Trinity-Led Research Reveals Progress and Challenges in Insurance Coverage for Same-Sex Couples

A new national study led by Trinity University faculty highlights a historic shift in health insurance for same-sex couples, while also underscoring inequities across income levels and regions. 

Published in JAMA Network Open, a peer-reviewed journal of the American Medical Association, the study found that for the first time, married same-sex couples are now slightly more likely to have health insurance than their married straight counterparts. This reversal of a long-standing disparity marks a milestone in LGBTQ+ health equity.  

The research team included Trinity economist Benjamin Harrell, lead author; Nicole Jones, assistant professor of sociology at Trinity; and Gabe H. Miller, sociologist at the University of Alabama at Birmingham.

Drawing on data from the American Community Survey covering more than 20 million adults from 2008 to 2022, the team of researchers traced the impact of two key policy shifts: the 2015 Supreme Court decision Obergefell v. Hodges, which guaranteed marriage rights nationwide, and provisions of the Affordable Care Act (ACA), which expanded coverage through Medicaid and new insurance marketplaces. Together, these changes helped close insurance gaps between same-sex and straight couples.

“On balance, this is good news,” Harrell said. “Health insurance rates have substantially improved for same-sex couples, who historically were far less likely to be insured despite higher healthcare needs.”

Between 2013 and 2018, insurance rates for married same-sex couples rose sharply, surpassing those of married straight couples by about four percentage points. Today, same-sex couples are 1.7 to 2.5 percentage points more likely to be insured overall.

Still, the gains are uneven. Improvements were concentrated among married couples—especially male couples—with higher incomes, employer-sponsored insurance, and residence in Medicaid expansion states. Couples in the South and Midwest, where many states rejected expansion, were less likely to benefit.

“Marriage has given many same-sex couples access to coverage they were previously denied,” the authors wrote. “But not everyone is sharing in the progress.”

Income levels further shape disparities: at the lowest incomes, coverage rates for same-sex and straight couples are nearly equal, but among middle- and higher-income groups, same-sex couples are significantly more likely to be insured.

The authors recommend that policymakers focus on extending coverage to unmarried couples, lower-income households, and residents of states that have not expanded Medicaid.

Read the full study