Funded by a grant from the Robert Wood Johnson Foundation

State Variation in Health Insurance

Coverage Among Same-Sex Couples

Gilbert Gonzales

Gender and Health Interest Group Meeting

Orlando, FL

June 23, 2012

Background: Who are same-sex couples?

• Sexual minorities

Gay, Lesbian, Bisexual, Transgender (GLBT)

• Partnered

Married

Civil Union

Domestic Partnership

Unmarried, but cohabitating

2

States differ in their policies on same-sex couples

3

Why does marriage matter?

• Most Americans are covered through a family

member’s employer health plan

“Legal” spouse

Dependent children

4

Example: University of Minnesota, Office of Human Resources

The role of employers

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

benefits

5

12%

16% 19%

21% 24%

27% 29%

34% 34%

39% 39%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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

Improvements vary by region

39%

52%

28%

59%

24%

39%

64%

26%

49%

27%

All large

employers

West Midwest Northeast South

2009

2010

6

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

Same-sex domestic partner coverage among large employers (500+ employees)

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)

7

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)

8

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?

9

Methods

1. Multinomial Logit: Marginal Effects

Yij = α + β1Maritali + βiXi + ε

2. State-Level Coverage Estimates

3. Coverage Across the Life Continuum

10

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.

11

Control Variables & Outcomes

• Educational attainment

• Age

• Sex

• Race

• Employment

• Hours Worked

• Industry

• Own child in household

• Citizenship

12

• 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

13

Larger sample size compared to previous studies

Non-elderly adults in same-sex relationships

14

316 486

2,384

16,235

298 478

2,881

17,420

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

45%

66%

5% 9%

33%

62%

4% 8%

21%

52%

8%

15%

≥ College Degree Full-Time

Employment

Unemployment In Poverty

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

15

Demographic Characteristics

17%

77%

8% 11% 12%

23%

71%

7%

14%

25%

7%

66%

11%

17%

25%

Age 55-65 White Black Hispanic Minor Child in

Household

Same-Sex Couples

Married Opposite-Sex Couples

Unmarried Opposite-Sex Couples

16

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

6%

-8%

1% 1%

-16%

0%

16%

Same-Sex Couples

17

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

18

Uninsured

Employer

Individual Medicaid

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

region, citizenship, minor child, survey year

State Variation in Insurance Coverage

(Public & Private) among Same-Sex Couples

19

Coverage Gaps in Insurance Coverage

Compared to Married Opposite-Sex Couples

20

State Variation in ESI Coverage

21

Coverage Gaps in ESI

Compared to Married Opposite-Sex Couples

22

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

23

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

24

Summary

• Men and women in same-sex couples are

roughly 10% less likely to be insured through

an employer

• Same-sex couples have lower rates of

coverage than married, opposite-sex couples

in all but 7 states

• Across the life continuum, partnered sexual

minorities are less likely than their married

peers to be covered by an employer

25

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 strategy to attract

employees

• Repealing DOMA could remove barriers to

coverage for same-sex couples

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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