Preemption and Generational Health Equity: The Role of Forced Inaction in Shaping Outcomes

Policy Points When shaping policies on the upstream determinants of health, such as economic and housing policies, state lawmakers should evaluate the potential consequences of state preemption-i.e., restricting policymaking among other levels of government. State preemption is associated with higher rates of childhood poverty among Black residents and White residents as well as low birthweight among Black residents. For both outcomes, the associations are stronger among Black residents. When deliberating on preemptive policies, state decision-makers should consider whether these policies are likely to exacerbate racial disparities, thereby indicating the need to develop policy alternatives.

Racial disparities-unequal outcomes between racial groups-persist in the United States, particularly with respect to health and economic outcomes. There has been increased focus on the ways in which upstream determinants of health contribute to these disparities; however, little is known about how forced inaction on these upstream determinants affects health and economic outcomes. The prevalence of state preemption-when state lawmakers restrict policy actions among local decision-makers-is increasing. Therefore, it is essential to understand how restricting local policymaking affects racial disparities in health and economic outcomes.

This study examines the associations of state preemption with childhood poverty levels and low birthweight. The data for low birthweight were collected from 1,377 counties, and the data for childhood poverty were collected from 1,607 counties. We used ordinary least squares regression and spatial regression to analyze racial disparities in these two outcomes. Furthermore, we used seemingly unrelated estimation to determine whether the effects of state preemption differed significantly between Black and White models for each outcome.

The results indicated that state preemption is significantly associated with higher rates of low birthweight among Black residents. Specifically, each additional preemptive policy was associated with a .5 percentage-point increase in the low birthweight rate among Black residents. State preemption was also significantly associated with higher rates of childhood poverty among both Black and White residents. Specifically, each additional preemptive policy was associated with a 5 percentage-point and a 1.4 percentage-point higher rate of childhood poverty among Black residents and White residents, respectively. Additional testing of childhood poverty models confirms that the association was stronger in the Black model than the White model.

This study reveals that state preemption of local policymaking on social determinants of health may exacerbate racial disparities in health and economic outcomes. To minimize these disparities and increase health equity, state policymakers should consider the current findings before restricting local policymaking.