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Pres paa apr12_gonzales

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  • 1. Funded by a grant from the RobertWood Johnson Foundation State Variation in Health Insurance Coverage Among Same-Sex Couples Gilbert Gonzales, MHA Population Association of America New Orleans, LA April 12, 2013
  • 2. Background: Who are same-sex couples? • Sexual minorities Lesbian, Gay & Bisexual (LGB) • Partnered Married Civil Union Domestic Partnership Unmarried, but cohabitating 2
  • 3. States differ in their policies on same-sex couples 3 Source: National Conference of State Legislatures
  • 4. 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
  • 5. 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% 46% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: 2011 Mercer National Survey of Employer-Sponsored Health Plans
  • 6. Federal barriers to coverage • Employee Retirement Income Security Act (ERISA)  Health insurance coverage is mandated for same-sex spouses in 16 states, but state mandates only affect fully- insured employers (42% employees)  Self-insured employers are regulated by the federal government, not states • 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) 6 Source: Badget MVL. The economic value of marriage for same-sex couples. Drake Law Review. 2010.
  • 7. 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) 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) • What can the American Community Survey tell us about national and regional disparities in health insurance coverage? 8
  • 9. Methods 1. National-level disparities 2. Adjusted state-level disparities in ESI 3. Adjusted disparities in ESI by state marriage policy 9
  • 10. GLB Population in the ACS • Same-sex spouses / unmarried partners 10
  • 11. Control Variables & Outcomes • Educational attainment • Age • Sex • Race • Employment • Hours Worked • Industry • Own child in household • Citizenship 11 • Health Insurance • Employer-Sponsored Insurance (ESI) • Individual • Medicare • Medicaid • Uninsured
  • 12. 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 12
  • 13. Economic Characteristics 48% 71% 5% 4% 34% 77% 5% 8% 18% 68% 10% 13% ≥ College Degree Full-Time Employment Unemployment In Poverty Same-Sex Couples Married Opposite-Sex Couples Unmarried Opposite-Sex Couples 13
  • 14. Demographic Characteristics 20% 77% 5% 12% 12% 18% 70% 8% 15% 50% 43% 63% 14% 19% 40% Age 25-34 White Black Hispanic Minor Child in Household Same-Sex Couples Married Opposite-Sex Couples Unmarried Opposite-Sex Couples 14
  • 15. Disparities in Insurance: Men Compared to married men in opposite-sex relationships 15 Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010. * indicates p<0.05 0.58 0.75 1.31 1.04 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Employer Individual Medicaid Medicare * * *
  • 16. Disparities in Insurance: Women Compared to married women in opposite-sex relationships 16 0.49 0.64 0.90 1.09 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Employer Individual Medicaid Medicare Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010. * indicates p<0.05 * *
  • 17. Where are the coverage gaps in ESI? 17
  • 18. Coverage Gaps in ESI Men in SS relationships vs. Married Men in OS Relationships 18 RD: 0-10% RD: > 10% Same-sex couples equal or better off Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010. RD=relative difference.
  • 19. Coverage Gaps in ESI Women in SS relationships vs. Married Women in OS relationships 19 RD: 0-10% RD: > 10% Same-sex couples equal or better off Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010. RD=relative difference.
  • 20. Does state marriage policy modify coverage gaps? 20
  • 21. MEN in Same-Sex Relationships 21 Compared to living in states without provisions • Same-Sex Marriage: +1.45% (p>0.10) • Civil unions or domestic partnerships: +1.66% (p>0.10) Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010
  • 22. WOMEN in Same-Sex Relationships 22 Compared to living in states without provisions • Same-Sex Marriage: +3.84% (p<0.01) • Civil unions or domestic partnerships: +3.00% (p<0.01) Adjusts for race/ethnicity, age, employment, industry, income, region, citizenship, minor child, survey year Source: American Community Survey, 2008-2010
  • 23. Summary • Men and women in same-sex couples are less likely to be insured through an employer nationwide • Largest ESI coverage gaps located in the South for men and in the Midwest for women • Living in a state with same-sex marriage, civil unions or domestic partnerships is associated with increased levels of ESI for women in same-sex relationships 23
  • 24. 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 24
  • 25. Sign up to receive our newsletter and updates at www.shadac.org @shadac Gilbert Gonzales, MHA Doctoral Student Graduate Research Assistant gonza440@umn.edu University of Minnesota School of Public Health Division of Health Policy & Management