Fearful of higher medical costs, more than a dozen states this year considered--but ultimately rejected--legislation that would have allowed competing physicians to collectively negotiate prices with health plans.
Only the city council of the District of Columbia followed the lead of Texas, passing a measure to provide antitrust exemptions to physicians.
Similar legislation stalled in Alaska, Arizona, California, Connecticut, Delaware, Florida, Illinois, Michigan, Missouri, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Tennessee, according to the American Medical Association.
Donald Palmisano, M.D., a New Orleans surgeon and a member of the AMA's board of trustees, said simple caution on the part of politicians may be one reason the so-called state-action doctrine stumbled in so many legislatures.
It's also a complicated law that requires both an affirmative vote in the legislature and active oversight by a state government agency. He suggested that many states are taking a wait-and-see approach.
"It may well be that they're stalling because they're not able to work out the details," said Palmisano, a principal AMA spokesman on antitrust legislation. "The devil's in the details. We'll really have a better accounting in February (during the AMA legislative meeting)."
At the same time that state legislatures grappled with the issue, Congress remained deeply divided over providing antitrust exemptions to doctors. Despite overwhelming support in the House last year, legislation sponsored by Rep. Tom Campbell (R-Calif.) failed to find a Senate sponsor.
Palmisano said the AMA prefers federal legislation over a patchwork of antitrust laws in the states. It's unclear what will happen with the federal measure when the 107th Congress convenes in January.
Last year, Texas lawmakers approved an exemption to federal antitrust law for independent physicians. Yet critics say that legislation does not satisfy doctors' key concerns or include the range of worker protections of the National Labor Relations Act.
"What this really is is a way of getting around federal legislation," said Mark Levy, executive director of the New York-based Committee of Interns and Residents. "It doesn't really deal with any of the central issues. And it sets up procedures so complicated that they will neither give doctors the clout they want nor will it be cost-effective."
Levy said the passage only of Campbell's legislation will address the most vital issues.
In June, the D.C. Council followed Texas' lead and passed a bill to allow independent physicians to negotiate collectively with insurers. It prohibits doctor strikes or boycotts, and health plans would participate voluntarily.
Health insurers have aggressively opposed antitrust exemptions, saying the cost of medical care would increase dramatically if doctors were allowed to bargain collectively in what they say amounts to price-fixing.
A similar antitrust exemption was passed about 15 years ago in the state of Washington, but the exemption has never been used.
In California, which often establishes laws that become trends across America, an antitrust exemption for physicians will be considered again next year, said Jack Lewin, M.D., chief executive officer of the state medical association. But Lewin says even such a measure won't solve the fundamental problem.
"We need a new set of relationships between health plans and doctors, so we can talk frankly--together with employees, the government and the public--about what it really costs to provide health benefits," Lewin said.