PHOENIX -- Criticized for its own handling of head injuries, the NFL launched an extensive lobbying campaign to pass laws protecting kids who get concussions while playing sports. The result: Within just five years, every state had a law on the books.
But are the laws strong enough?
An Associated Press analysis of the 51 youth concussion laws -- one in each state and the District of Columbia -- found that fewer than half contain all of the key principles in the initial bill passed in Washington state in 2009. That measure mandated education for coaches about concussion symptoms, removal of a player from a game if a head injury is suspected, written clearance to return, and a concussion information form signed by parents and players.
About a third of the laws make no specific reference to which ages or grades are covered. Even fewer explicitly apply to both interscholastic sports and rec leagues such as Pop Warner or Little League. Certain laws make clear they cover public and private schools, others only refer to public schools, while some don't say at all. Almost all lack consequences for schools or leagues that don't comply.
"We did make compromises ... in some states where we wanted to get something. A 'B'-level law, as opposed to an 'A'-level law," said NFL senior vice president of health and safety policy Jeff Miller, who testified about concussions before Arizona's legislature on Tuesday while in town for the Super Bowl.
"Better to get something good, and get something in place," Miller said, "as opposed to shoot for something fantastic in all places -- and fail."
The laws were passed with remarkable speed, and many were weakened because of concerns about cost. Jay Rodne, the Republican who sponsored Washington's initial law, said putting expensive enforcement mechanisms in the bills would have caused many to fail.
Judy Pulice, in charge of state legislation for the National Athletic Trainers' Association, helped guide the NFL as bills were written and was disappointed that the final products didn't include penalties for noncompliance.
"What happens if you don't pull the kid out of the game? What happens if you put them back in with no medical release?" Pulice said. "Nothing happens."
The AP's review of the laws passed after Washington found that only 21 have all four of the requirements in the model legislation.
All but two of the laws call for the immediate removal of an athlete from a game or practice if a concussion is suspected. All but four contain language about education for coaches.
Yet only 34 say that before returning to action, an athlete with a head injury must have written clearance from a licensed health care provider trained in the evaluation and management of concussions. Just 30 mandate that a concussion information form be signed both by the athlete and a parent or guardian.
"They don't all have the [main] principles. Not every state has the same bite as Washington state," said Dr. Richard Ellenbogen, chairman of neurological surgery at the University of Washington and co-chairman of the NFL head, neck and spine committee.
He treated Zackery Lystedt, the middle-school football player who nearly died after getting two concussions in a game. Washington's law was named for the teen.
After that landmark bill was passed, Ellenbogen recalled, he had a conversation with NFL commissioner Roger Goodell about efforts to replicate the legislation.
"The commissioner asked me, 'What do [you] want to get out of this?' I said, 'I want to see, in my lifetime, 10 more states pass a Zack Lystedt law," Ellenbogen said. "And he said, 'No. We're going to get all 50 states. And we're going to get them in under five years.'"
Goodell pushed for the laws at a time his league was facing almost daily reminders of concerns about the link between football and head injuries.
Researchers studying brain tissue of deceased former players such as Junior Seau and Dave Duerson, who both committed suicide, found signs of a degenerative disease also found in boxers and often connected to repeated blows to the head. Thousands of ex-players sued the league, saying it didn't do enough to inform them about, and protect them from, concussions. President Barack Obama suggested fans might have a guilty conscience while watching football.
Against that backdrop, Ellenbogen said, the NFL held weekly conference calls with state legislators, doctors and other advocates. Miller, who led the lobbying, estimated the effort cost hundreds of thousands of dollars.
Their success was swift. By comparison, it took more than twice as long to get mandatory seat belt laws passed in 49 states; New Hampshire still doesn't have one for adults.
"We wouldn't have had 50 states pass these laws," Ellenbogen said, "if it wasn't for the financial backing and political gravitas of the NFL."
Goodell wrote 44 governors whose states had not enacted laws. He spoke about the topic at Harvard's School of Public Health and in an address to the Congress of Neurological Surgeons.
And when, a few days before last year's Super Bowl, Mississippi became the last state to finalize its law -- albeit a measure missing elements -- the league patted itself on the back, saying it had "actively advocated" for the regulations. In October, the NFL trumpeted that Goodell would accept the Brain Injury Alliance of Washington's 2014 Leadership Award.
Now the question becomes how effective these laws might be in a country where, according to the Centers for Disease Control, nearly a quarter-million people under 19 were treated in emergency rooms for nonfatal, sports-related concussions in 2009.
For 10 years, Dr. Dawn Comstock has collected data from athletic trainers at hundreds of U.S. high schools, and she is comparing state-by-state concussion statistics from before and after each law was enacted to try to understand the practical effect the legislation is having.
"I'm sensitive to people getting a false sense of security," said Comstock, of the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus. "It's great what [state lawmakers] did. But has it made a difference for any player playing any sport?"
Larry Cooper, athletic trainer at a school for grades 7-12 outside of Pittsburgh, charts concussions reported in all sports. In the 2007-08 academic year, three years before Pennsylvania passed its law, there were 10 concussions reported at his school, he said. That rose to 15 in 2013-14, and 18 already in 2014-15.
"Parents and student-athletes are much more aware of signs and symptoms," Cooper said.
He's not the only one noticing. Despite the weaknesses in a majority of the laws, there does seem to be consensus that they have increased awareness.
The NFL's Miller said they can always be amended.
"I say, 'Let's go back and make them better.' That's OK, too," he said. "There's only 10 laws that are etched in stone, and those are the Ten Commandments. Everything else can be changed. Everything else can be improved."