Health Benefits Mandates and Their Potential Impacts on Racial/Ethnic Group Disparities in Insurance Markets

Addressing racial/ethnic group disparities in health insurance benefits through legislative mandates requires attention to the different proportions of racial/ethnic groups among insurance markets. This necessary baseline data, however, has proven difficult to measure. We applied racial/ethnic data from the 2009 California Health Interview Survey to the 2012 California Health Benefits Review Program Cost and Coverage Model to determine the racial/ethnic composition of ten health insurance market segments. We found disproportional representation of racial/ethnic groups by segment, thus affecting the health insurance impacts of benefit mandates. California’s Medicaid program is disproportionately Latino (60 % in Medi-Cal, compared to 39 % for the entire population), and the individual insurance market is disproportionately non-Latino white. Gender differences also exist. Mandates could unintentionally increase insurance coverage racial/ethnic disparities. Policymakers should consider the distribution of existing racial/ethnic disparities as criteria for legislative action on benefit mandates across health insurance markets.     

Explaining Racial Disparities in Infant Health in Brazil

Objectives. We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.Methods. We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.Results. The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.Conclusions. Public policies to improve children’s health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.Large health disparities exist between Black and White infants in Brazil.1−4 Infant mortality is more than twice as common among Black as White infants in Southern Brazil (30.4 vs 13.9 per 1000).5 Poor birth outcomes including low birth weight (LBW) and preterm birth (PTB) are also more common among Black infants. Racial disparities are also reported in prenatal and postnatal care, with White mothers having more and higher-quality prenatal visits and greater use of postnatal care.6,7Documenting the prevalence and magnitude of racial disparities in infant’s and children’s health is important. However, of more importance is explaining these disparities and identifying the pathways through which they arise to identify contributors that can be targeted by policy interventions. Such effort has lifelong implications because of the importance of children’s health for adult health and human capital attainment.8−12 Because children’s health may have multiplicative effects on health over life, early health disparities may extend into large health and human capital disparities later in life.13,14Studies in the United States have shed light on several pathways that lead to racial disparities in infant’s and children’s health.15−21 Individual-level factors including socioeconomic status (SES),22 maternal age, prenatal care use,22−24 and stressful life events before delivery,17 as well as differences in health care access and quality25−27 and social inequalities because of residential segregation and poverty,15,28,29 are thought to be important contributors to racial disparities in infants’ health in the United States.To our knowledge, there are no studies that simultaneously quantify the contributions of a large number of conceptually relevant factors to racial disparities in infants’ health in Brazil. In this study, we examined the extent to which socioeconomic, health care, demographic, and geographic effects explain disparities in LBW (< 2500 grams) and PTB (< 37 gestational weeks) rates by African ancestry in Brazil. Unlike any previous study for Brazil, we evaluated the contributions of the explanatory factors to the disparities by different degrees of African ancestry. We focused on disparities by African ancestry because they are the most prevalent and affect a large percentage of the Brazilian population.1−5Our study is the first to simultaneously quantify the contributions of several factors both as a group and each on its own (with control for the others) to explaining racial disparities in infant health in Brazil. Such a study is needed not only because Brazil is the largest country in South America but also because there are many historical, demographic, economic, social, cultural, and health care system differences between Brazil and other racially admixed countries such as the United States. These differences limit the generalizability of studies of racial infant health disparities in the United States to the Brazilian population as these differences may modify the underlying factors and the extent of their contributions to the disparities.There is a sharp contrast in perception of race between Brazil and the United States.30 Race for individuals of African and European ancestry in Brazil has been historically and socially defined on a “continuum” of skin color including Black, Brown (mixed between Black and White), or White, instead of the Black or White color line as in the United States. This is in part because of the large racial admixing in Brazil.31 The difference in perceptions of racial identity between Brazil and the United States implies potential differences in cultural and socioeconomic factors related to race and how these may affect health and contribute to racial disparities. Brazil also differs significantly in its economic growth and extent of economic disparities by race from the United States.32 Finally, there are major differences in access to and quality of health care between Brazil and the United States.33,34 For all of these reasons, a study that explains the racial disparities in LBW and PTB in Brazil is needed to draw inferences that can help to inform policymaking and interventions to reduce these disparities in that country.     

Health Insurance Coverage and Mortality Revisited

Objective. To improve understanding of the relationship between lack of insurance and risk of subsequent mortality. Data Sources. Adults who reported being uninsured or privately insured in the National Health Interview Survey from 1986 to 2000 were followed prospectively for mortality from initial interview through 2002. Baseline information was obtained on 672,526 respondents, age 18–64 at the time of the interview. Follow‐up information on vital status was obtained for 643,001 (96 percent) of these respondents, with approximately 5.4 million person‐years of follow‐up. Study Design. Relationships between insurance status and subsequent mortality are examined using Cox proportional hazard survival analysis. Principal Findings. Adjusted for demographic, health status, and health behavior characteristics, the risk of subsequent mortality is no different for uninsured respondents than for those covered by employer‐sponsored group insurance at baseline (hazard ratio 1.03, 95 percent confidence interval [CI], 0.95–1.12). Omitting health status as a control variable increases the estimated hazard ratio to 1.10 (95 percent CI, 1.03–1.19). Also omitting smoking status and body mass index increases the hazard ratio to 1.20 (95 percent CI, 1.15–1.24). The estimated association between lack of insurance and mortality is not larger among disadvantaged subgroups; when the analysis is restricted to amenable causes of death; when the follow‐up period is shortened (to increase the likelihood of comparing the continuously insured and continuously uninsured); and does not change after people turn 65 and gain Medicare coverage. Conclusions. The Institute of Medicine's estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.     

乳癌根治术后的非加压双管负压引流法临床应用研究

目的探讨更为有效和经济的乳癌手术后皮瓣下引流方法,促进术后创面愈合。方法2000年2月-2007年2月间共收治乳腺癌患者96例,分别行乳癌改良根治术、根治术和扩大根治术,术后随机分为传统加压包扎单管引流组和非加压包扎双管负压引流组,每组各48例,然后就引流液量、皮下积液发生率及切口延迟愈合发生率等临床愈合指标和术后平均住院日以及平均总住院费用进行对比研究。结果双管组术后前3d引流量显著大于单管组(P<0.01),皮下积液发生率明显低于单管组(P<0.05),切口延迟愈合发生率低于单管组(P<0.01);同时,双管组术后住院日明显少于单管组(P<0.05),而总住院费用相比无明显差异。结论在乳腺癌根治术后,双管负压引流方法可靠,引流更为充分,其并发症发生率低,并能缩短术后住院时间,有利于患者早日康复,值得推广应用。     

Exploring Racial,Gender, and Insurance Disparities in Patients with Osteoporotic Fractures

The objective of this study is to examine racial, gender, and insurance disparities in hospital outcomes among patients diagnosed with osteoporotic fractures aged 55 years and older. A total of 36,153 patients were included in this study. The sample was constructed from de-identified patient-level data for 2011 through 2014 from the Virginia Health Information (VHI) inpatient discharge database. Differences in mortality and 30-day readmission across race, gender, and insurance status were examined using logistic regression and generalized linear models for hospital charges and length of stay. Whites and Asians had a shorter stay than Blacks [5.2 days (95% confidence interval (CI) 5.1–5.3) and 5.0 days (95% CI 4.7–5.2) vs. 5.6 days (95% CI 5.4–5.7)], while Hispanics had a significantly longer stay [6.0 days (95% CI 5.6–6.5)]. On average, total charges were the highest among Blacks [$37,916 (95% CI 36,784–39,083)]. All outcomes were poorer for men than women. Privately and publicly insured patients were more likely to be readmitted [odds ratio (OR) 1.6 (95% CI 1.0-2.6) and OR 2.0 (95% CI 1.3–3.2)] and had a shorter stay than the uninsured [4.9 days (95% CI 4.8–5.0) and 5.2 days (95% CI 5.1–5.3) vs. 5.7 days (95% CI 5.4–6.0)], while privately insured patients had considerably lower total charges than those who were uninsured [$34,163 (95% CI 33,214–35,139) vs. $36,335 (95% CI 34,334–38,452)]. As evidenced from this study, there are racial, gender, and insurance disparities in health outcomes. These results and further exploration of these disparities could provide information necessary for strategies to improve these outcomes in at-risk patients diagnosed with osteoporotic fractures.     

Racial and Ethnic Disparities in the Use of Mental Health Services

The authors used data from the 1998-1999 Community Tracking Study (CTS) household survey to examine variations in predictors of use of mental health services among different racial and ethnic groups (white, African American, Hispanic, and other). African Americans and Hispanics were less likely to have visited a mental health professional (MHP) in the prior year than were whites. Independent of health insurance and health status, low- to middle-income African Americans may be at particular risk for inadequate use of an MHP compared to higher-income African Americans. Similarly, upper-income Hispanics were more likely to have visited an MHP than Hispanics in the lowest income range. Adults aged 50 and older were less likely to visit an MHP than individuals aged 18-49. Depressed men were more likely to visit an MHP than depressed women. Efforts to reduce disparities should focus on lower-income racial and ethnic minorities.     

Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia

Objective

To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes.

Data Sources/Study Setting

Female patients in Georgia diagnosed with BC in the years 2000–2009.

Study Design

Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level.

Principal Findings

Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death.

Conclusions

Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.     

Conceptualising the Lack of Health Insurance Coverage

This paper examines the lack of health insurancecoverage in the US as a public policy issue. It first comparesthe problem of health insurance coverage to theproblem of unemployment to show that in terms of thenumbers of individuals affected lack of healthinsurance is a problem comparable in importance to theproblem of unemployment. Secondly, the paperdiscusses the methodology involved in measuring healthinsurance coverage, and argues that the current methodof estimation of the uninsured underestimates theextent that individuals go without health insurance. Third, the paper briefly introduces Amartya Sen'sfunctionings and capabilities framework to suggest away of representing the extent to which individualsare uninsured. Fourth, the paper sketches a means ofoperationalizing the Sen representation of theuninsured in terms of the disability-adjusted lifeyear (DALY) measure.     

Health Insurance Disparities in Traditional and Contingent/Alternative Employment

Relative to whites, Hispanics and blacks are less likely to have employer health insurance coverage. We examine whether ethnicity or race affects employment in traditional jobs or in contingent and alternative work arrangements, and whether ethnicity or race affects insurance offer, eligibility, and/or enrollment, conditional on employment sector. Health insurance disparities relative to whites are more pronounced for Hispanics, primarily due to disparities in employment by firms that offer coverage. Eliminating racial/ethnic disparities in offers, eligibility, and takeup would increase insurance coverage rates of Hispanics in traditional jobs and of both Hispanics and blacks in contingent and alternative jobs. JEL classification: I10, J32, J70     

Changing Patterns of Health Insurance Coverage:

Health care expenditures and utilization have increased dramatically in recent years, but gaps in health insurance coverage restrict access to care for a growing portion of the population. Women are especially vulnerable given the structure of insurance coverage and demographic factors. The erosion of insurance coverage can be attributed to several trends, particularly employer cost containment strategies, restricted public program eligibility and changes in the characteristics of the work force. Numerous measures have been adopted at the federal and state levels to maintain or expand coverage on an incremental basis. As broader segments of the population suffer reduction or loss of coverage, a comprehensive approach will be necessary to ensure universal access to health care.     

Health Status and Health Insurance Coverage of Women with Live-Born Infants: An Opportunity for Preventive Services After Pregnancy

Most women in the US have access to health care and insurance during pregnancy; however women with Medicaid-paid deliveries lose Medicaid eligibility in the early postpartum period. This study examined the association between health insurance coverage at the time of delivery and health conditions that may require preventive or treatment services extending beyond pregnancy into the postpartum period. We used 2008 Pregnancy Risk Assessment Monitoring System data from 27 states (n = 35,980). We calculated the prevalence of maternal health conditions, including emotional and behavioral risks, by health insurance status at the time of delivery. We used multivariable logistic regression to assess the association between health insurance coverage, whether Medicaid or private, and maternal health status. As compared to women with private health insurance, women with Medicaid-paid deliveries had higher odds of reporting smoking during pregnancy (adjusted odds ratio [AOR]: 1.85, 95 % confidence interval [CI]: 1.56–2.18), physical abuse during pregnancy (AOR: 1.73, 95 % CI: 1.24–2.40), having six or more stressors during pregnancy (AOR: 2.48, 95 % CI: 1.93–3.18), and experiencing postpartum depressive symptoms (AOR: 1.24, 95 % CI: 1.04–1.48). There were no significant differences by insurance status at delivery in pre-pregnancy overweight/obesity, pre-pregnancy physical activity, weight gain during pregnancy, alcohol consumption during pregnancy, or postpartum contraceptive use. Compared to women with private insurance, women with Medicaid-paid deliveries were more likely to experience risk factors during pregnancy such as physical abuse, stress, and smoking, and postpartum depressive symptoms for which continued screening, counseling, or treatment in the postpartum period could be beneficial.     

The Role of Social Context in Racial Disparities in Self-Rated Health

Race disparities in self-rated health in the USA are well-documented, such that African Americans rate their health more poorly than whites. However, after adjusting for health status, socioeconomic status (SES), and health behaviors, residual race differences are observed. This suggests the importance of unmeasured variables. Because African Americans and whites tend to live in differing social contexts, it is possible that accounting for social and environmental conditions may reduce racial disparities in self-rated health. Differences in self-rated health among whites and African Americans were assessed in a low-income, urban integrated community (Exploring Health Disparities in Integrated Communities (EHDIC)) and compared with a national sample (National Health Interview Survey (NHIS)). Controlling for demographics, SES, health insurance, status, and behaviors, African Americans in NHIS had higher odds of reporting fair or poor health (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.18–1.66) than whites. In EHDIC, there was no race difference in self-rated health (OR = 0.83, 95% CI = 0.63–1.11). These results demonstrate the importance of social context in understanding race disparities in self-rated health.     

Reducing Racial and Ethnic Disparities in Disease Management to Improve Health Outcomes

The heightened awareness of substantial racial and ethnic disparities in health outcomes has major implications for how healthcare providers effectively manage health conditions among diverse populations. This report identifies five dimensions that address the major causes of disparities that can exert significant influence over the success and quality of the patient-physician relationship, treatment plans, and health outcomes. These five dimensions are (i) biological and genetic influences; (ii) differential access to care; (iii) quality of care disparities; (iv) clinical-patient perceptions and realities; and (v) language and communication barriers.Recommended disease management actions for health practitioners and healthcare organizations focus on promoting more effective interactions between both the patient and the physician in the clinical encounter, methods for improving patient understanding, and education and information to improve treatment adherence and outcome. Educational strategies include: adapting existing protocols in the clinical setting; using communities, the internet and other sources of information; recognizing the importance of racial and ethnic concordance; and assuring competent communication and interpretation in the clinical encounter. Governments also perform several critical functions in addressing racial and ethnic disparities, such as setting the tone and offering leadership, guidance and support for practitioners and their healthcare settings.Ultimately, effective disease management will require practitioners, as well as healthcare organizations and agencies to integrate knowledge and actions around the multiple causes of ethnic and racial disparities into clinical regimens through training, on-site services and resource development.     

Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents

Objective

To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.

Data Source

Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.

Study Design

Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.

Principal Findings

Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.

Conclusions

U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.     

Minority Response to Health Insurance Coverage for Mental Health Services

BACKGROUND: To promote access to mental health services, policy makers have focused on expanding the availability of insurance and the generosity of mental health benefits. Ethnic minority populations are high priority targets for outreach. However, among persons with private insurance, minorities are less likely than whites to seek outpatient mental health treatment. Among those with Medicaid coverage, minorities continue to be less likely than whites to use services. AIMS OF THE STUDY: The present study sought to determine if public insurance is as effective in promoting outpatient mental healthtreatment as private coverage for ethnic minority groups. METHODS: The analysis uses data from the 1987 National Medical Expenditure Survey to model mental health expenditures as a function of minority status and private insurance coverage. An interaction term between the two highlights any differences in response to private and public insurance coverage. The analysis uses a two stage least squares method to account for endogeneity of insurance coverage in the model. RESULTS: Minorities are less responsive to private insurance than whites in two ways. First, minorities are less responsive to private insurance than to public insurance whereas whites do not show this difference. Second, minorities are less responsive to private insurance than whites are to private insurance. DISCUSSION: Results suggest that there is a difference in the effectiveness of public and private health insurance to encourage use of mental health services. Among minorities but not among whites, those with private coverage used fewer mental health services than those with public coverage. Minorities were not only less responsive to private insurance than public insurance, but among those who were privately insured, minorities used fewer mental health services than whites. These results imply that insurance may not be as effective a mechanism as hoped to encourage self-initiated treatment seeking particularly among minority and other low income populations. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest that increasing private insurance coverage to minority populations will not eliminate racial and ethnic gaps in professional help-seeking for outpatient mental health care. Although the total number of people receiving treatment might increase, these results suggest that whites would seek care in greater numbers than minorities and the size of the minority-white differential might grow. IMPLICATIONS FOR FURTHER RESEARCH: Areas for further research include the impacts of alternative definitions of mental health services, the dynamics of the substitution of inpatient for outpatient mental health care, elucidation of nonfinancial barriers to care for minorities, and determinants of timely help-seeking among minorities.     

National and State-Specific Health Insurance Disparities for Adults in Same-Sex Relationships

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.6The 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.13These 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.