Even as the Senate debates a plan to end insurance companies' exemption from federal antitrust laws, the likely effects of lifting the exemption remain unclear after more than 60 years on the books.

Sen. Charles Schumer, D-N.Y., a leading advocate of the proposal, called the antitrust exemption "one of the worst accidents of American history" and said that "it deserves a lot of the blame for the huge rise in premiums that has made health insurance so unaffordable." The issue has become a flash point in an escalating fight between the insurance industry and Democrats over a questionable report issued by insurers last week.

But analysts debate how much of a role the exemption has played in encouraging industry consolidation and whether lifting it now will have much effect. Thomas Greaney, the co-director of the Center for Health Law Studies at St. Louis University, said there was no evidence linking the antitrust exemption to a lack of competition in some markets and that repealing it wouldn't suddenly guarantee vigorous competition.

"Consolidation is probably the problem," Greaney said. "The simplest argument is that a lack of vigorous competition in local and regional health insurance markets means they act in concert or like a traditional monopoly."

At issue is the McCarran-Ferguson Act, passed by Congress in 1945, which gave the insurance companies protection from antitrust oversight but also gave states the authority to regulate insurance. Former Missouri state insurance commissioner Jay Angoff explained that exemption hypothetically would allow insurers to drive up prices.

"State insurance codes explicitly authorize price fixing," said Angoff, currently a lawyer with Mehri & Skalet. "So on the one hand there's an exemption from federal laws, but on the other hand states authorize price fixing by insurers in many cases. Still, that's different than saying insurance companies do in fact fix prices."

Some have blamed rising premium prices on a lack of regulation. A report from Health Care for America Now details insurance company abuses, among them a deal between a Massachusetts Blue Cross provider and a hospital that resulted in higher prices for consumers.

Though Angoff said such deals are currently legal, he thought repealing the exemption would lower prices. "It would be a whole new world. Companies would have to change their way of doing business," Angoff said. "If all insurance companies were fully subject to the antitrust laws, it would have a substantial effect and would reduce prices."

Not all experts agree. "Frankly, I'm not sure it would make that much of a difference," Greaney said. "I'm not sure that's an issue that will change industry behavior so much, unless removing it means they'll regulate it more tightly. It's pretty hard under antitrust law to break up a monopoly."

Because of that, Greaney said that threats from Democrats to simply repeal the exemption shouldn't frighten insurers. A House bill from Rep. John Conyers, D-Mich., would go further, creating new regulations for insurers while also repealing McCarran-Ferguson. Angoff noted, however, that several of these proposals have come up before without passing.

"It's the same reason health care reform hasn't gone any place," Angoff said. "The opposition is very influential. The insurance industry has been successful in all efforts to stop any repeal efforts."

If the repeal effort fails, there's still hope for lowering premium prices by other means. As Greaney noted, encouraging competition could achieve the same results without regulation.

"It would take decades for antitrust actions to even partially unravel the health insurance cartels that have grown up in most American markets," said Jeremy Funk, a spokesman for Americans United for Change, which recently launched an ad campaign pushing the public option as a way to lower premiums. "To assure there is a major competitor to drive down costs, a public option is an absolute necessity. It is the only means of standing up a large network of providers over a short time frame."

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