1. State Variation in Health Insurance
Coverage Among Same-Sex Couples
Gilbert Gonzales
Gender and Health Interest Group Meeting
Orlando, FL
June 23, 2012
Funded by a grant from the Robert Wood Johnson Foundation

2. Background: Who are same-sex couples?
• Sexual minorities
Gay, Lesbian, Bisexual, Transgender (GLBT)
• Partnered
Married
Civil Union
Domestic Partnership
Unmarried, but cohabitating
2

3. States differ in their policies on same-sex couples
3

4. 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
4

5. The role of employers
Large employers (500+ employees) offering same-sex domestic partner
benefits
39% 39%
34% 34%
29%
27%
24%
21%
19%
16%
12%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans
5

6. Improvements vary by region
Same-sex domestic partner coverage among large employers (500+ employees)
64%
59% 2009
52% 2010
49%
39% 39%
28% 26% 27%
24%
All large West Midwest Northeast South
employers
Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans
6

7. 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.
7

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)
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)
• What can the American Community Survey tell us
about national and regional disparities in health
insurance coverage?
9

10. Methods
1. Multinomial Logit: Marginal Effects
Yij = α + β1Maritali + βiXi + ε
2. State-Level Coverage Estimates
3. Coverage Across the Life Continuum
10

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.
11

12. 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
12

13. 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

14. Larger sample size compared to previous studies
Non-elderly adults in same-sex relationships
17,420
16,235
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
14

15. Economic Characteristics
66% Same-Sex Couples
62%
Married Opposite-Sex Couples
52%
Unmarried Opposite-Sex Couples
45%
33%
21%
15%
8% 9% 8%
5% 4%
≥ College Degree Full-Time Unemployment In Poverty
Employment
15

16. Demographic Characteristics
Same-Sex Couples
77%
71% Married Opposite-Sex Couples
66%
Unmarried Opposite-Sex Couples
23% 25%25%
17% 17%
14% 12%
11% 11%
7% 8% 7%
Age 55-65 White Black Hispanic Minor Child in
Household
16

17. Marginal Effects: Men
Compared to married men in opposite-sex relationships
16%
6%
Employer 1% 1%
0%
Uninsured Individual Medicaid
-8%
Same-Sex Couples
-16%
Controls: Race/ethnicity, age, employment, industry, income,
region, citizenship, minor child, survey year
17

18. Marginal Effects: Women
Compared to married women in opposite-sex relationships
16%
6% 6%
Employer 1%
0%
Uninsured Individual Medicaid
-9%
Same-Sex Couples
-16%
Controls: Race/ethnicity, age, employment, industry, income,
region, citizenship, minor child, survey year
18

19. State Variation in Insurance Coverage
(Public & Private) among Same-Sex Couples
19

20. Coverage Gaps in Insurance Coverage
Compared to Married Opposite-Sex Couples
20

21. State Variation in ESI Coverage
21

22. Coverage Gaps in ESI
Compared to Married Opposite-Sex Couples
22

23. 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
23

24. 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
24

25. 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

26. 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
26

27. 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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