BACKGROUND: Preemption occurs when a higher level of government eliminates or reduces the authority of a lower level of government to pass laws. U.S. state legislatures have increasingly used preemption to limit local policies with variable impacts on public health and health equity. The purpose of this study is to examine the relationship between state preemption prior to the COVID-19 pandemic and state-level vulnerability and mortality related to COVID-19. This study focused on a cross-section of policies relevant to public health, COVID-19, and other public health emergencies.

METHODS: Historical examples and case studies were explored to describe the public health significance of preemption. To evaluate the relationship between state-level preemption and adverse COVID-19 outcomes, preemption was examined in 50 states across five policy domains: minimum wage, paid sick and family medical leave, mandatory inclusionary zoning, smokefree laws, and municipal broadband networks. State-level vulnerability data were obtained from the 2020 Surgo Ventures’ COVID-19 Community Vulnerability Index, and total COVID-19 deaths per 100,000 were obtained from Surgo Ventures’ Precision for COVID-19 Data Explorer. A preemption index was created, and Spearman’s rank correlation coefficient was used to assess the strength and direction of the relationship between the number of preemptive policies and state-level vulnerability and deaths per 100,000 during the pandemic.

RESULTS: As of August 31, 2019, 71 instances of preemption were found across the five selected policy domains. There was a higher average number of preemption laws per state in the Midwest and South compared to Northeast and Western regions. States with higher preemption levels had statistically significant, moderate associations with overall vulnerability, and certain elements of COVID-19 specific vulnerability compared to states with lower levels of preemption. Variations also existed by individual policy domains.

CONCLUSION: Overall, these data demonstrate a relationship between state-level preemption and vulnerability in the context of the COVID-19 pandemic. This highlights the critical need for public health professionals and stakeholders to engage in policy advocacy that preserves and restores local authority. Future research is needed to better understand the direct impacts of preemption across a range of policy domains that impact public health, health equity, and emergency response and preparedness.