Public Health’s Preemption Problem: Key Health Justice Impacts and Updates

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CENTER FOR PUBLIC HEALTH LAW RESEARCH
 
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Law shapes behaviors and environments, but
the effects of laws are not equitably distributed
among our communities.
 
T
he Center for Public Health Law Research
supports the widespread adoption of
scientific tools and methods for 
mapping
 
and
evaluating
 
the impact of law on health
.
 
Legal epidemiology
 
The scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a
population.
 
Policy surveillance
 
The systematic collection, analysis, and dissemination of laws and policies across jurisdictions or institutions, and over
time.
 
The Policy Surveillance Process
 
Legal doctrine permitting
higher levels of government to
usurp lawmaking authority
from lower levels
E.g., minimum wage laws
 
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Dillon’s Rule
Narrowly defines local authority
Local governments only possess authority delegated
by the state
Home Rule
Generally, more permissive than Dillon’s rule
 
States can preempt local
governments by:
Setting a minimum or
maximum legal standard
Preempting local control in
an entire area of law
 
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Imposes civil and criminal penalties or removal from
public office when public officials propose or enact
legislation that exceeds local lawmaking authority
 
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The State Preemption Project was a collaboration
between the Center for Public Health Law
Research and the National League of Cities.
Support was provided by the Robert Wood
Johnson Foundation. The views expressed here
do not necessarily reflect the views of the
Foundation.
 
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Longitudinal dataset (August 1, 2019 to November 1, 2022) analyzing
and tracking preemption laws in 15 domains across the country
Updated annually, next update coming in late 2023
National League of Cities uses legal data to shape discussion and
increase awareness of state preemption and provides supports to
thwart state preemptive activity
Housed with free, open-access on Lawatlas.org
 
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1.
Ban the Box
2.
Firearms
3.
Mandatory inclusionary zoning
4.
Municipal broadband
5.
Mandatory paid leave
6.
Rent control
7.
Full disclosure tax requirements
8.
General revenue limits
 
9.
General expenditure limits
10.
Property tax rate limits
11.
Tax assessment limits
12.
Tax levy limits
13.
Transgender rights
14.
Local law enforcement budgets
15.
Race and racism in school
curriculum
 
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Four states (Florida, Georgia, Missouri, and
Texas) passed laws preempting local control
over police budgets
Three states (Alabama, New Hampshire, and
Utah) added new preemptive elements to
their laws related to local regulation of
firearms
One state (Ohio) passed a new law
prohibiting local governments from passing
any laws imposing rent control or rent
stabilization on private landlords
 
Figure 1. Firearms
Preemption as of
November 1, 2022
 
Figure 2. Rent
Control Preemption
as of November 1,
2022
 
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CENTER FOR PUBLIC HEALTH LAW RESEARCH
 
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Source: University of Florida
 
Source: Orange County
Regional History Center
 
 
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Broad Categories Prohibited from Being Taught in Classrooms
The U.S. is fundamentally racist or sexist
Meritocracy or traits such as a hard work ethic are racist or sexist or were created by a particular race
to oppress another race
Any individual should feel discomfort, guilt, anguish, or any other form of psychological distress on
account of his or her race or sex
An individual, by virtue of his or her race or sex, bears responsibility for actions committed in the past
by other members of the same race or sex
"Divisive concepts" or "controversial issues“
Racial scapegoating
 
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Source: Getty Images
 
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CENTER FOR PUBLIC HEALTH LAW RESEARCH
 
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For the last couple of decades, transgender
rights have been ostensibly under attack.
The rise in laws and regulations infringing
on these rights have grown exponentially in
the last few years.  Not all anti-trans laws
are preemptive, but the usage of
preemption as an anti-trans tactic is
prevalent and especially worrying.
 
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These bills are especially sinister as they
prevent localities from protecting a vulnerable
population.  North Carolina’s HB2 is the most
prominent example, even though the
“Bathroom Bill” section stole all the headlines.
 
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Five more states have introduced bills since 2021 (
https://www.tracktranslegislation.com/
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As is often the case with moral panics, the
alleged corrupted youth is the target.  And
given the state’s control over education, this is
the avenue for which most preemption related
anti-trans legislation are occurring.  This is
occurring both in and out of the classroom.
 
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Four States - Curriculum
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Altogether 87 bills involving education have been so far introduced in 2023
(
https://www.tracktranslegislation.com/
).
 
*other states have also enacted  parental bills of rights, but these three states’ laws specifically invovle mental health and the ability for children to socially transition
 
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HB2 represents
 how far these types of bans can be taken.
 
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Restrictions are not limited to schools and
anti-discrimination protections.  The most
worrisome trend we are seeing are states
prohibiting gender-affirming care in its entirety
for transgender youth.
 
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https://lawatlas.org/datasets/preemption-project
https://www.tracktranslegislation.com/
https://translegislation.com/
https://www.aclu.org/legislative-attacks-on-lgbtq-rights
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Erin Reed (Activist following state legislature movement) – 
https://twitter.com/ErinInTheMorn
Alejandra Caraballo (Lawyer and clinical instructor) - 
https://twitter.com/Esqueer_
Ari Drennen (Media Matters journalist) – 
https://twitter.com/AriDrennen
Allison Chapman (Legislative researcher) - 
https://twitter.com/AlliRaine22
 
 
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54
 
Legal Abortions Fell Around
6 Percent In Two Months
After End of 
Roe
 
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New York Times (Oct. 30, 2022)
 
55
 
Requests for Self-managed Medication Abortion
Before and After 
Dobbs
, JAMA (Nov. 1, 2022)
 
56
 
Putting both
studies
together, there
were about
2,000 fewer
abortions per
month,
compared with
April, when
abortion was
legal in every
state.
 
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New York Times (Nov. 1, 2022)
undefined
 
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P
A
T
H
W
A
Y
:
FDA’s authority to approve safe & effective drugs for circulation in
interstate commerce 
may preempt 
contradictory state laws seeking to
limit or restrict medication abortion access, enabling access to
medication abortion nationally.
C
O
V
E
R
A
G
E
:
Pregnant individuals seeking
abortion 
up to 10 weeks
gestation
.
C
A
V
E
A
T
S
:
Litigation
 has emerged
regarding the extent of 
FDA
authority
 and preemption vis-à-
vis state authority over the
practice of medicine.
 
In a challenge by anti-
abortion medical
associations, Judge
Matthew Kacsmaryk, an
appointee of President
Donald Trump, stayed
FDA’s approval of
medication abortion drug
mifepristone in an attempt
to remove it from the U.S.
marketplace.
 
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,
 
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)
 
59
 
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3
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60
 
FDA originally approved mifepristone in 2020
under an approval pathway aimed at providing
more stringent control of the drug (“subpart H”).
 
According to Judge Kacsmaryk,
the Subpart H approval was
unlawful because:
Pregnancy is not an “illness,”
and
Drugs for medication
abortion “do not provide a
‘meaningful therapeutic
benefit’” above surgical
abortion.
 
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61
 
S
t
a
n
d
i
n
g
Plaintiffs need to initially prove a concrete and
particularized injury has occurred, or imminently will
occur, that is traceable back to the defendant.
 
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,
 
2
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2
3
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62
 
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l
 
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(
1
8
7
3
)
:
 
“Every article or thing designed, adapted, or
intended for producing abortion, or for
any indecent or immoral use; and . . .
 
Every article, instrument, substance, drug,
medicine, or thing which is advertised or described
in a manner calculated to lead another to use or
apply it for producing abortion, or for
any indecent or immoral purpose; . . .
 
Is declared to be nonmailable matter and shall not
be conveyed in the mails or delivered from any post
office or by any letter carrier.”
 
18 U.S.C. §1461.
 
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.
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,
 
2
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2
3
)
 
63
 
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K
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.
 
The court preliminarily enjoined FDA from
“altering the status quo and rights as it relates to
the availability of Mifepristone” in the 17
challenging states and Washington, D.C.
 
W
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64
 
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h
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r
e
 
d
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,
 
l
e
g
a
l
l
y
?
 
65
 
E
m
e
r
g
e
n
c
y
 
M
e
d
i
c
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l
 
T
r
e
a
t
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c
t
 
(
E
M
T
A
L
A
)
P
A
T
H
W
A
Y
:
EMTALA requires most U.S. hospitals to provide screening & stabilizing
emergency care. On July 11, 2022, 
HHS confirmed 
that physicians may
conclude life-saving abortion care is necessary under EMTALA when
pregnant patients present with an “emergency medical condition” (EMC).
EMTALA expressly preempts conflicting state laws
.
 
C
O
V
E
R
A
G
E
:
Pregnant patients with an EMC
necessitating abortion as treatment
at most hospitals.
 
C
A
V
E
A
T
S
:
Litigation may determine 
what is
considered an EMC
 or how state &
federal laws intersect. In select
challenges (TX, ID), 
federal courts
have issued contradictory opinions
.
undefined
 
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Explore the key issues surrounding public health preemption and its implications on health justice through insights from experts like Moderator Amy Cook and Presenters Jennifer L. Piatt, Sabrina Ruchelli, Sterling Johnson, and Adam Herpolsheimer. Discover how state preemption laws can influence health outcomes and why law is considered a social determinant of health, affecting communities unequally. Delve into legal epidemiology and policy surveillance to evaluate the impact of law on health systematically.


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  1. Public Healths Preemption Problem: Key Health Justice Impacts and Updates April 12, 2023

  2. Moderator Amy Cook, J.D., Senior Law and Policy Analyst, Center for Public Health Law Research, Temple University Beasley School of Law 2

  3. Presenter Jennifer L. Piatt, J.D., Deputy Director, Network for Public Health Law Western Region Office 3

  4. Presenter Sabrina Ruchelli, J.D., Law and Policy Analyst, Center for Public Health Law Research, Temple University Beasley School of Law 4

  5. Presenter Sterling Johnson, J.D., Center for Public Health Law Research, Temple University Beasley School of Law; Ph.D. Student, Geography & Urban Studies, Temple University 5

  6. Presenter Adam Herpolsheimer, J.D., Law and Policy Analyst, Center for Public Health Law Research, Temple University Beasley School of Law 6

  7. State Preemption Laws Sabrina Ruchelli, JD CENTER FOR PUBLIC HEALTH LAW RESEARCH April 12, 2023

  8. Law is a social determinant of health. Law shapes behaviors and environments, but the effects of laws are not equitably distributed among our communities.

  9. The Center for Public Health Law Research supports the widespread adoption of scientific tools and methods for mappingand evaluatingthe impact of law on health.

  10. Legal epidemiology The scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population.

  11. Policy surveillance The systematic collection, analysis, and dissemination of laws and policies across jurisdictions or institutions, and over time.

  12. The Policy Surveillance Process Defining the Project Scope Tracking & Updating the Law Background Research Quality Control Developing Coding Questions Publication & Dissemination Collecting Law & Creating Legal Text Coding the Law

  13. What is Preemption? Federal State Legal doctrine permitting higher levels of government to usurp lawmaking authority from lower levels Local E.g., minimum wage laws 13

  14. State Authority to Preempt Dillon s Rule Narrowly defines local authority Local governments only possess authority delegated by the state Home Rule Generally, more permissive than Dillon s rule 14

  15. Forms of Preemption States can preempt local governments by: CEILING Setting a minimum or maximum legal standard Preempting local control in an entire area of law FIELD FLOOR 15

  16. Punitive Preemption Imposes civil and criminal penalties or removal from public office when public officials propose or enact legislation that exceeds local lawmaking authority 16

  17. Preemption and Firearms 17

  18. The State Preemption Project was a collaboration between the Center for Public Health Law Research and the National League of Cities. Support was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

  19. Preemption Project Longitudinal dataset (August 1, 2019 to November 1, 2022) analyzing and tracking preemption laws in 15 domains across the country Updated annually, next update coming in late 2023 National League of Cities uses legal data to shape discussion and increase awareness of state preemption and provides supports to thwart state preemptive activity Housed with free, open-access on Lawatlas.org 19

  20. Preemption Domains Ban the Box Firearms Mandatory inclusionary zoning Municipal broadband Mandatory paid leave Rent control Full disclosure tax requirements General revenue limits General expenditure limits 10. Property tax rate limits 11. Tax assessment limits 12. Tax levy limits 13. Transgender rights 14. Local law enforcement budgets 15. Race and racism in school curriculum 1. 9. 2. 3. 4. 5. 6. 7. 8. 20

  21. 2022 Updates Four states (Florida, Georgia, Missouri, and Texas) passed laws preempting local control over police budgets Three states (Alabama, New Hampshire, and Utah) added new preemptive elements to their laws related to local regulation of firearms One state (Ohio) passed a new law prohibiting local governments from passing any laws imposing rent control or rent stabilization on private landlords Figure 1. Firearms Preemption as of November 1, 2022 Figure 2. Rent Control Preemption as of November 1, 2022 21

  22. Race and Racism in the Classroom Sterling Johnson JD, MA April 12, 2023 CENTER FOR PUBLIC HEALTH LAW RESEARCH

  23. Race and Racism in the Classroom Preemption Context

  24. Race and Racism in the Classroom Black History as U.S. History

  25. Source: Orange County Regional History Center Source: University of Florida

  26. Race and Racism in the Classroom Anti- Critical Race Theory Laws

  27. Black History Education as Critical Race Theory

  28. 30

  29. Broad Categories Prohibited from Being Taught in Classrooms The U.S. is fundamentally racist or sexist Meritocracy or traits such as a hard work ethic are racist or sexist or were created by a particular race to oppress another race Any individual should feel discomfort, guilt, anguish, or any other form of psychological distress on account of his or her race or sex An individual, by virtue of his or her race or sex, bears responsibility for actions committed in the past by other members of the same race or sex "Divisive concepts" or "controversial issues Racial scapegoating 31

  30. CRT Book Bans 32

  31. Race and Racism in the Classroom Real-world Impact

  32. Florida Education Guidelines Source: Getty Images 34

  33. Transgender Rights and Preemption CENTER FOR PUBLIC HEALTH LAW RESEARCH APR 12, 2023

  34. For the last couple of decades, transgender rights have been ostensibly under attack. The rise in laws and regulations infringing on these rights have grown exponentially in the last few years. Not all anti-trans laws are preemptive, but the usage of preemption as an anti-trans tactic is prevalent and especially worrying.

  35. Types of anti-trans preemption laws

  36. Anti- Discrimination Protections as of November 1, 2022. These bills are especially sinister as they prevent localities from protecting a vulnerable population. North Carolina s HB2 is the most prominent example, even though the Bathroom Bill section stole all the headlines.

  37. Prohibiting adding gender identity as a protected class Two states currently Arkansas Tennessee North Carolina (HB2) finally and completely repealed in 2019. Attempts to safeguard: Michigan Ballot initiative court case (https://ballotpedia.org). Five more states have introduced bills since 2021 (https://www.tracktranslegislation.com/). 40

  38. Rights in the School Setting as of November 1, 2022. As is often the case with moral panics, the alleged corrupted youth is the target. And given the state s control over education, this is the avenue for which most preemption related anti-trans legislation are occurring. This is occurring both in and out of the classroom.

  39. Inclusive School Curriculum and Parental Bills of Rights* Four States - Curriculum Texas Arkansas Alabama Florida Three states Parental Bills of Rights Arizona Alabama Florida Altogether 87 bills involving education have been so far introduced in 2023 (https://www.tracktranslegislation.com/). *other states have also enacted parental bills of rights, but these three states laws specifically invovle mental health and the ability for children to socially transition 42

  40. Participation in Sports Nineteen states (AL, AZ, AR, FL, GA, ID, IA, IN, KY, LA, MS, MT, OK, SC, SD, TX, TN, UT, WV) Eleven states passed bills in 2022 alone Three states had bills fail in 2022 (KS, WI, WY) According to other sources, four more bills have passed in 2023 (both Kansas and Wyoming overcoming previous failure) (https://www.tracktranslegislation.com/) 43

  41. Single-Sex or Sex-Segregated Spaces (Bathroom Bills) Oklahoma, North Carolina (HB2), Alabama The bills in Oklahoma and Alabama apply in the school setting whereas North Carolina s law applied in any public facility Since our research, Arkansas and Idaho have both passed school bathroom bill. HB2 represents how far these types of bans can be taken. 44

  42. Gender- Affirming Care as of November 1, 2022. Restrictions are not limited to schools and anti-discrimination protections. The most worrisome trend we are seeing are states prohibiting gender-affirming care in its entirety for transgender youth.

  43. Prohibitions of Gender-Affirming Care for Trans Youth (and sometimes adults ) Only Arkansas preempted as of November 1. In lieu of an outright ban, Arkansas banned using public funds for gender-affirming care and anyone in state or county-owned facilities from providing care. Two states have followed suit (AZ and MS) while nine states have passed non- preemptive bans (AL, FL, GA, ID, IN, SD, TN, UT, and WV) (https://blog.petrieflom.law.harvard.edu/2023/03/22/trans-antagonism-creates-space-for- the-worst-side-of-the-law/ GA, ID, and IN all enacting bills in the three weeks since I wrote that blogpost https://www.tracktranslegislation.com/). 46

  44. How We Can Move Forward

  45. 490+ Anti-Trans Bills in 2023 Source: https://translegislation.com/

  46. Activism and Advocacy Reactive:Each time a law is passed, organizations like the ACLU, National Center for Transgender Equality, Lambda Legal, Transgender Legal Defense & Education Fund, National Center for Lesbian Rights and others have lawsuits ready to go challenging the constitutionality of these laws. Proactive:Organizers across the country attend and broadcast committee hearings and legislative sessions when proposed bills are on the docket. Giving testimony, raising community concerns, and even protesting state legislatures themselves is proving invaluable to this fight. 49

  47. Resources Law and Bill Tracking https://lawatlas.org/datasets/preemption-project https://www.tracktranslegislation.com/ https://translegislation.com/ https://www.aclu.org/legislative-attacks-on-lgbtq-rights Organizers and Commentators Erin Reed (Activist following state legislature movement) https://twitter.com/ErinInTheMorn Alejandra Caraballo (Lawyer and clinical instructor) - https://twitter.com/Esqueer_ Ari Drennen (Media Matters journalist) https://twitter.com/AriDrennen Allison Chapman (Legislative researcher) - https://twitter.com/AlliRaine22 50

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