Insurance Coverage Improves for Same-Sex Couples, Yet Disparities Persist

Although same-sex couples in the US now report higher rates of insurance coverage than different-sex couples, more work is needed to ensure these gains are distributed equitably, according to a study published in JAMA Network Open.¹

The researchers noted that the nationwide legalization of same-sex marriage and key provisions of the Patient Protection and Affordable Care Act (ACA) have helped minimize insurance coverage gaps for sexual and gender minority (SGM) adults. Prior studies found that ACA Medicaid expansion improved coverage among low-income same-sex couples and that gay and lesbian married or cohabitating adults were more likely to have private insurance than their single counterparts.

Despite these gains, disparities persist in employer-sponsored insurance, particularly in the Midwest and South. The researchers also highlighted that little research has explored how coverage varies by sexual orientation across sociodemographic characteristics.

To address this, they conducted a cross-sectional study to test 3 hypotheses: improvements in insurance coverage among same-sex couples are largely driven by married couples, these improvements vary by state, and coverage gains are concentrated among higher-income groups.

Using pooled 2008 to 2022 data from the American Community Survey (ACS), an annual, nationally representative survey of over 3 million US households, the researchers analyzed adults aged 18 to 64 in cohabitating relationships. The primary outcome was reporting any health insurance coverage. They used linear probability models to assess the association between same-sex couple status and the likelihood of insurance coverage.

The sample included 20,938,414 respondents with a mean (SD) age of 45.57 (11.86) years. Most were women (n = 11,139,506), married (n = 13,988,414), and employed (n = 15,921,280). Respondents reported a mean (SD) annual personal income of $43,944.33 ($61,608.05) and a median (IQR) household income of $88,000 ($84,000). Insurance coverage levels were high overall, with 3,453,491 reporting public coverage and 14,248,083 reporting private coverage.

Insurance coverage significantly varied by couple type across the sample period. Individuals in different-sex couples had lower coverage rates than those in same-sex couples (204,471 vs 18,382,787 respondents; P < .001). On average, same-sex couples were 1.7 to 2.5 percentage points more likely to be insured than those in different-sex couples, with higher rates of employer-sponsored coverage and lower rates of public insurance.

However, disparities remained across income levels and geography. Same-sex couples in the lower-income quintiles were less likely to be insured compared with their counterparts in higher quintiles. Additionally, same-sex couples living in states that had not yet expanded Medicaid, including Alabama, Georgia, Kansas, Mississippi, South Carolina, Tennessee, and Wyoming, were less likely to be insured during the sample period.

Overall, the researchers noted that recent gains in insurance coverage among same-sex couples have been concentrated among male couples, married couples, those insured by plans offered by their employers, those in states that have expanded Medicaid, and those at the top of the income distribution.

The researchers acknowledged their study's limitations, including its descriptive nature, which prevents establishing causal mechanisms. Still, they emphasized the importance of monitoring these trends amid ongoing threats to sexual and gender minority protections. The researchers cautioned that with the reversal of sexual and gender minority protections, these gains may be undone, potentially widening coverage gaps among same-sex couples who did not benefit equally.²

“…efforts to retain existing SGM protections must be expanded to ensure that these gains are distributed across the income distribution, to unmarried couples, and to those living in states that have not yet expanded access to public health insurance,” the authors concluded.¹

References

1. Harrell BJ, Jones NE, Miller GH. Health insurance coverage among same-sex vs different-sex couples. JAMA Netw Open. 2025;8(9):e2532844. doi:10.1001/jamanetworkopen.2025.32844
2. Sandhu S, Liu M, Keuroghlian AS. The future of US sexual and gender minority health policy. JAMA Intern Med. 2025;185(4):364-365. doi:10.1001/jamainternmed.2024.7551