摘要：Objectives. We examined national and state-specific disparities in health insurance coverage, specifically employer-sponsored insurance (ESI) coverage, for adults in same-sex relationships. Methods. We used data from the American Community Survey to identify adults (aged 25–64 years) in same-sex relationships (n = 31 947), married opposite-sex relationships (n = 3 060 711), and unmarried opposite-sex relationships (n = 259 147). We estimated multinomial logistic regression models and state-specific relative differences in ESI coverage with predictive margins. Results. Men and women in same-sex relationships were less likely to have ESI than were their married counterparts in opposite-sex relationships. We found ESI disparities among adults in same-sex relationships in every region, but we found the largest ESI gaps for men in the South and for women in the Midwest. ESI disparities were narrower in states that had extended legal same-sex marriage, civil unions, and broad domestic partnerships. Conclusions. Men and women in same-sex relationships experience disparities in health insurance coverage across the country, but residing in a state that recognizes legal same-sex marriage, civil unions, or broad domestic partnerships may improve access to ESI for same-sex spouses and domestic partners. There are approximately 646 000 same-sex couples in the United States according to the 2010 decennial census. 1 Same-sex couples reside in every state, but each state has its own laws and regulations regarding the legal status of same-sex marriage. At the time of this writing, 16 states and the District of Columbia had recognized legal marriages for same-sex couples; an additional 3 states had extended civil unions or comprehensive domestic partnerships to same-sex couples; and the remaining states had banned same-sex marriage altogether through legislative action or amendments to their state constitutions. 2 Differences in same-sex marriage laws can affect access to health insurance for same-sex couples or members of the lesbian, gay, bisexual, and transgender (LGBT) population. When states adopt same-sex marriage or civil unions that extend spousal rights and protections to same-sex couples, fully insured private employers regulated by state insurance laws are often required to treat married same-sex couples as married opposite-sex couples. The Employee Retirement Income Security Act of 1974 limits the reach of state insurance regulation. Although states maintain jurisdiction over fully insured health plans, employers that self-insure—or assume the risk of health claims out of their own assets—are regulated under the federal Employee Retirement Income Security Act, as health benefits are treated not as insurance but as an employee benefit similar to employer-provided pension plans. 3,4 In 2010, more than half of all workers (57.5%) with employer-sponsored insurance (ESI) were covered by self-insured plans. 5 Because so many workers are covered by self-insured plans, state-level marriage policies can have a limited effect. Buchmueller and Carpenter, using data from the 2001–2007 California Health Interview Surveys, found that insurance mandates that extended health care benefits to same-sex spouses in California had no statistically significant effect on dependent coverage for gay and bisexual men and only a small positive effect on lesbian and bisexual women. 6 The federal Defense of Marriage Act, passed in 1996, created additional barriers for LGBT workers interested in adding their spouses to their ESI plan, even when states acknowledged the legality of same-sex marriage. Section 3 of the Defense of Marriage Act (ruled unconstitutional by the US Supreme Court in 2013) defined marriage as “a legal union between one man and one woman as husband and wife” for federal purposes. 7 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 as if the employer contribution was taxable income. LGBT employees paid, on average, $1069 in additional federal income taxes when they added their same-sex spouses to employer health plans. 8 These barriers to ESI may have led LGBT persons to enroll in public programs or forgo health insurance and access to affordable health care. Data on the LGBT population have historically been limited to convenience and nonprobability samples of gay men and lesbians through health care providers and researchers focusing their research on LGBT health. 9 Although federal surveys do not ascertain sexual orientation, data have been edited to identify same-sex couples and households. Three previous studies have used intrahousehold information from federal population surveys to compare the health insurance coverage of individuals in same-sex relationships with that of those in opposite-sex relationships. Heck et al. used the National Health Interview Survey to compare health insurance coverage and access to medical care of adults in same-sex relationships with that of married adults in opposite-sex relationships. 10 They used multivariate logistic regression models for men and women and found women in same-sex relationships significantly less likely to have health insurance, to have seen a medical provider in the previous 12 months, and to have a usual source of care. Health insurance coverage, unmet medical needs, and having a usual source of care were not statistically different between men in same-sex relationships and married men in opposite-sex relationships. The authors believed the HIV epidemic motivated gay men to maintain a regular provider. Compared with the other studies using federal surveys, the National Health Interview Survey accommodates the smallest sample size (316 men and 298 women in same-sex relationships)—even after pooling data across a wide time frame (1997–2003). Ash and Badgett took advantage of larger samples in the Current Population Survey. 11 Designed to measure labor force participation and unemployment, the Annual Social and Economic Supplement to the Current Population Survey requires respondents to report health insurance coverage during the previous 16 months for each person in the household. Pooled data between 1996 and 2003 still produced relatively small sample sizes (486 men and 478 women in same-sex relationships), but their study found that both men and women in same-sex couples were 2 to 3 times more likely to be uninsured than were married individuals in opposite-sex relationships. Buchmueller and Carpenter used a national sample of adults aged between 25 and 64 years in the Behavioral Risk Factor Surveillance System to compare health insurance and utilization of health services of same-sex couples with those of opposite-sex couples (both married and unmarried). 12 Again, both men and women in same-sex relationships were significantly less likely to be insured. Married people in opposite-sex relationships had the highest rates and odds of insurance coverage, followed by men and women in same-sex relationships, and then by unmarried men and women in opposite-sex relationships. Although it provides the largest sample to date (2384 men and 2881 women in same-sex relationships), their study pooled data across a wide period (2000–2007) of decline in health insurance coverage, especially for people with ESI. 13 These 3 studies were restricted to national-level estimates and surveys with limited sample sizes. Our research builds on the previous work but extends the analysis to all states. To our knowledge, only 1 other study has estimated health insurance disparities for same-sex couples in a single state using the California Health Interview Study. 14 Because of the variation in state policies and attitudes toward same-sex couples, 15,16 we expected geographic patterns in health insurance. We took advantage of relatively large samples in the American Community Survey (ACS) to compare state-specific health insurance disparities, particularly in ESI coverage. Following recent studies examining the potential for same-sex marriage to improve the health of the LGBT population, 17–20 we sought to add early evidence on the relationship between legal same-sex marriage and health insurance coverage.
