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  • 1. HEALTH INSURANCE COVERAGE AMONG SAME-SEX COUPLES: DISPARITIES AND TRENDS UNDER DOMA Gilbert Gonzales, MHA University of Minnesota American Public Health Association Social Contexts and Social Determinants of LGBT Health Monday, November 4, 2013
  • 2. Disclosure Statement Click to edit Master title style Click to edit Master text styles No Second level to disclose relationships Third level Fourth level Fifth level 2
  • 3. Acknowledgments Click to edit Master title style Click to edit Master text styles Co-Authors: Second level Department of Sociology Ryan Moltz, Third level Miriam King, Minnesota Population Center Fourth level Fifth Minnesota University oflevel 3
  • 4. State marriage policy rapidly Click to edit Master title style evolving Click to edit Master text styles Second level Third level Fourth level Fifth level Source: National Conference of State Legislatures 4
  • 5. Why to edit Master matter? Clickdoes marriage title style Most to edit Master covered Click Americans aretext stylesthrough a family member’s employer health plan Second level  “Legal” Third level spouse Fourth level  Dependent children Fifth level 5
  • 6. More to edit Master title style Click employers extending insurance Large employers (500+ employees) offering same-sex domestic partner Click to edit Master text styles benefits Second level 46% 47% Third level 39% 39% Fourth level Fifth level 16% 19% 21% 24% 34% 34% 27% 29% 12% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: 2012 Mercer National Survey of Employer-Sponsored Health Plans 6
  • 7. Federal edit Master title style Click to policies limited state action Employee Retirement Income Security Act (ERISA) Click to edit Master text styles  Health insurance coverage is mandated for same-sex spouses Second level in 16 states, but state mandates only affect fully-insured Third level employers (42% employees) Fourth level  Self-insuredlevel Fifth employers are regulated by the federal government, not states Defense of Marriage Act (DOMA), 1996-2013  Did not recognize same-sex unions at the federal level  Insurance for same-sex spouses treated as taxable income (adds $1,000 annually) Source: Badget MVL. The economic value of marriage for same-sex couples. Drake Law Review. 2010. 7
  • 8. The latest trend Click to edit Master title style Droppingedit Master text styles state marriage reform Click to domestic partners following Second level Third level Fourth level Fifth level 8
  • 9. Research Questions Click to edit Master title style Is private Master insurance Click to edit health text styles coverage improving for same-sex couples? Second level Third level Fourth level Fifth level Are there differences in health insurance coverage between married and unmarried same-sex couples? 9
  • 10. Data Click to edit Master title style Nationaledit Master text styles (NHIS), 1997-2012 Click to Health Interview Survey Second level Non-elderly (25-64 years) partnered adults • Third level 487,561 opposite-sex married spouses Fourth level • 56,807 opposite-sex unmarried partners Fifth level • 667 same-sex spouses • 4,005 same-sex unmarried partners Health Insurance • Policy holder: Employer-sponsored insurance (ESI) • Dependent: Employer-sponsored insurance (ESI) • Directly Purchased from Insurer • Public Insurance (Medicaid & Medicare) • Uninsured 10
  • 11. Methods Click to edit Master title style • Trends in uninsurance by relationship type Click to edit Master text styles Second level Third level • Distributional changes in insurance coverage type Fourth level Fifth level • Multivariate analysis • • Logistic regression analysis estimating odds of uninsurance Adjusted for age, race and ethnicity, education, poverty status, employment, region, presence of a child in household, health status and year 11
  • 12. Uninsurance increases among most couples Click to edit Master title style Click Different-Sex Married styles to edit Master text 40% 35% 30% 25% Same-Sex Men Second level Third level 32% Different-Sex Unmarried Same-Sex Women 33% 34% Fourth level Fifth level 34% 24% 21% 18% 20% 20% 18% 17% 15% 16% 10% 12% 13% 13% 1997-2000 2001-2004 2005-2008 18% 14% 5% 2009-2012 Notes: Same-sex couples include all adults that identify another person in the household of the same sex as a husband, wife or unmarried partner. Source: National Health Interview Survey, 1997-2012. 12
  • 13. Men in to edit Master title style likely to Click same-sex relationships less have ESI as policy holders Click to edit Master text styles 70% 60% Second level Third level Fourth level Fifth level 50% 40% 30% 21% 1997-2000 58% 2009-2012 50%* 24% 20% 9% 10% 12% 7% 4% 5% 9% * 0% Uninsured ESI Policy Holder ESI Dependent Directly Purchased Public Source: National Health Interview Survey, 1997-2012. Notes: * indicates p<0.05; **p<0.01 13
  • 14. Women inedit Master title stylemore likely Click to same-sex relationships to have ESI as a dependent Click to edit Master text styles 60% 50% Second level 56% 55% Third level 1997-2000 2009-2012 Fourth level Fifth level 40% 30% 20% 20% 18% 12% 14% 10% 4% 3% 7% 11% 0% Uninsured ESI Policy Holder ESI Dependent Directly Purchased Public Source: National Health Interview Survey, 1997-2012. Notes: * indicates p<0.05; **p<0.01 14
  • 15. Odds Ratio of Being Uninsured, Men Click to edit Master title style Opposite-Sex Married Same-Sex Click to edit Master text stylesUnmarried Second level Same-Sex Married 3.14 * Third level 2.65* Fourth level Fifth level 1.71 1.00 1997-2000 1.00 2009-2012 15
  • 16. Odds Ratio of Being Uninsured, Women Click to edit Master title style Opposite-Sex Married Same-Sex Click to edit Master text stylesUnmarried Same-Sex Married Second level 2.98 Third level * Fourth level Fifth level 1.71 * 1.34 1.00 1997-2000 1.00 2009-2012 16
  • 17. Key Findings Click to edit Master title style • Uninsurance has been increasing for all Click to edit Master text styles couples—except for women in same-sex Second level relationships Third level Fourth level adultslevel same-sex in Fifth • More relationships are covered by another person’s health plan as a dependent • Unmarried same-sex couples still more likely to be uninsured 17
  • 18. Click to Gilbert Gonzales, MHA edit Master title style Click to edit Master textPhD Student styles Second level Third level Graduate Research Assistant gonza440@umn.edu Fourth level Fifth level University of Minnesota School of Public Health Division of Health Policy & Management www.shadac.org @shadac