1. State Variation in Health Insurance
Coverage Among Same-Sex Couples
Gilbert Gonzales, MHA
American Public Health Association
San Francisco, CA
October 31, 2012
Funded by a grant from the Robert Wood Johnson Foundation
3. Background: Who are same-sex couples?
• Sexual minorities
Lesbian, Gay & Bisexual (LGB)
• Partnered
Married
Civil Union
Domestic Partnership
Unmarried, but cohabitating
3
5. Why does marriage matter?
• Most Americans are covered through a family
member’s employer health plan
“Legal” spouse
Dependent children
Example: University of Minnesota, Office of Human Resources
5
6. The role of employers
Large employers (500+ employees) offering same-sex domestic partner
benefits
46%
39% 39%
34% 34%
29%
27%
24%
21%
19%
16%
12%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans
6
7. Improvements vary by region
79%
2009
2010
64%
2011
59%
55%
52%
49%
46%
39% 39%
34%
28% 26% 27% 28%
24%
All large West Midwest Northeast South
employers
Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans
7
8. 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)
Source: Badget MVL. The economic value of marriage for same-sex couples. Drake Law Review. 2010.
8
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)
9
10. 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
11. Methods
1. Multinomial Logistic Regression
Yij = α + β1Maritali + βiXi + ε
2. Adjusted State-Level Coverage Estimates
3. Coverage Across the Life Continuum
11
12. 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
13. Control Variables & Outcomes
• Educational attainment • Health Insurance
• Age • Employer-Sponsored
Insurance (ESI)
• Sex
• Individual
• Race • Medicare
• Employment • Medicaid
• Hours Worked • Uninsured
• Industry
• Own child in household
• Citizenship
13
14. 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
15. Larger sample size compared to previous studies
Non-elderly adults in same-sex relationships
16,418
15,529
Men
Women
2,881
2,384
316 298 486 478
NHIS CPS BRFSS ACS
1997-2003 1996-2003 2000-2007 2008-2010
Heck et al. 2006 Ash & Badget 2006 Buchmueller & Gonzales, forthcoming
Carpenter 2010
15
16. Economic Characteristics: Men
Same-Sex Couples
77%
71% Married Opposite-Sex Couples
68%
Unmarried Opposite-Sex Couples
48%
34%
18%
13%
10% 8%
5% 5% 4%
≥ College Degree Full-Time Unemployment In Poverty
Employment
16
17. Economic Characteristics: Women
Same-Sex Couples
67%
Married Opposite-Sex Couples
55% Unmarried Opposite-Sex Couples
47% 47%
34%
23%
13%
5% 4%
7% 6% 8%
≥ College Degree Full-Time Unemployment In Poverty
Employment
17
18. Demographic Characteristics: Men
Same-Sex Couples
77%
70% Married Opposite-Sex Couples
63%
Unmarried Opposite-Sex Couples
50%
43%
40%
20%18% 19%
14% 15% 12%
12%
5% 8%
Age 25-34 White Black Hispanic Minor Child in
Household
18
19. Demographic Characteristics: Women
Same-Sex Couples
77%
71% Married Opposite-Sex Couples
65%
Unmarried Opposite-Sex Couples
48%
45%
40%
25%
22%20%
18%
14%
11% 11%
7% 7%
Age 25-34 White Black Hispanic Minor Child in
Household
19
20. Marginal Effects: Men
Compared to married men in opposite-sex relationships
16%
6%
2%
1%
Employer
0%
Uninsured Individual Medicaid
-8%
Same-Sex Couples
-16%
Controls: Race/ethnicity, age, employment, industry, income,
region, citizenship, minor child, survey year
20
21. Marginal Effects: Women
Compared to married women in opposite-sex relationships
16%
6% 6%
1%
Employer
0%
Uninsured Individual Medicaid
-9%
Same-Sex Couples
-16%
Controls: Race/ethnicity, age, employment, industry, income,
region, citizenship, minor child, survey year
21
23. Coverage Gaps in Any Insurance:
Men in SS relationships vs. Married Men in OS Relationships
Not available
RD: 0-10%
RD: > 10%
Same-sex couples
better off
23
24. Coverage Gaps in ESI:
Men in SS relationships vs. Married Men in OS Relationships
Not available
RD: 0-10%
RD: > 10%
Same-sex couples
better off
24
25. Coverage Gaps in Any Insurance:
Women in SS relationships vs. Married Women in OS relationships
Not available
RD: 0-10%
RD: > 10%
Same-sex couples
better off
25
26. Coverage Gaps in ESI:
Women in SS relationships vs. Married Women in OS relationships
Not available
RD: 0-10%
RD: > 10%
Same-sex couples
better off
26
28. Uninsurance over the Life Continuum
50%
45%
40% Same-Sex Couples
35%
Married Opposite-Sex Couples
Uninsured
30%
25%
20%
15%
10%
5%
0%
20 30 40 50 60 70 80 90
Age
28
29. ESI over the Life Continuum
80% Same-Sex Couples
Employer-Sponsored Insurance
70% Married Opposite-Sex Couples
60%
50%
40%
30%
20%
10%
0%
20 30 40 50 60 70 80 90
Age
29
30. 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
31. 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
32. Gilbert Gonzales, MHA
Doctoral Student
Graduate Research Assistant
gonza440@umn.edu
University of Minnesota
School of Public Health
Division of Health Policy & Management
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