In the case of North Carolina Board of Dental Examiners v. Federal Trade Commission (2014), the U.S. Supreme Court ruled 6-3 that a state licensing board composed primarily of active market participants, such as dentists, can be held liable under antitrust laws for anti-competitive conduct unless it is actively supervised by the state. The ruling came after an investigation by FTC into complaints about non-dentist providers offering teeth whitening services in North Carolina at lower prices than dentists. The dental board had sent cease-and-desist letters to these providers arguing they were practicing dentistry without a license. However, FTC argued this was an attempt to limit competition and filed charges against the board for violating federal antitrust law which led to this landmark decision.

In the dissenting opinion for NC BD. OF DENTAL EXAMINERS v. FTC, Justice Alito argued that the majority's decision failed to respect state sovereignty and blurred the lines between federal and state power. He contended that states should be able to determine their own regulatory schemes without interference from federal antitrust laws unless Congress explicitly says otherwise. According to him, this case was not about a private trade association trying to regulate itself but rather a state agency carrying out its statutory duties as defined by North Carolina law. Therefore, he believed it should have been granted immunity under Parker v Brown (1943), which exempts certain anti-competitive conduct of states from federal antitrust laws when acting in their sovereign capacity.