Implications of Obergefell on Healthcare Access

On June 26, 2015, the U.S. Supreme Court decided in Obergefell v. Hodges that same-sex marriage is a constitutional right under the Fourteenth Amendment. Despite this seminal moment in civil rights, individuals within the LGBT community still face numerous barriers, including equal access to healthcare and other rights afforded to heterosexuals.


Photo from the official White House Facebook page.

Insurance Company Benefits

One such barrier to access that has great potential to be resolved as a result of the Obergefell decision is that insurance companies will likely need to alter their policies to reflect language surrounding same-sex marriages, and allow an employee’s spouse to be covered under the policy. According to the Kaiser Family Foundation’s 2014 Employer Health Benefits Survey, while 96 percent of employer-based coverage plans cover dependents, only 39 percent of the same firms providing health coverage provide coverage to employees in domestic partnerships (either same-sex or opposite-sex). By removing the barrier to marriage, employees in same-sex partnerships are now more likely to have access to, and receive, health care services. For employers that have been offering coverage to employees in domestic partnerships, they may be questioning of how to transition from that type of coverage to the more “traditional” spousal coverage. In Michigan, Henry Ford Health System expects to offer a long time frame for employees to transition, if they choose to do so.

For individuals currently covered by Medicaid, the Supreme Court ruling is also expected to affect spouses’ eligibility for Medicaid coverage. Medicaid agencies in states that have not already recognized same-sex marriage will have to develop and rewrite state policies and plans. In addition to increasing coverage and eligibility for same-sex couples under Medicaid, same-sex spouses in all states will now be shielded from Medicaid estate recovery, which requires states to recover funds from the estates of deceased Medicaid clients for any long-term care costs incurred from the time that a client was age 55 to when they became Medicare-eligible at age 65. With the Obergefell decision, no such claims on the deceased’s estate can be made, as long as there is a surviving spouse.

In Vitro Benefits

Another area in which greater parity has been achieved for LGBT couples is in the area of infertility health benefits. In March, the Maryland General Assembly passed SB 416 / HB 838, and in June, Governor Hogan allowed the bill to become law without his signature. The law prohibits insurers from restricting same-sex couples to access in vitro fertility treatments that are already available to opposite-sex couples.  Previously, Maryland law required that couples experiencing infertility demonstrate a history of infertility for at least two years; insurers often interpreted this requirement to mean having intercourse during that time without conceiving. Furthermore, fertility coverage would be permitted only for infertility treatments that used the husband’s sperm. The passage of the new law removing these restrictions is a great step towards improved access to healthcare and a couple’s rights to build their family as they so choose.

Transgender Health

Despite this great victory in same-sex relationship recognition, there is still much left to be done to improve health equity and outcomes for members of the LGBT community. In particular, for people who identify as transgender, receiving services for gender reassignment that are covered under their health insurance plan can be difficult and stressful. Recently, in partnership with TrueChild, HMACS designed a survey to gather information about the effects of covering versus denying transition-related care for transgender individuals.  For individuals who are denied care and coverage, or who experience lengthy (sometimes years or decades-long) delays in access to transition-related care, the health and social impacts can be enormous, including loss of employment, loss of housing, and/or poor mental health, including depression or substance abuse. The survey asks about these and other “hidden” costs of lack of coverage and access to care.  Over 350 transgender adults responded to the survey. Data analysis is underway, and publication of the results is forthcoming.  By shedding more light on the impacts of delays in care and limited access to care, we can begin to understand more fully the potential benefits of increasing access to care.

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