QuickTake: Uninsurance Rate Nearly Halved for Lesbian, Gay, and Bisexual Adults since Mid-2013
Michael Karpman, Laura Skopec, and Sharon K. Long
April 16, 2015
The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage since the first quarter of 2013. Recent HRMS data show an estimated 15.0 million (95% CI [11.9 million, 18.1 million]) adults ages 18 to 64 gained coverage between September 2013, just before the first open enrollment period for the Affordable Care Act’s (ACA) health insurance Marketplaces, and March 2015, just after the close of the second open enrollment period (Long et al. 2015).
This QuickTake explores how coverage changed between June/September 2013 and December 2014/March 20151 for lesbian, gay, and bisexual (LGB) adults,2 overall and by family income, state Medicaid expansion status,3 and gender. Lesbian, gay, bisexual, and transgender (LGBT) adults report poorer access to health care and more health problems (Ranji et al. 2014) and likely face challenges getting coverage that are different from those faced by non-LGBT adults (Baker et al. 2014).4
Between June/September 2013 and December 2014/March 2015, the share of LGB adults without insurance coverage decreased from 21.7 percent to 11.1 percent (data not shown). This represents a decline in uninsurance for LGB adults of 10.6 percentage points (95% CI [5.8, 15.4]; figure 1) or 48.9 percent over this time frame.5 The decline in uninsurance for LGB adults during this period is larger than the decline for non-LGB adults (figure 1). Consequently, the uninsurance rates for LGB adults and other adults were similar in December 2014/March 2015 (11.1 percent for both; data not shown).
Coverage increases were near or above 10 percentage points for LGB adults in Medicaid expansion and nonexpansion states and among men and women, though the uninsured rate for LGB adults remained higher in nonexpansion states (15.0 percent) than in expansion states (9.1 percent) as of December 2014/March 2015 (data not shown). Nearly all of the increase in coverage occurred among LGB adults in the income ranges targeted by either the ACA’s Medicaid expansion (family income at or below 138 percent of the federal poverty level [FPL]) or Marketplace tax credits (family income between 139 and 399 percent of FPL). The share of LGB adults with income below 400 percent of FPL who have insurance increased 15.5 percentage points (95% CI [8.8, 22.2]) between June/September 2013 and December 2014/March 2015.
The large coverage gains among LGB adults with income below 400 percent of FPL highlight the potential value of continuing to build on targeted outreach efforts that have been launched to connect LGBT adults with coverage (Out2Enroll 2014). A federal LGBT Issues Coordinating Committee established within the US Department of Health and Human Services has identified Marketplace outreach to LGBT individuals as a priority.6
Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and regression adjustment to control for differences in the demographic and socioeconomic characteristics of the respondents across the different rounds of the survey. This allows us to remove changes in insurance coverage caused by changes in the types of people responding to the survey over time rather than by changes in the health insurance landscape. The basic patterns shown for the regression-adjusted measures are similar to those based solely on simple weighted estimates. In presenting the regression-adjusted estimates, we use the predicted rate of coverage in each quarter for the same nationally representative population. For this analysis, we base the nationally representative sample on survey respondents from the most recent 12-month period from the HRMS (i.e., quarter 1 of 2015 and quarters 2–4 of 2014). We focus on statistically significant changes in insurance coverage over time (defined as differences that are significantly different from zero at the 5 percent level or lower) and highlight changes relative to September 2013, just before the open enrollment period for the Marketplaces began. We provide a 95 percent confidence interval for key estimates.
Limitations to the analysis: The HRMS is designed to provide early feedback on ACA implementation to complement the more robust assessments that will be possible as more federal survey data become available. Though HRMS estimates capture the changes in insurance coverage from the first open enrollment period under the ACA, the estimates understate the full effects of the ACA because the estimates do not reflect the effects of some important ACA provisions (such as the ability to keep dependents on health plans until age 26 and early state Medicaid expansions) that were implemented before 2013. In addition, these change estimates might not reflect only the effects of the ACA, because they do not control for long-term trends in health insurance coverage that predate the ACA nor do they control for changes in the business cycle. Further, the difference in coverage gains between the states that did and did not expand Medicaid should not be entirely attributed to the ACA; there were other policy choices that likely affected enrollment. For example, most of the states that have expanded Medicaid are also states in which same-sex marriage is legal, which has led to greater access to dependent coverage and changes in eligibility rules for public coverage in these states (Ranji et al. 2014).
Baker, Kellan E., Laura E. Durso, and Andrew Cray. 2014. Moving the Needle: The Impact of the Affordable Care Act on LGBT Communities. Washington, DC: Center for American Progress.
GfK. 2013. KnowledgePanel Design Summary. Palo Alto, CA: GfK.
Long, Sharon K., Michael Karpman, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Nathaniel Anderson, and Katherine Hempstead. 2015. Taking Stock: Gains in Health Insurance Coverage under the ACA as of March 2015. Washington, DC: Urban Institute.
Out2Enroll. 2014. Key Lessons for LGBT Outreach and Enrollment under the Affordable Care Act.
Ranji, Usha, Adara Beamesderfer, Jen Kates, and Alina Salganicoff. 2014. Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S. Menlo Park, CA: Kaiser Family Foundation.
Ward, Brian W., James M. Dahlhamer, Adena M. Galinsky, and Sarah S. Joestl. 2014. Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. National Health Statistics Report No. 77. Hyattsville, MD: National Center for Health Statistics.
About the Series
This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the Affordable Care Act before data from federal government surveys are available. The QuickTakes provide information on health insurance coverage, access to and use of health care, health care affordability, and self-reported health status, as well as timely data on important implementation issues under the ACA. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.
For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.
1 Given the small sample size for the LGB population in a single round of the HRMS, we pool data across quarters to increase the sample size and the precision of our estimates. June/September 2013 refers to pooled data that were collected separately in the June 2013 round and the September 2013 round of the HRMS (i.e., the survey was not fielded in the intervening months). Similarly, December 2014/March 2015 refers to pooled data that were collected in the December 2014 round and the March 2015 round of the HRMS.
2 We limit our sample to adults who have identified themselves as lesbian, gay, or bisexual when completing their household demographic profile, part of becoming a member of GfK’s KnowledgePanel, the Internet-based panel that underlies the HRMS (GfK 2013). We do not include adults who identify as transgender or whose sexual orientation is “other” because the high prevalence of those responses leads to a much larger than expected share of the sample identifying as LGBT or not heterosexual relative to other data sources that collect information on this population (Ward et al. 2014; Gary Gates and Frank Newport, “Special Report: 3.4% of U.S. Adults Identify as LGBT,” Gallup, October 18, 2012). However, we tested the sensitivity of our results by including transgender adults and found little difference in the patterns of change for LGB and LGBT adults.
3 For this analysis, we focus on state decisions to expand Medicaid by March 1, 2015. The states that had expanded Medicaid by this date are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IN, IA, KY, MD, MA, MI, MN, NH, NV, NJ, NM, NY, ND, OH, OR, PA, RI, VT, WA, and WV. Several of those states, including CA, CT, DC, and MN, expanded Medicaid under the ACA before 2013.
4 A recent analysis of Gallup-Healthways Well-Being Index data showed significant differences in uninsurance rates between LGBT and non-LGBT adults ages 18 and older, including the elderly, in quarter 3 of 2013 and quarter 2 of 2014. See Gary J. Gates, “In U.S., LGBT More Likely Than Non-LGBT to Be Uninsured,” Gallup, August 26, 2014. Analysis of National Health Interview Survey data for 2013 for adults ages 18 to 64 did not show statistically significant differences in uninsurance by sexual orientation (Ward et al. 2014).
5 Although the estimates are for an earlier time period with respect to the implementation of the major coverage provisions of the ACA, Gallup-Healthways Well-Being Index data also show an increase in the share of LGBT adults with insurance coverage under the ACA. Those data, which focus on all adults age 18 and older, show a decrease from 24.2 percent on average without coverage in quarter 3 of 2013 to 17.6 percent on average without coverage in quarter 2 of 2014. See Gates, “In U.S., LGBT More Likely Than Non-LGBT to Be Uninsured.” Another study found that the share of LGBT adults ages 18 to 64 with income below 400 percent of FPL who do not have insurance declined from 34 percent to 26 percent between June/July 2013 and July 2014 (Baker et al. 2014).
6 US Department of Health and Human Services, “LGBT Health and Well-Being: HHS LGBT Issues Coordinating Committee 2013 Report,” last updated June 4, 2014.