsity team's official roster. I offer the following in response.
I support the concept of a reasonable formula to help restore balance for American athletes who have lost access to college sport opportunities. I do not offer a view on the specific percentage; setting that number is a legislative judgment, and doing so myself would exceed what my data can responsibly support. I will note, however, that a 20 percent threshold is not without precedent: it can be placed in comparative context alongside restrictions and locally trained-player mechanisms used in several major European football markets.
For brief comparative context, several European countries and top leagues limit non-EU player registrations or use locally trained-player requirements. While the rules sometimes have exceptions, such as for players from former colonies and the like, rules affecting non-EU player registrations operate in La Liga in Spain, Serie A in Italy, and Ligue 1 in France, although their scope, exceptions, and operation differ. European football systems use several mechanisms to balance open recruitment and local development. Their legal and institutional settings differ materially from American higher education. I offer them only as evidence that leading football markets have recognized a policy interest in domestic development alongside international mobility, not as a direct regulatory template. A 20 percent cap for college soccer is not a material deviation from international player restriction caps found in many European football markets.
Beyond soccer, I believe Congress should also consider whether similar access and fairness concerns are affecting other non-revenue, Olympic-pathway sports.
IV. Beyond Soccer: Access and Fairness Across Non-Revenue Sports
My concern for athlete pathways did not begin with the international-recruiting question, and it does not end with soccer. In December 2024, before the House v. NCAA settlement was finalized, I coauthored an analysis for Sports Illustrated, with Attorney Brandon Leopoldus, examining the projected effect of the settlement's proposed roster caps on non-revenue college sports. That analysis estimated that as many as 25,000 Division I roster spots -- spread across sports that produced roughly threequarters of Team USA's roster and more than four-fifths of its medalists at the 2024 Paris Olympics -- were at risk of elimination, predominantly in non-revenue, Olympic-pathway sports.
I raise this history for two reasons. First, it illustrates that the pressures reshaping college soccer are part of a larger pattern affecting non-revenue sports broadly, not a phenomenon unique to soccer or to international recruiting. Second, it reflects a distinction I believe is important for the Committee to keep in view throughout this hearing: there are at least three related but distinct pathway questions before Congress. Who receives the roster spots that exist is the question most directly raised by international recruiting. How many roster spots exist in the first place is the question raised by the House v. NCAA settlement and its roster caps. And what the quality and reliability of a roster opportunity actually is, once granted, is a third question -- one I return to later in this testimony in the context of athlete information and protection.
V. What the Data Suggests About Athlete Pathways
A. The Traditional Pathway
For generations, the pathway for an American soccer player has followed a recognizable sequence: youth club soccer, often high school soccer next, and college soccer, with the possibility of continued play or coaching beyond graduation.
B. The Emerging Pathway
The data presented above suggest this pathway is changing. Increasing international competition for roster spots, growing demand from coaches for athletes who are competitively ready upon arrival, and the resulting pressure on domestic recruits to seek additional development time before college are reshaping what were once standard expectations for an American player and family. In many cases, graduating high school players are pursuing a gap year abroad, incurring substantial costs, in order to physically develop to better compete against older college players, and to improve their talent level for college soccer.
C. The Policy Question
These findings raise a question that is squarely within this Committee's jurisdiction: who is the American collegiate soccer system intended to develop, and how should the opportunities it offers be balanced between American and international athletes?
VI. Broader Policy Questions: Athlete Protection and Transparency
A. Lessons from House v. NCAA and the Sports Illustrated Analysis
My perspective on today's student-athlete experience is informed not only by coaching and research, but also by my representation of NCAA athletes objecting to roster limits in the House v. NCAA litigation. I was subsequently appointed by Chief Judge Claudia Wilken to participate in the court-ordered final settlement mediation, where I advocated on behalf of affected athletes and supported consideration of athlete-protection mechanisms, including my recommendation for an ombuds program to protect athlete rights and to address unfairness in the modern college sport landscape.
That experience, together with the roster-cap analysis I co-authored in December 2024, showed me directly how information and power imbalances affect athletes during periods of roster transition -- imbalances that persist regardless of an athlete's nationality, and regardless of how Congress ultimately resolves the international-participation question.
B. Voices from Continued Representation
Since the final settlement in House v. NCAA, I have continued to represent college athletes navigating its aftermath. These athletes have competed in soccer, golf, swimming, tennis, and track and field.
Nearly all are Division I athletes; several hold the equivalent of four-star national recruiting rankings and hold other impressive accolades and championship accomplishments in their respective sports, and several presently compete for Power Four Conference sport programs. Across sports and programs, I have heard a common refrain from them, centered on a single word: fairness. The examples below are drawn from separate athlete experiences, presented without identifying details. These experiences raise questions that extend beyond playing time or disappointment with a coach's competitive decisions.
While maintaining client confidences and privacy, I present now the voices of elite college athletes with their common questions, compiled and paraphrased:
Is it fair for a college to market a varsity opportunity to an American athlete without disclosing that the recruited class is already highly concentrated with older, professionally-groomed international players, or that the full roster is so oversized that the entire team cannot even be accommodated in its own locker room?
Is it fair to accept that athlete's commitment and tuition payment without disclosing that the program has recruited more players than it can realistically train, develop, take to competitions, or play at the varsity level?
Is it fair for the athlete to discover those material facts only after enrolling, when transferring or withdrawing may mean interrupted education, lost development, additional expense, and the loss of a year within the athlete's eligibility period?
And if the athlete's enrollment helps subsidize the athletic program or institution, is it fair for the financial benefit to flow to the college while the athlete and family bear the consequences, including a diminished athletic opportunity and substantial student-loan debt?
These are not hypothetical concerns. They come from highly recruited athletes who did what was asked of them -- earned recognition, received offers, and signed agreements -- and still found that the opportunity they were recruited for differed materially from the opportunity they received.
Additionally, these questions are not objections to international student-athletes, nor do they ask Congress to guarantee playing time or second-guess legitimate coaching decisions. They concern the institutional practices surrounding recruitment. This is the human reality behind the economics and pressures that prevail in college sports today. When international concentration and oversized rosters materially narrow the opportunities realistically available to American athletes, colleges should disclose those conditions before accepting an athlete's commitment, tuition payment, and use of collegiate eligibility.
These concerns raise more than questions of abstract fairness. As an attorney who addressed unfair and deceptive practices during the House v. NCAA fairness hearing, I question whether a college should be permitted to market and financially benefit from a varsity opportunity while withholding material information about roster size, international concentration, overflow roster practices, and the realistic structure of the marketed (i.e., recruited) opportunity. Congress should examine whether existing laws adequately reach such conduct or whether recruited college athletes require more specific disclosure and protection.
C. Collegiate Athletics: A Holistic View
This hearing is not solely focused on NCAA Division I sports. Intercollegiate athletics includes all levels of collegiate sport. As my data illustrates, the international athlete participation question affects all levels. But additionally, as my clients' concerns illustrate, there are also other issues with intercollegiate athletics that warrant attention from Congress.
VII. Problems a Participation Cap Alone May Not Solve
A nationality-based participation cap regulates the allocation of existing roster positions. It does not, by itself:
* Prevent institutions from eliminating non-revenue sports programs
* Limit the practice of recruiting athletes for reasons unrelated to sport and which go undisclosed
* Require disclosure of recruited class size
* Afford student-athletes with governance mechanisms to redress violations of specified athlete rights
A. Over-Recruiting and Roster Inflation
Several incentives may contribute to recruiting more athletes than a roster can realistically place on the field. A larger roster provides competitive depth and insurance against injury and transfer-portal attrition. At tuition-dependent institutions, each additional recruited athlete -- especially for non-scholarship athletes -- also represents additional net tuition revenue. And in the post-NIL, post-House settlement environment, many non-revenue programs face new budget pressure as institutional resources shift toward revenue-sharing obligations in football and basketball, which can push coaches toward recruiting larger classes to sustain program visibility and results on a constrained budget.
The consequence is a widening gap between the number of athletes recruited and the number who receive meaningful playing time or developmental attention. This dynamic affects domestic and international athletes alike, and it operates independently of any nationality-based roster rule Congress might adopt.
B. Athlete Debt and Financial Exposure
For nonrevenue sports, recruited athletes often pay their way to school, as well as receive student loans.
My championship dataset includes college soccer rosters exceeding 40 or 50 players. Roster size alone does not prove improper over-recruiting, but it warrants inquiry into whether recruited athletes receive meaningful competitive and developmental opportunities. Materially incomplete or misleading recruiting information can expose athletes and families to educational, financial, and eligibility consequences that are difficult to reverse after enrollment. For the athlete, in addition to a lost year of athletic eligibility, significant student debt can accrue without receiving any athletic benefits from paying tuition at the school.
VIII. Policy Considerations
A. Ombudsman and Athlete-Advocacy Concepts
Congress need not reproduce Olympic governance to draw from an existing American framework. The Team USA Athlete Ombuds provides independent, confidential, and impartial assistance; supports fact-finding, facilitated communication, and mediation; and promotes fair, transparent, timely, and equitably administered processes. The reference points for college athletics are the underlying principles: independence, confidentiality, impartiality, retaliation protection, and the ability to identify recurring concerns and recommend systemic improvements. I offer that model as a reference for congressional consideration, not as a complete proposal or the centerpiece of this testimony.
The Aspen Institute's Children's Bill of Rights in Sports supplies a related youth-sport reference, emphasizing access, development, athlete voice, equal opportunity, dignity, and safe environments.
Together, these models suggest a limited collegiate framework centered on access, transparency, independent assistance, fair process, development, and dignity. Congress could use those principles to evaluate an ombudsman pilot or a focused college-athlete bill of rights.
These principles would require adaptation to the collegiate setting. They should not be understood to guarantee selection, playing time, or a particular competitive role. Rather, they would support accurate information, independent guidance, fair administration of established rules, and protection against retaliation for raising concerns.
B. International Participation and Domestic Pathways
Consistent with Section III, I support the concept of a reasonable formula to restore balance for American athletes, without endorsing a specific percentage. I encourage the Committee to consider any such formula alongside the additional measures below, since a nationality-based rule addresses only one of the three pathway questions this testimony has described.
C. Recruiting and Roster Transparency
I recommend that Congress consider requiring institutions to disclose the following to a recruited athlete and their family before a commitment is signed:
* The program's historical roster size and year-over-year attrition rate for the preceding three seasons
* The number of fully funded, partially funded, and unfunded roster positions on the team
* A de-identified and aggregated scholarship profile for the preceding three seasons that depicts the ratio of scholarships between international and US student-athletes
* Any additional material disclosures Congress determines necessary after consultation with athletes, institutions, associations, and recruiting experts
A standardized, plain-language disclosure form -- comparable to consumer financial disclosure requirements in other contexts -- would allow families to compare offers on a consistent basis and make an informed decision before committing to a program.
D. Athlete Protection Mechanisms
I recommend that Congress consider directing or funding a pilot athlete-ombudsman program, modeled on the principles of the Team USA Athlete Ombuds described above, at a defined set of institutions or conferences. Such a pilot should be structured so that the ombudsman:
* Operates independently of the athletic department's own reporting lines, perhaps operating at the conference level
* Receives inquiries and complaints on a confidential basis
* Has authority to recommend redress for any retaliation related to a complaint to the ombudsman
* Is authorized to identify systemic patterns across multiple complaints and report aggregate findings to institutional leadership and, where appropriate, to NCAA or NAIA governance bodies
I would recommend that Congress ask the NCAA, NAIA, and affected institutions to help define the pilot's scope and funding mechanism as a next step, rather than legislating a fully specified program at this stage.
IX. Conclusion
The central question before this Committee is not whether international athletes should participate in American college sports. The question is whether the pathway from American youth soccer to college soccer -- and, more broadly, from American youth sports to collegiate opportunity across non-revenue programs -- remains meaningful, accessible, and sustainable for future generations of American athletes.
Understanding the scale of internationalization is a necessary first step toward answering that question, but it is not the last step. My own path through this sport -- as a player, as a coach, and as a father who watched three sons navigate a pathway that grew more difficult with each passing year -- is what brought me to this data. I hope it can help bring the Committee to a more complete understanding of what is at stake, and of what Congress can do about it.
Thank you for the opportunity to testify. I am happy to answer the Committee's questions.
* * *
Appendix A
CRUNCHING 2025 COLLEGE SOCCER CHAMPIONSHIPS PLAYER DEMOGRAPHIC DATA
Douglas DePeppe | Originally published December 21, 2025 on Medium
Purpose and Background
What follows is an AI-supported analysis of the roster make-up for the men's college soccer teams that participated in their respective 2025 national championship playoffs for NCAA Divisions I, II, and III, the NAIA, and NJCAA Divisions I and II. The objective is to enumerate and compare the U.S. and international player make-up of college soccer. The original analysis was made available under a Creative Commons Attribution license.
The project grew from my life-long soccer interest; twenty years of youth coaching and player-pathway mentoring; sports-law work involving FIFA player-status and transfer rules and European work-permit requirements; the October 2025 U.S. Soccer and Next Gen College Soccer Committee white paper; and the 2026 World Cup. It also followed Representative Tim Walberg's December 16, 2025 remarks concerning international student-athlete recruiting and lost American scholarship or participation opportunities.
Summary of Overall Findings
NCAA Division III had the highest concentration of U.S. players, at 83.5 percent. Across all levels studied, the roster population was approximately 56.8 percent U.S. and 43.2 percent international.
Excluding Division III, the remaining championship-roster population was approximately 55.0 percent international and 45.0 percent U.S. players. International players constituted a majority in NCAA Division II, the NAIA, and NJCAA Divisions I and II.
NCAA Division I
48 teams; 1,433 players; 59.1% U.S.; 40.9% international. The 2025 College Cup was 84% U.S. National Champion Washington listed one international player and nineteen players from Washington State.
Highest: Marshall 93.1%; UCF 77.8%; Syracuse 76.0%; Hofstra 65.6%; Kansas City 65.5%.
Lowest: Princeton 3.4%; Washington 3.4%; Notre Dame 7.1%; Stanford 7.4%; Denver 9.4%.
NCAA Division II
40 teams; 1,420 players; 49.5% U.S.; 50.5% international; average roster 35.5. National Champion Midwestern State listed nine international players, below the tournament average.
Highest: Palm Beach Atlantic 79.3%; Wilmington (DE) 76.7%; Bridgeport 75.0%; Mississippi College 70.0%; Fort Hays State 68.8%.
Lowest: Seattle Pacific 0%; CSUSB 5.7%; Bentley 13.5%; Rockhurst 17.9%; UCCS 21.2%.
NCAA Division III
64 teams; 2,203 players; 83.5% U.S.; 16.5% international; average roster 34.4. National Champion Tufts listed no international players.
Highest: NC Wesleyan 90.9%; Lyon College 60.8%; Luther 59.5%; Wisconsin-Superior 57.1%; Penn State Harrisburg 27.3%.
Lowest: Tufts, Christopher Newport, Scranton, Catholic, and Stevens each 0%.
NAIA
40 teams; 1,369 players; 29.3% U.S.; 70.7% international; average roster 34.2. National Champion Cumberlands listed 32 international players; WVU Tech listed 40 on a 49-player roster.
Highest: William Penn 100%; Keiser 96.9%; Dalton State 96.8%; Bethel 94.3%; Campbellsville 91.4%.
Lowest: Warner Pacific 1.8%; Indiana East 11.5%; Carroll 39.0%; Concordia 42.9%; Baker 46.0%.
NJCAA Divisions I and II
24 teams; 758 players; 38.5% U.S.; 61.5% international; average roster 31.6. Reported champions illustrated opposite models: Indian Hills fully international (100%) and Phoenix College 96.7% U.S.
Highest: Indian Hills 100%; Iowa Lakes 90.0%; Murray State College 89.3%; Northeast CC 85.7%; St. Clair County CC 84.6%.
Lowest: Phoenix College 3.3%; Mississippi Gulf Coast CC 16.0%; Pima CC 17.1%; Mohave College 18.2%; Pearl River CC 20.0%.
Study Limitations and Notes
A single season's champion should not be treated as proof for or against a broader recruiting pattern.
The relevant evidence is the composition of the full 216-team championship field and the differences among levels and programs. The study covers men's soccer only, is a 2025 championship snapshot, excludes NJCAA Division III, and does not measure age, academy tenure, prior senior competition, scholarship value, playing time, retention, or causation.
* * *
Original text here: https://edworkforce.house.gov/uploadedfiles/depeppe_written_testimony_9-16.pdf
Bingaman & Son Lumber Chief Operating Officer Shields Testifies Before House Agriculture Committee
WASHINGTON, Sept. 30 -- The House Agriculture Committee released the following written testimony by Tyler Shields, chief operating officer of Bingaman and Son Lumber Inc., Kreamer, Pennsylvania, from a Sept. 16, 2026, hearing entitled "Increasing Demand and Opportunities for Homegrown Products Here and Abroad":
* * *
Chairman Thompson, Ranking Member, and Members of the Committee,
Thank you for the opportunity to testify today.
My name is Tyler Shields, and I serve as Chief Operating Officer of Bingaman & Son Lumber, a third-generation, family-owned hardwood products manufacturer headquartered ... Show Full Article WASHINGTON, Sept. 30 -- The House Agriculture Committee released the following written testimony by Tyler Shields, chief operating officer of Bingaman and Son Lumber Inc., Kreamer, Pennsylvania, from a Sept. 16, 2026, hearing entitled "Increasing Demand and Opportunities for Homegrown Products Here and Abroad": * * * Chairman Thompson, Ranking Member, and Members of the Committee, Thank you for the opportunity to testify today. My name is Tyler Shields, and I serve as Chief Operating Officer of Bingaman & Son Lumber, a third-generation, family-owned hardwood products manufacturer headquarteredin Pennsylvania.
Our company operates five facilities across the Commonwealth and purchases green lumber from more than 125 sawmills throughout Pennsylvania and neighboring states. We produce a full range of hardwood products - from logs and lumber to chips, pulpwood, and value-added products - serving customers in more than 40 states and 35 countries and generating more than $75 million in annual sales.
Today, I come before you as a proud member of an industry facing significant challenges. U.S. hardwood lumber production has fallen from 12 billion board feet in 2000 to roughly 4 billion in 2025, driven largely by low-cost imports and substitute products. Hundreds of rural sawmills and pulp mills have closed, and in just the last five years the hardwood industry has lost more than 40,000 jobs.
Despite these challenges, I believe our industry remains optimistic about the future of American hardwoods because we understand a simple truth: Americans are deeply connected to their forests, and healthy forests are only possible when strong, reliable wood product markets make active management economically feasible.
Well-structured federal programs and policies can rebuild and expand demand for American wood products, supporting rural economies and forest health.
Federal innovation programs already demonstrate what is possible. Efforts like the Farm Bill's Wood Innovation and Community Wood Grant Program help manufacturers modernize equipment, adopt advanced technologies, and bring new value-added hardwood products to market. Bingaman is proud to be Pennsylvania's first manufacturer of thermally modified hardwood lumber, and we are now a partner in advancing emerging hardwood mass timber applications in the construction space.
With assistance from the USDA and U.S. Forest Service, we have invested over $20 million in modernizing our material handling systems, expanding kiln-drying capacity, and implementing AI-enabled lumber inspection technology. These investments have improved efficiency, addressed workforce challenges, and strengthened our ability to remain resilient in a rapidly changing global marketplace.
But innovation reaches its full potential only when paired with strong, reliable markets. That is where federal policy plays a critical role.
Federal procurement is one of the most direct tools available. When federal agencies build, renovate, or furnish facilities American hardwood products should be prioritized. This aligns with recommendations advanced by the National Hardwood Lumber Association, sets an example for state and local institutional investment, and ensures taxpayer dollars support domestic manufacturers, forest landowners, and rural communities. A targeted tax incentive for the use of American hardwoods in residential and commercial construction would further strengthen demand and encourage broader adoption of sustainable, domestically produced wood products.
Wood Innovation Grants strengthen the Real American Hardwood Coalition boost consumer and specifier awareness and demand. Abroad, the American Hardwood Export Council - funded through Access and Foreign Market Development programs - expands markets, reduces trade barriers, and grows global demand for American hardwoods.
Research investments should be increased and coupled with a stronger, results-driven commercialization strategy to accelerate the transfer of promising Forest Products Laboratory innovations into marketable products.
Workforce development remains essential. Programs like the Jobs in the Woods Act and the Rural Innovation Stronger Economy (RISE) Program will support training models shaped by employers - responsive to modern skill demands and capable of preparing workers for the full forest products supply chain.
Bioenergy and renewable fuel markets offer another opportunity to create demand for low-grade wood, mill residuals, and forest restoration material. Updating the Renewable Fuel Standard to allow woody biomass from public and private lands to qualify as a RIN-eligible feedstock will create exciting new renewable fuel markets while supporting forest resilience.
As we work to strengthen these long-term foundations, short-term stability also matters. The proposed $12 billion agriculture relief package includes $200 million designated for hardwood manufacturers. This will provide critical short-term support as businesses continue to navigate economic uncertainty. We appreciate Chairman Thompson's leadership in ensuring hardwoods were included in this package and look forward to its passage.
A stronger future for the American hardwood industry depends on vibrant, well-functioning markets that reward innovation, support existing infrastructure, sustain rural communities, and keep forest landowners engaged in the active management our forests need.
Thank you to the Committee for your leadership, support of rural manufacturing, and commitment to America's working forests. I look forward to your questions.
* * *
Original text here: https://agriculture.house.gov/uploadedfiles/testimony-package_shields_09.16.2026_1.pdf
* * *
Chairman Thompson, Ranking Member, and Members of the Committee,
Thank you for the opportunity to testify today.
My name is Tyler Shields, and I serve as Chief Operating Officer of Bingaman & Son Lumber, a third-generation, family-owned hardwood products manufacturer headquartered ... Show Full Article WASHINGTON, Sept. 30 -- The House Agriculture Committee released the following written testimony by Tyler Shields, chief operating officer of Bingaman and Son Lumber Inc., Kreamer, Pennsylvania, from a Sept. 16, 2026, hearing entitled "Increasing Demand and Opportunities for Homegrown Products Here and Abroad": * * * Chairman Thompson, Ranking Member, and Members of the Committee, Thank you for the opportunity to testify today. My name is Tyler Shields, and I serve as Chief Operating Officer of Bingaman & Son Lumber, a third-generation, family-owned hardwood products manufacturer headquarteredin Pennsylvania.
Our company operates five facilities across the Commonwealth and purchases green lumber from more than 125 sawmills throughout Pennsylvania and neighboring states. We produce a full range of hardwood products - from logs and lumber to chips, pulpwood, and value-added products - serving customers in more than 40 states and 35 countries and generating more than $75 million in annual sales.
Today, I come before you as a proud member of an industry facing significant challenges. U.S. hardwood lumber production has fallen from 12 billion board feet in 2000 to roughly 4 billion in 2025, driven largely by low-cost imports and substitute products. Hundreds of rural sawmills and pulp mills have closed, and in just the last five years the hardwood industry has lost more than 40,000 jobs.
Despite these challenges, I believe our industry remains optimistic about the future of American hardwoods because we understand a simple truth: Americans are deeply connected to their forests, and healthy forests are only possible when strong, reliable wood product markets make active management economically feasible.
Well-structured federal programs and policies can rebuild and expand demand for American wood products, supporting rural economies and forest health.
Federal innovation programs already demonstrate what is possible. Efforts like the Farm Bill's Wood Innovation and Community Wood Grant Program help manufacturers modernize equipment, adopt advanced technologies, and bring new value-added hardwood products to market. Bingaman is proud to be Pennsylvania's first manufacturer of thermally modified hardwood lumber, and we are now a partner in advancing emerging hardwood mass timber applications in the construction space.
With assistance from the USDA and U.S. Forest Service, we have invested over $20 million in modernizing our material handling systems, expanding kiln-drying capacity, and implementing AI-enabled lumber inspection technology. These investments have improved efficiency, addressed workforce challenges, and strengthened our ability to remain resilient in a rapidly changing global marketplace.
But innovation reaches its full potential only when paired with strong, reliable markets. That is where federal policy plays a critical role.
Federal procurement is one of the most direct tools available. When federal agencies build, renovate, or furnish facilities American hardwood products should be prioritized. This aligns with recommendations advanced by the National Hardwood Lumber Association, sets an example for state and local institutional investment, and ensures taxpayer dollars support domestic manufacturers, forest landowners, and rural communities. A targeted tax incentive for the use of American hardwoods in residential and commercial construction would further strengthen demand and encourage broader adoption of sustainable, domestically produced wood products.
Wood Innovation Grants strengthen the Real American Hardwood Coalition boost consumer and specifier awareness and demand. Abroad, the American Hardwood Export Council - funded through Access and Foreign Market Development programs - expands markets, reduces trade barriers, and grows global demand for American hardwoods.
Research investments should be increased and coupled with a stronger, results-driven commercialization strategy to accelerate the transfer of promising Forest Products Laboratory innovations into marketable products.
Workforce development remains essential. Programs like the Jobs in the Woods Act and the Rural Innovation Stronger Economy (RISE) Program will support training models shaped by employers - responsive to modern skill demands and capable of preparing workers for the full forest products supply chain.
Bioenergy and renewable fuel markets offer another opportunity to create demand for low-grade wood, mill residuals, and forest restoration material. Updating the Renewable Fuel Standard to allow woody biomass from public and private lands to qualify as a RIN-eligible feedstock will create exciting new renewable fuel markets while supporting forest resilience.
As we work to strengthen these long-term foundations, short-term stability also matters. The proposed $12 billion agriculture relief package includes $200 million designated for hardwood manufacturers. This will provide critical short-term support as businesses continue to navigate economic uncertainty. We appreciate Chairman Thompson's leadership in ensuring hardwoods were included in this package and look forward to its passage.
A stronger future for the American hardwood industry depends on vibrant, well-functioning markets that reward innovation, support existing infrastructure, sustain rural communities, and keep forest landowners engaged in the active management our forests need.
Thank you to the Committee for your leadership, support of rural manufacturing, and commitment to America's working forests. I look forward to your questions.
* * *
Original text here: https://agriculture.house.gov/uploadedfiles/testimony-package_shields_09.16.2026_1.pdf
Deputy Assistant Secretary of State for European & Eurasian Affairs Lawton Testifies Before House Foreign Affairs Subcommittee
WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Europe released the following testimony by Daniel J. Lawton, deputy assistant secretary of State for European and Eurasian affairs, from a Sept. 15, 2026, hearing entitled "U.S. Policy and Regional Security Challenges in the Western Balkans":
* * *
Chairman Self, Ranking Member Keating, distinguished Members of the Subcommittee on Europe, thank you for the opportunity to testify today on U.S. policy in the Western Balkans. This is an important region for U.S. interests, and we appreciate congressional attention and visits to the ... Show Full Article WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Europe released the following testimony by Daniel J. Lawton, deputy assistant secretary of State for European and Eurasian affairs, from a Sept. 15, 2026, hearing entitled "U.S. Policy and Regional Security Challenges in the Western Balkans": * * * Chairman Self, Ranking Member Keating, distinguished Members of the Subcommittee on Europe, thank you for the opportunity to testify today on U.S. policy in the Western Balkans. This is an important region for U.S. interests, and we appreciate congressional attention and visits to theregion, including Chairman Self's most recent visit in May.
The United States seeks a stable, peaceful, and prosperous Western Balkans that contributes to regional and global security. We are pursuing positive relations with key actors in the region to maintain stability, expand economic cooperation, and counter threats that directly affect the United States.
Last year, at the thirtieth anniversary commemoration of the Dayton Peace Agreement, Deputy Secretary Landau made clear that the era of externally-imposed nation-building is over. As the Deputy Secretary noted, "The United States is not offering unlimited means for undefined, uncertain, and unrealistic ends." Instead, we are urging local leaders to forge local solutions to local problems. We want leaders across the region to move beyond relitigating past disputes and focus instead on pragmatic initiatives that move their countries forward. This does not mean disengagement. The U.S. remains active in pursuing constructive outcomes that advance our interests and facilitate local actors in pursuing those local solutions. We remain ready to work with those prepared to move into the future, but have little interest in those who would undermine stability for selfish purposes, or who relitigate decades-old grievances.
U.S. policy rests on three pillars. The first is maintaining stability, a prerequisite for all our objectives. Second, we are advancing U.S. economic and commercial interests through private-sector-led growth and investment climates that welcome American business. We see these two pillars -stability and prosperity - as mutually reinforcing. Third, we are working with our partners to counter threats, including from Balkan transnational criminal organizations that directly cooperate with Western Hemisphere cartels that threaten the United States.
We pursue these objectives through sustained, high-level engagement and the use of all the tools at our disposal. Actors realize we have these additional tools enacted by Congress at our disposal.
We also expect European partners to carry a greater share of the region's security burden. For our Western Balkan NATO allies, this includes by modernizing their militaries and meeting NATO defense spending commitments to advance our shared vision of a more balanced and resilient NATO 3.0.
The United States remains committed to Bosnia and Herzegovina's sovereignty and territorial integrity and to the stability brought by the Dayton Agreement. Last year, U.S. diplomacy resolved a long-running crisis, preserving the country's legal cohesion and constitutional order, while securing the withdrawal of the Republika Srpska's most anti-Dayton legislation. Reduced tensions created space for progress on the Southern Interconnection gas pipeline with Croatia, which will diversify Bosnia's energy supply and security. It will also promote economic growth while creating opportunities for U.S. companies. Next month the people of Bosnia and Herzegovina will cast their ballots in elections, and we stand ready to work the new leadership on shared interests.
Similarly, the United States remains committed to Kosovo's independence and territorial integrity. We enjoy a broad, collaborative agenda with Kosovo, which unfortunately has been hindered by repeated elections, a prolonged caretaker government, and the delayed formation of the institutions required to advance our shared priorities. We have urged Kosovo's leaders to bring this process to conclusion in accordance with the Constitution and court rulings. We have also raised concerns about excessive legal scrutiny and policing of Kosovo's Serbian population. All of Kosovo's citizens should enjoy equal right and protection of the law if Kosovo is to preserve stability. The NATO-led Kosovo Force remains critical to maintaining a safe and secure environment in Kosovo and is supported by U.S. force contributions.
In Serbia, we are advocating for the United States as the partner of choice to counter adversarial influence. Our efforts are working, and our bilateral partnership is getting stronger. In July, we hosted the first-ever U.S.-Serbia Strategic Dialogue advancing energy, defense, security, and commercial cooperation. Engagement with this pivotal country in the regional balance will remain critical to safeguarding U.S. interests.
Normalization of relations, and the maintenance of peace, between Serbia and Kosovo is essential to regional stability. Significant progress has occurred since the 2020 Washington Agreement, which President Trump brokered during his first term. Nevertheless, the EU-facilitated Dialogue has stalled because of insufficient political will on both sides. We continue to urge both Belgrade and Pristina to avoid provocations, uphold their commitments, and resume direct talks without preconditions.
We are working closely with our NATO ally Albania to dismantle transnational criminal organizations and expand market access for U.S. companies. A recently finalized Foreign Military Financing loan will help Albania meet its NATO defense spending commitments and increase the sale of U.S.-made equipment.
North Macedonia and Montenegro are both close NATO allies and security partners, each advancing strategic priorities and key projects that improve regional connectivity. North Macedonia is on a credible path to meet its NATO defense spending commitments and boost our defense cooperation. Sitting at a regional crossroads, North Macedonia is poised to receive and connect LGN exports from Greece to Serbia as well as develop north-south and east-west transportation infrastructure projects. The U.S.-North Macedonia Strategic Dialogue held in April reaffirmed both countries' commitment to working together to advance these strategic lines of effort. Similarly, the recently concluded U.S.-Montenegro Intergovernmental Agreement locks in a framework for cooperation, including on the Adriatic-Ionian corridor. These projects are vital to regional connectivity and expanding opportunities for U.S. companies in the region.
Our engagements in the Western Balkans are tied to achievable objectives and measurable results. Our focus is on supporting pragmatic, locally driven solutions, expanding economic and security cooperation, and advancing American interests.
Thank you, and I look forward to your questions.
* * *
Original text here: https://docs.house.gov/meetings/FA/FA14/20260915/119554/HHRG-119-FA14-Wstate-LawtonD-20260915.pdf
* * *
Chairman Self, Ranking Member Keating, distinguished Members of the Subcommittee on Europe, thank you for the opportunity to testify today on U.S. policy in the Western Balkans. This is an important region for U.S. interests, and we appreciate congressional attention and visits to the ... Show Full Article WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Europe released the following testimony by Daniel J. Lawton, deputy assistant secretary of State for European and Eurasian affairs, from a Sept. 15, 2026, hearing entitled "U.S. Policy and Regional Security Challenges in the Western Balkans": * * * Chairman Self, Ranking Member Keating, distinguished Members of the Subcommittee on Europe, thank you for the opportunity to testify today on U.S. policy in the Western Balkans. This is an important region for U.S. interests, and we appreciate congressional attention and visits to theregion, including Chairman Self's most recent visit in May.
The United States seeks a stable, peaceful, and prosperous Western Balkans that contributes to regional and global security. We are pursuing positive relations with key actors in the region to maintain stability, expand economic cooperation, and counter threats that directly affect the United States.
Last year, at the thirtieth anniversary commemoration of the Dayton Peace Agreement, Deputy Secretary Landau made clear that the era of externally-imposed nation-building is over. As the Deputy Secretary noted, "The United States is not offering unlimited means for undefined, uncertain, and unrealistic ends." Instead, we are urging local leaders to forge local solutions to local problems. We want leaders across the region to move beyond relitigating past disputes and focus instead on pragmatic initiatives that move their countries forward. This does not mean disengagement. The U.S. remains active in pursuing constructive outcomes that advance our interests and facilitate local actors in pursuing those local solutions. We remain ready to work with those prepared to move into the future, but have little interest in those who would undermine stability for selfish purposes, or who relitigate decades-old grievances.
U.S. policy rests on three pillars. The first is maintaining stability, a prerequisite for all our objectives. Second, we are advancing U.S. economic and commercial interests through private-sector-led growth and investment climates that welcome American business. We see these two pillars -stability and prosperity - as mutually reinforcing. Third, we are working with our partners to counter threats, including from Balkan transnational criminal organizations that directly cooperate with Western Hemisphere cartels that threaten the United States.
We pursue these objectives through sustained, high-level engagement and the use of all the tools at our disposal. Actors realize we have these additional tools enacted by Congress at our disposal.
We also expect European partners to carry a greater share of the region's security burden. For our Western Balkan NATO allies, this includes by modernizing their militaries and meeting NATO defense spending commitments to advance our shared vision of a more balanced and resilient NATO 3.0.
The United States remains committed to Bosnia and Herzegovina's sovereignty and territorial integrity and to the stability brought by the Dayton Agreement. Last year, U.S. diplomacy resolved a long-running crisis, preserving the country's legal cohesion and constitutional order, while securing the withdrawal of the Republika Srpska's most anti-Dayton legislation. Reduced tensions created space for progress on the Southern Interconnection gas pipeline with Croatia, which will diversify Bosnia's energy supply and security. It will also promote economic growth while creating opportunities for U.S. companies. Next month the people of Bosnia and Herzegovina will cast their ballots in elections, and we stand ready to work the new leadership on shared interests.
Similarly, the United States remains committed to Kosovo's independence and territorial integrity. We enjoy a broad, collaborative agenda with Kosovo, which unfortunately has been hindered by repeated elections, a prolonged caretaker government, and the delayed formation of the institutions required to advance our shared priorities. We have urged Kosovo's leaders to bring this process to conclusion in accordance with the Constitution and court rulings. We have also raised concerns about excessive legal scrutiny and policing of Kosovo's Serbian population. All of Kosovo's citizens should enjoy equal right and protection of the law if Kosovo is to preserve stability. The NATO-led Kosovo Force remains critical to maintaining a safe and secure environment in Kosovo and is supported by U.S. force contributions.
In Serbia, we are advocating for the United States as the partner of choice to counter adversarial influence. Our efforts are working, and our bilateral partnership is getting stronger. In July, we hosted the first-ever U.S.-Serbia Strategic Dialogue advancing energy, defense, security, and commercial cooperation. Engagement with this pivotal country in the regional balance will remain critical to safeguarding U.S. interests.
Normalization of relations, and the maintenance of peace, between Serbia and Kosovo is essential to regional stability. Significant progress has occurred since the 2020 Washington Agreement, which President Trump brokered during his first term. Nevertheless, the EU-facilitated Dialogue has stalled because of insufficient political will on both sides. We continue to urge both Belgrade and Pristina to avoid provocations, uphold their commitments, and resume direct talks without preconditions.
We are working closely with our NATO ally Albania to dismantle transnational criminal organizations and expand market access for U.S. companies. A recently finalized Foreign Military Financing loan will help Albania meet its NATO defense spending commitments and increase the sale of U.S.-made equipment.
North Macedonia and Montenegro are both close NATO allies and security partners, each advancing strategic priorities and key projects that improve regional connectivity. North Macedonia is on a credible path to meet its NATO defense spending commitments and boost our defense cooperation. Sitting at a regional crossroads, North Macedonia is poised to receive and connect LGN exports from Greece to Serbia as well as develop north-south and east-west transportation infrastructure projects. The U.S.-North Macedonia Strategic Dialogue held in April reaffirmed both countries' commitment to working together to advance these strategic lines of effort. Similarly, the recently concluded U.S.-Montenegro Intergovernmental Agreement locks in a framework for cooperation, including on the Adriatic-Ionian corridor. These projects are vital to regional connectivity and expanding opportunities for U.S. companies in the region.
Our engagements in the Western Balkans are tied to achievable objectives and measurable results. Our focus is on supporting pragmatic, locally driven solutions, expanding economic and security cooperation, and advancing American interests.
Thank you, and I look forward to your questions.
* * *
Original text here: https://docs.house.gov/meetings/FA/FA14/20260915/119554/HHRG-119-FA14-Wstate-LawtonD-20260915.pdf
Deputy Assistant Secretary of State for Counterterrorism Borkert Testifies Before House Foreign Affairs Subcommittee
WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Middle East and North Africa released the following written testimony by Deputy Assistant Secretary of State for Counterterrorism Joel Borkert from a Sept. 16, 2026, hearing entitled "Twenty-Five Years After 9/11: The Evolving Terrorism Landscape and State's Counterterrorism Response":
* * *
Chairman Lawler, Ranking Member Sherman, and members of the Subcommittee--thank you for the opportunity to appear today.
Twenty-five years ago this week, I was a senior in college. September 11 changed me forever. Within months, I commissioned ... Show Full Article WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Middle East and North Africa released the following written testimony by Deputy Assistant Secretary of State for Counterterrorism Joel Borkert from a Sept. 16, 2026, hearing entitled "Twenty-Five Years After 9/11: The Evolving Terrorism Landscape and State's Counterterrorism Response": * * * Chairman Lawler, Ranking Member Sherman, and members of the Subcommittee--thank you for the opportunity to appear today. Twenty-five years ago this week, I was a senior in college. September 11 changed me forever. Within months, I commissionedas an infantry officer, and that morning set the course for the next 20 years of my life.
That is true for a whole generation of Americans. We deployed. Most came home, but some did not. Twenty-five years later, I measure our work against what it cost to get here.
The Department of State has been in this fight longer than most people realize. We stood up our first counterterrorism office in 1972. Congress wrote the Coordinator position into law in 1994. And in 2012, it became the Bureau of Counterterrorism.
We got a number of things right. We assembled a global coalition. We took away the sanctuary al Qaeda used to plan those attacks. We destroyed the ISIS caliphate and killed al-Baghdadi, al-Zawahiri, bin Laden, and many of their associates. And we built a counterterrorism architecture designed to stop attacks before they happen. By God's grace, our Nation has not suffered another attack on the scale of September 11.
But we also got some things wrong. We sometimes measured effort instead of effect. We stood up partner forces we could not sustain. We treated counterterrorism as a permanent condition rather than a means of solving a specific problem. And suffered from mission creep.
Today, we face a fundamentally different terrorist landscape than we did 25 years ago. President Trump's counterterrorism strategy recognizes that change and puts the American homeland first, with a focus on identifying threats before they happen and targeting those with the intent and capability to harm Americans. While we have significantly degraded the threat from global radical Islamic terrorist organizations, it persists--fueled by Iran's support for terrorist proxies and Salafijihadist groups exploiting weak borders and fragile states. At the same time, narcoterrorism has devastated American communities and families, contributing to the deaths of hundreds of thousands of Americans. And the threat of far-left terrorism has reemerged, targeting the institutions, ideals, and principles at the foundation of our constitutional republic, as well as the lives and decisions of American people who they seek to coerce or silence.
Terrorists have adapted and are using new technologies. Advances in AI, drones, and digital assets have reduced their dependence on traditional camps and safe havens to radicalize, recruit, finance, and inspire. Today, small cells--and even a single individual--can achieve effects that once required disciplined organizations, extensive resources, and physical sanctuary. Terrorist groups can also spot, recruit, radicalize, and direct individuals around the globe through interactive media, games, messages, and other forms of cyberspace connectivity.
The lessons of the last 25 years are clear. So are many of the threats we face today.
The President's National Security Strategy and Counterterrorism Strategy reflect that reality: Protect the American homeland first. Identify threats before they happen. Act with precision over permanence. And expect capable partners to carry their fair share of the burden.
I am proud of the critical role the Department of State--and especially the dedicated men and women of the Bureau of Counterterrorism under Ambassador LoGerfo's leadership--plays in advancing the President's counterterrorism priorities.
First, we put the strategy into action by focusing on the homeland and working outward. That means confronting the threats closest to home. We have secured our border. And at President Trump's direction from his inaugural speech, we are designating cartels and gangs as terrorist organizations, bringing the full weight of our counterterrorism architecture to bear. Under President Trump and Secretary Rubio's leadership, we have designated twenty-one cartels and transnational criminal organizations as Foreign Terrorist Organizations or Specially Designated Global Terrorists. That means more than prosecutions and asset freezes. It means equipping capable partners to dismantle these organizations before their violence reaches American communities. The Strategy calls for prioritizing these hemispheric threats and using the full range of counterterrorism tools to disrupt their financing, logistics, and access to the United States. This year alone, our counterterrorism assistance to the Western Hemisphere has increased markedly in line with these priorities.
Second, we focus on high-payoff efforts that stop terrorists before they reach our borders. By sharing terrorist screening and traveler information and strengthening aviation and border security, we push our defenses outward. A single watchlist hit at a foreign airport can stop a terrorist before they ever board a plane--at a fraction of the cost of deploying military forces.
Third, strong partners are force multipliers for American security. That is why we are mobilizing partners to shoulder their share of the fight. Against Iran, we are applying the same principle: deny the regime and its proxies the resources that sustain their terrorist networks. NSPM-2 directs a sustained campaign to disrupt, degrade, and deny the IRGC and its surrogates access to the resources that sustain their activities, while using financial pressure and diplomacy to isolate Iran. We are also leading efforts with partners to combat far-left terrorism--strengthening detection and information sharing so today's violence does not grow into a threat that jeopardizes the fundamental values and freedoms we too often take for granted.
And finally, we are maximizing coordination, efficiency, and effectiveness for the threats we face today and tomorrow. The reorganization has strengthened our ability to coordinate across the Department and interagency, eliminate redundancy, and demand results--ensuring that every program, every dollar, and every partnership makes America safer, stronger, and more prosperous.
That brings me back to where I started.
I am often asked what we learned from 9/11. Two of the hijackers were known to this government but not on a watchlist. Today, our watchlist system is greatly improved and designed to make that kind of failure far less likely.
I have devoted the past 25 years of my life to helping ensure this country would never suffer an attack like that again.
This summer, my son will commission as an Army officer. He was not alive on September 11, but he inevitably inherits this mission. My obligation--and, I would respectfully submit, our obligation--is to hand him a country that does not have to learn this lesson twice.
Thank you. I look forward to your questions.
* * *
Original text here: https://docs.house.gov/meetings/FA/FA13/20260916/119555/HHRG-119-FA13-Wstate-BorkertJ-20260916.pdf
* * *
Chairman Lawler, Ranking Member Sherman, and members of the Subcommittee--thank you for the opportunity to appear today.
Twenty-five years ago this week, I was a senior in college. September 11 changed me forever. Within months, I commissioned ... Show Full Article WASHINGTON, Sept. 30 -- The House Foreign Affairs Subcommittee on Middle East and North Africa released the following written testimony by Deputy Assistant Secretary of State for Counterterrorism Joel Borkert from a Sept. 16, 2026, hearing entitled "Twenty-Five Years After 9/11: The Evolving Terrorism Landscape and State's Counterterrorism Response": * * * Chairman Lawler, Ranking Member Sherman, and members of the Subcommittee--thank you for the opportunity to appear today. Twenty-five years ago this week, I was a senior in college. September 11 changed me forever. Within months, I commissionedas an infantry officer, and that morning set the course for the next 20 years of my life.
That is true for a whole generation of Americans. We deployed. Most came home, but some did not. Twenty-five years later, I measure our work against what it cost to get here.
The Department of State has been in this fight longer than most people realize. We stood up our first counterterrorism office in 1972. Congress wrote the Coordinator position into law in 1994. And in 2012, it became the Bureau of Counterterrorism.
We got a number of things right. We assembled a global coalition. We took away the sanctuary al Qaeda used to plan those attacks. We destroyed the ISIS caliphate and killed al-Baghdadi, al-Zawahiri, bin Laden, and many of their associates. And we built a counterterrorism architecture designed to stop attacks before they happen. By God's grace, our Nation has not suffered another attack on the scale of September 11.
But we also got some things wrong. We sometimes measured effort instead of effect. We stood up partner forces we could not sustain. We treated counterterrorism as a permanent condition rather than a means of solving a specific problem. And suffered from mission creep.
Today, we face a fundamentally different terrorist landscape than we did 25 years ago. President Trump's counterterrorism strategy recognizes that change and puts the American homeland first, with a focus on identifying threats before they happen and targeting those with the intent and capability to harm Americans. While we have significantly degraded the threat from global radical Islamic terrorist organizations, it persists--fueled by Iran's support for terrorist proxies and Salafijihadist groups exploiting weak borders and fragile states. At the same time, narcoterrorism has devastated American communities and families, contributing to the deaths of hundreds of thousands of Americans. And the threat of far-left terrorism has reemerged, targeting the institutions, ideals, and principles at the foundation of our constitutional republic, as well as the lives and decisions of American people who they seek to coerce or silence.
Terrorists have adapted and are using new technologies. Advances in AI, drones, and digital assets have reduced their dependence on traditional camps and safe havens to radicalize, recruit, finance, and inspire. Today, small cells--and even a single individual--can achieve effects that once required disciplined organizations, extensive resources, and physical sanctuary. Terrorist groups can also spot, recruit, radicalize, and direct individuals around the globe through interactive media, games, messages, and other forms of cyberspace connectivity.
The lessons of the last 25 years are clear. So are many of the threats we face today.
The President's National Security Strategy and Counterterrorism Strategy reflect that reality: Protect the American homeland first. Identify threats before they happen. Act with precision over permanence. And expect capable partners to carry their fair share of the burden.
I am proud of the critical role the Department of State--and especially the dedicated men and women of the Bureau of Counterterrorism under Ambassador LoGerfo's leadership--plays in advancing the President's counterterrorism priorities.
First, we put the strategy into action by focusing on the homeland and working outward. That means confronting the threats closest to home. We have secured our border. And at President Trump's direction from his inaugural speech, we are designating cartels and gangs as terrorist organizations, bringing the full weight of our counterterrorism architecture to bear. Under President Trump and Secretary Rubio's leadership, we have designated twenty-one cartels and transnational criminal organizations as Foreign Terrorist Organizations or Specially Designated Global Terrorists. That means more than prosecutions and asset freezes. It means equipping capable partners to dismantle these organizations before their violence reaches American communities. The Strategy calls for prioritizing these hemispheric threats and using the full range of counterterrorism tools to disrupt their financing, logistics, and access to the United States. This year alone, our counterterrorism assistance to the Western Hemisphere has increased markedly in line with these priorities.
Second, we focus on high-payoff efforts that stop terrorists before they reach our borders. By sharing terrorist screening and traveler information and strengthening aviation and border security, we push our defenses outward. A single watchlist hit at a foreign airport can stop a terrorist before they ever board a plane--at a fraction of the cost of deploying military forces.
Third, strong partners are force multipliers for American security. That is why we are mobilizing partners to shoulder their share of the fight. Against Iran, we are applying the same principle: deny the regime and its proxies the resources that sustain their terrorist networks. NSPM-2 directs a sustained campaign to disrupt, degrade, and deny the IRGC and its surrogates access to the resources that sustain their activities, while using financial pressure and diplomacy to isolate Iran. We are also leading efforts with partners to combat far-left terrorism--strengthening detection and information sharing so today's violence does not grow into a threat that jeopardizes the fundamental values and freedoms we too often take for granted.
And finally, we are maximizing coordination, efficiency, and effectiveness for the threats we face today and tomorrow. The reorganization has strengthened our ability to coordinate across the Department and interagency, eliminate redundancy, and demand results--ensuring that every program, every dollar, and every partnership makes America safer, stronger, and more prosperous.
That brings me back to where I started.
I am often asked what we learned from 9/11. Two of the hijackers were known to this government but not on a watchlist. Today, our watchlist system is greatly improved and designed to make that kind of failure far less likely.
I have devoted the past 25 years of my life to helping ensure this country would never suffer an attack like that again.
This summer, my son will commission as an Army officer. He was not alive on September 11, but he inevitably inherits this mission. My obligation--and, I would respectfully submit, our obligation--is to hand him a country that does not have to learn this lesson twice.
Thank you. I look forward to your questions.
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Original text here: https://docs.house.gov/meetings/FA/FA13/20260916/119555/HHRG-119-FA13-Wstate-BorkertJ-20260916.pdf