Funded by a grant from the Robert Wood Johnson Foundation

State Variation in Health Insurance

Coverage Among Same-Sex Couples

Gilbert Gonzales, MHA

American Public Health Association

San Francisco, CA

October 31, 2012

Disclosures

• No relationships to disclose

2

Background: Who are same-sex couples?

• Sexual minorities

Lesbian, Gay & Bisexual (LGB)

• Partnered

Married

Civil Union

Domestic Partnership

Unmarried, but cohabitating

3

States differ in their policies on same-sex couples

4

Why does marriage matter?

• Most Americans are covered through a family

member’s employer health plan

“Legal” spouse

Dependent children

5

Example: University of Minnesota, Office of Human Resources

The role of employers

Large employers (500+ employees) offering same-sex domestic partner

benefits

6

12%

16% 19%

21% 24%

27% 29%

34% 34%

39% 39%

46%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans

Improvements vary by region

39%

52%

28%

59%

24%

39%

64%

26%

49%

27%

46%

79%

34%

55%

28%

All large

employers

West Midwest Northeast South

2009

2010

2011

7

Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans

Federal barriers to coverage

• Defense of Marriage Act (DOMA)

Does not recognize same-sex unions at the federal level

Insurance for same-sex spouses treated as taxable income (adds $1,000 annually)

• Employee Retirement Income Security Act (ERISA)

Self-insured employers are regulated by the federal government, not states

Health insurance coverage is mandated for same-sex spouses in 16 states, but state mandates only reach fully-insured employers (42% private employees)

8

Source: Badget MVL. The economic value of marriage for same-sex couples. Drake Law Review. 2010.

What are the outcomes?

• Men and women in same-sex couples are less

likely to have health insurance

BRFSS (Buchmueller & Carpenter, 2010)

CPS (Ash & Badget, 2006)

NHIS (Heck et al., 2006)

9

What are the outcomes?

• Men and women in same-sex couples are less

likely to have health insurance

BRFSS (Buchmueller & Carpenter, 2010)

CPS (Ash & Badget, 2006)

NHIS (Heck et al., 2006)

• What can the American Community Survey tell us

about national and regional disparities in health

insurance coverage?

10

Methods

1. Multinomial Logistic Regression

Yij = α + β1Maritali + βiXi + ε

2. Adjusted State-Level Coverage Estimates

3. Coverage Across the Life Continuum

11

GLB Inclusion in the American Community Survey

• Same-sex spouses / unmarried partners

• What is an unmarried partner?

An “unmarried partner,” also known as a domestic partner, is a

person who shares a close personal relationship with Person 1.

12

Control Variables & Outcomes

• Educational attainment

• Age

• Sex

• Race

• Employment

• Hours Worked

• Industry

• Own child in household

• Citizenship

13

• Health Insurance

• Employer-Sponsored

Insurance (ESI)

• Individual

• Medicare

• Medicaid

• Uninsured

Limitations to the ACS

• Missing Information • Sexual orientation and gender identity

• Health status

• Firm size

• Source of coverage (own ESI or dependent)

• Missing Same-Sex Couples • If identified as roommates or unrelated adults

• If neither is the respondent

14

Larger sample size compared to previous studies

Non-elderly adults in same-sex relationships

15

316 486

2,384

15,529

298 478

2,881

16,418

Men

Women

NHIS

1997-2003 Heck et al. 2006

BRFSS

2000-2007 Buchmueller &

Carpenter 2010

CPS

1996-2003 Ash & Badget 2006

ACS

2008-2010 Gonzales, forthcoming

Economic Characteristics: Men

48%

71%

5% 4%

34%

77%

5% 8%

18%

68%

10% 13%

≥ College Degree Full-Time

Employment

Unemployment In Poverty

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

16

Economic Characteristics: Women

47%

67%

5% 6%

34%

47%

4% 8%

23%

55%

7%

13%

≥ College Degree Full-Time

Employment

Unemployment In Poverty

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

17

Demographic Characteristics: Men

20%

77%

5%

12% 12% 18%

70%

8%

15%

50%

43%

63%

14% 19%

40%

Age 25-34 White Black Hispanic Minor Child in

Household

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

18

Demographic Characteristics: Women

22%

77%

7% 11%

25% 20%

71%

7%

14%

48% 45%

65%

11%

18%

40%

Age 25-34 White Black Hispanic Minor Child in

Household

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

19

Marginal Effects: Men Compared to married men in opposite-sex relationships

6%

-8%

1% 2%

-16%

0%

16%

Same-Sex Couples

20

Uninsured

Employer

Individual Medicaid

Controls: Race/ethnicity, age, employment, industry, income,

region, citizenship, minor child, survey year

Marginal Effects: Women Compared to married women in opposite-sex relationships

6%

-9%

1%

6%

-16%

0%

16%

Same-Sex Couples

21

Uninsured

Employer

Individual Medicaid

Controls: Race/ethnicity, age, employment, industry, income,

region, citizenship, minor child, survey year

Where are the coverage gaps?

22

Coverage Gaps in Any Insurance: Men in SS relationships vs. Married Men in OS Relationships

23

Not available

RD: 0-10%

RD: > 10%

Same-sex couples

better off

Coverage Gaps in ESI: Men in SS relationships vs. Married Men in OS Relationships

24

Not available

RD: 0-10%

RD: > 10%

Same-sex couples

better off

Coverage Gaps in Any Insurance: Women in SS relationships vs. Married Women in OS relationships

25

Not available

RD: 0-10%

RD: > 10%

Same-sex couples

better off

Coverage Gaps in ESI: Women in SS relationships vs. Married Women in OS relationships

26

Not available

RD: 0-10%

RD: > 10%

Same-sex couples

better off

“Prevention and Wellness

Across the Life Span”

27

Uninsurance over the Life Continuum

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

20 30 40 50 60 70 80 90

Un

insu

red

Age

Same-Sex Couples

Married Opposite-Sex Couples

28

ESI over the Life Continuum

0%

10%

20%

30%

40%

50%

60%

70%

80%

20 30 40 50 60 70 80 90

Em

plo

yer-

Sp

on

sore

d I

nsu

ran

ce

Age

Same-Sex Couples

Married Opposite-Sex Couples

29

Summary

• Men and women in same-sex couples are

roughly 10% less likely to be insured through

an employer

• Largest ESI coverage gaps located in the South

for men and in the Midwest for women

• Across the life continuum, partnered sexual

minorities are less likely than their married

peers to be covered by an employer

30

Policy Implications

• Potential for states to require fully insured

employers to extend benefits to same-sex

spouses

• Employers can voluntarily expand coverage to

same-sex spouses as a strategy to attract

employees

• Repealing DOMA could remove barriers to

coverage for same-sex couples

31

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Gilbert Gonzales, MHA

Doctoral Student

Graduate Research Assistant

gonza440@umn.edu

University of Minnesota

School of Public Health

Division of Health Policy & Management