State variation in health insurance coverage for same-sex couples: Results from the American Community Survey

Background: Most nonelderly adults access health insurance through a family member's employer-sponsored health insurance (ESI) plan. Same-sex couples can face additional barriers to enrolling spouses and their children onto ESI. Only a few state-level surveys and limited national estimates are available to evaluate access to ESI, Medicaid, and uninsurance among same-sex couples. Methods: I use data from the 2008-2010 American Community Surveys to compare health insurance coverage between non-elderly adults in same-sex relationships to those in opposite-sex relationships across each state. Multinomial logistic regression models estimated national-level predictive margins for health insurance status among men and women in same-sex relationships. Results: Nationally, individuals in same-sex relationships are less likely to maintain coverage through ESI (67%) compared to individuals in opposite-sex relationships (73%). Variation in ESI coverage among individuals in same-sex relationships ranges from less than 50% in New Mexico to 77% in Massachusetts. Men and women in same-sex relationships are more likely to be uninsured compared to their opposite-sex counterparts after controlling for income, education, and race. Individuals in same-sex couples are twice as likely to be uninsured in 11 states—many of them located in the Midwest. States that have passed legislation recognizing same-sex marriage, domestic partnerships, or civil unions prior to data collection are among those with the highest ESI coverage rates and lowest uninsurance rates for nonelderly individuals in same sex-couples. Conclusions: My results indicate substantial variation across states in health insurance coverage among nonelderly adults in same-sex couples. Additionally, marriage equality laws might serve as a pathway to improving access to ESI for same-sex couples.