摘要：Objectives. We examined disparities in health insurance coverage for racial/ethnic minorities in same-sex relationships. Methods. We used data from the 2009 to 2011 American Community Survey on nonelderly adults (aged 25–64 years) in same-sex (n = 32 744), married opposite-sex (n = 2 866 636), and unmarried opposite-sex (n = 268 298) relationships. We used multinomial logistic regression models to compare differences in the primary source of health insurance while controlling for key demographic and socioeconomic factors. Results. Adults of all races/ethnicities in same-sex relationships were less likely than were White adults in married opposite-sex relationships to report having employer-sponsored health insurance. Hispanic men, Black women, and American Indian/Alaska Native women in same-sex relationships were much less likely to have employer-sponsored health insurance than were their White counterparts in married opposite-sex relationships and their White counterparts in same-sex relationships. Conclusions. Differences in coverage by relationship type and race/ethnicity may worsen over time as states follow different paths to implementing health care reform and same-sex marriage. Alongside the social determinants of health, lacking health insurance is consistently identified as a driver of health care disparities in the United States. 1–4 Without health insurance, people are much less likely to afford and seek medical treatment or maintain a regular medical provider. Yet, data from the 2012 American Community Survey (ACS) indicate that Hispanics (29.1%) and Blacks (19.0%) are much more likely to be uninsured than are Whites (11.1%). 5 The reliance on employer-sponsored health insurance (ESI) in the United States exacerbates racial/ethnic disparities in insurance status, as racial/ethnic minorities are more likely to experience spells of unemployment or not hold jobs that offer health insurance. 6 Among those with insurance, Blacks and Hispanics are less likely to be covered with private insurance and more likely to be covered through public programs such as Medicare and Medicaid than are Whites. 7–9 Individuals in same-sex relationships, or sexual minorities, are also at increased risk for not having health insurance, particularly through employers. Not all employers allow lesbian, gay, or bisexual (LGB) workers to add a domestic partner to ESI plans. Even among large companies with more than 500 employees, approximately half offer health benefits to same-sex partners. 10–12 The federal Defense of Marriage Act, ruled unconstitutional by the US Supreme Court in 2013, added barriers for LGB workers interested in adding a partner to ESI plans. The federal government does not tax employer contributions to an opposite-sex spouse’s health benefits, but under the Defense of Marriage Act, a same-sex partner’s health benefits were taxed (approximately $1000) 13 as if the employer contribution was taxable income. Several studies have indicated that barriers to ESI led LGB persons and adults in same-sex relationships to enroll in public programs or forgo health insurance. Ponce et al., using data from the California Health Interview Survey, found significant disparities in insurance coverage between adults in same-sex partnerships and those in opposite-sex relationships. 14 Heck et al., using data from the National Health Interview Survey, found that women in same-sex relationships were less likely to have insurance, to have seen a medical provider in the previous 12 months, and to have a usual source of care than were their counterparts in opposite-sex relationships. 15 Federal survey data from the Current Population Survey, 16 the Behavioral Risk Factor Surveillance Survey, 17 and the ACS 18 show that men and women in same-sex relationships are consistently less likely to have health insurance, particularly through employers. Not only is having health insurance important for access to health care services, but it has also been independently linked to better health and reduced mortality in vulnerable populations. 19 Because of the heavy reliance on ESI in the United States, racial/ethnic minorities as well as sexual minorities are at higher risk for lacking health insurance. Yet, no studies to date have examined disparities in health insurance at the intersections of race/ethnicity and sexual orientation. Much of the available literature has treated adults in same-sex relationships as a single, monolithic population without exploring variation in disparities across different racial/ethnic groups. The 2011 report by the Institute of Medicine on lesbian, gay, bisexual, and transgender health identified a need for more research highlighting the intersectional perspectives of individuals who are both sexual minorities and racial/ethnic minorities. 20 We examined heterogeneity within lesbian, gay, bisexual, and transgender populations by assessing disparities in health insurance status—particularly in ESI—by relationship type and across racial/ethnic identities using information from a large population survey that serves as the nation’s primary data resource on health insurance status and same-sex households.
