Pres apha oct31_gonzales

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Pres apha oct31_gonzales

  1. 1. State Variation in Health InsuranceCoverage Among Same-Sex CouplesGilbert Gonzales, MHAAmerican Public Health AssociationSan Francisco, CAOctober 31, 2012 Funded by a grant from the Robert Wood Johnson Foundation
  2. 2. Disclosures• No relationships to disclose 2
  3. 3. Background: Who are same-sex couples?• Sexual minorities Lesbian, Gay & Bisexual (LGB)• Partnered Married Civil Union Domestic Partnership Unmarried, but cohabitating 3
  4. 4. States differ in their policies on same-sex couples 4
  5. 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. 6. The role of employersLarge employers (500+ employees) offering same-sex domestic partnerbenefits 46% 39% 39% 34% 34% 29% 27% 24% 21% 19% 16% 12% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans 6
  7. 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 employersSource: 2011 Mercer National Survey of Employer-Sponsored Health Plans 7
  8. 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. 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. 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. 11. Methods1. Multinomial Logistic Regression Yij = α + β1Maritali + βiXi + ε2. Adjusted State-Level Coverage Estimates3. Coverage Across the Life Continuum 11
  12. 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. 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. 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. 15. Larger sample size compared to previous studiesNon-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. 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. 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. 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. 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. 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. 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
  22. 22. Where are the coverage gaps? 22
  23. 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. 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. 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. 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
  27. 27. “Prevention and Wellness Across the Life Span” 27
  28. 28. Uninsurance over the Life Continuum 50% 45% 40% Same-Sex Couples 35% Married Opposite-Sex CouplesUninsured 30% 25% 20% 15% 10% 5% 0% 20 30 40 50 60 70 80 90 Age 28
  29. 29. ESI over the Life Continuum 80% Same-Sex CouplesEmployer-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. 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. 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. 32. Gilbert Gonzales, MHA Doctoral Student Graduate Research Assistant gonza440@umn.edu University of Minnesota School of Public HealthDivision of Health Policy & ManagementSign up to receive our newsletter and updates at www.shadac.org @shadac

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