Post on 21-Jun-2015
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
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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