Recently in Perry v. Schwarzenegger, District Court Judge Vaughn Walker issued a momentous decision when he found that California's ban on same-sex marriage (Proposition 8) violated the Due Process and Equal Protection Clauses of the U.S. Constitution. Much of the media's attention has focused on the unprecedented nature of the holding, the implications for other states that ban same-sex marriage, and what this civil rights victory means for gay men and lesbians.
I want to highlight an important potential benefit of same-sex marriage that has not been getting much media attention, but that intersects with another major civil rights struggle we witnessed over this past year: improving health care access and outcomes.
Bans on same-sex marriage can negatively impact the health of gay men and lesbians in three ways: they leave more people uninsured and thus unable to access care; they stigmatize gay men and lesbians, encouraging discrimination and compounding other social and legal barriers to health; and they create harmful mental and physical health effects. Thus, marriage equality plays an important role in improving health care access and outcomes.
1. Bans on Same-Sex Marriage Leave More People Uninsured
Marriage provides heterosexual couples with a tool for getting insurance, which we know is critical for ensuring health care access and quality. Bans on same sex marriage mean that gay and lesbian partners do not have this same option. Even where states provide domestic partnerships as an option, there is still a disparitiy in access to insurance coverage for gay couples, as shown in a recent UCLA study. The UCLA study found that "Partnered gay men are less than half as likely (42 percent) as married heterosexual men to get employer-sponsored dependent coverage, and partnered lesbians have an even slimmer chance (28 percent) of getting dependent coverage compared to married heterosexual women." The study notes the individual and societal costs of this disparity: "The exclusion of gay men and women from civil marriage and the failure of domestic partnership benefits to provide insurance parity contribute to unequal access to health coverage, with the probable result that more health spending is pushed onto these individuals and onto the public."
This disparity exists even in a state like California that requires group health insurance plans and plans with spousal coverage to extend the same coverage to domestic partners. This is because of a federal law, ERISA, which exempts employers with self-insured plans from state insurance and antidiscrimination protections. According to the Bureau of National Affairs, more than 30 percent of employers in California are self-insured.
2. Bans on Same-Sex Marriage Stigmatize Gays and Lesbians, Compounding Social and Legal Barriers to Health
When issues affecting the gay community are discussed in the media, the dominant image portrayed is of a privileged, white, gay male. This leads to certain assumptions about the plight of gay people -- that it is not as bad as that of other groups, especially from a socio-economic perspective. While this may be true for some people within the gay community, it causes us to overlook the number of gay people living in poverty and at the margins of society who cannot afford to buy insurance on their own, and who have legally been denied the right to the insurance and other economic benefits that heterosexual couples can get. This image also obscures a harsh reality about many gay men and women who suffer from multiple barriers to health care.
I have seen this first-hand through the work of organizations like HALSA (HIV/AIDS Legal Services Alliance) because I serve on its board and have served as a volunteer attorney there. HALSA helps people living with HIV/AIDS get or keep health care benefits, housing, and the other resources necessary to access care and stay healthy. Many of HALSA's clients are gay, but they are also primarily people of color, living in poverty, and often struggling from disabling medical conditions other than HIV. For clients of HALSA's immigration practice, these barriers are further compounded by linguistic challenges and immigration status. While legalizing same-sex marriage is certainly not the perfect answer to these problems, it could have immediate and tangible health benefits for some.
One of most important points made by the challengers of Proposition 8 was that bans on same-sex marriage stigmatize gays and lesbians by rejecting their relationships as less valuable, and providing state endorsement of private discrimination. This can have a dangerous impact on health care access in two ways. First, this kind of stigma is never restricted to one area - it consciously and subconsciously influences society's views and treatment of gays and lesbians more broadly. Indeed, we have already seen how this stigma can infect public and private decisions about health care access and resources. The AIDS epidemic is a perfect example. I am currently rereading the book And the Band Played On by Randy Shilts, about the beginning of the AIDS epidemic. It documents how most of the people in the media, government, and even the medical community ignored the seriousness of AIDS in the beginning, in part because people associated it solely or primarily with gay men, and their lives were not valued enough to warrant an aggressive public health or research response. Once AIDS began to surface in babies, transfusion patients, and the heterosexual community, attention and resources were increased dramatically. Another example is in the area of fertility treatment. Lesbians seeking fertility treatment have been routinely discriminated by certain doctors because of judgments about the worth and desirability of same-sex families and parenting -- judgments that echo the same assumptions and claims used to justify bans on same-sex marriage.
3. Bans on Same-Sex Marriage Can Have Harmful Mental and Physical Health Effects
Challengers of the Proposition 8 ban have also argued that access to equal marriage rights is linked to mental and physical health. We can see this in three ways. The first is related to the above point - marriage discrimination creates government sanctioned stigma against gays and lesbians that leads to broader societal discrimination. We have ample evidence that societal discrimination creates pressures that lead to or aggravate depression, and the mental and physical effects that accompany it.
Stigma or discrimination can also undermine patient trust in the health care system, which means patients may be less willing to seek out care, and in some cases, to follow the appropriate medical regimen. This phenomenon is well documented among some racial and ethnic minorities who admittedly avoid the health care system because of racism and true horror stories about how blacks were used for medical research in deceptive and harmful ways (the Tuskegee syphilis study being the most infamous, but not the only, example). Increasingly, however, we have seen evidence of this for gay men and lesbians in need of mental, reproductive or sexual health care, especially those in isolated or underserved communities without providers that are knowledgeble and sensitive to issues impacting the gay community.
Finally, Proposition 8 challengers suggest an even more direct link between marriage and health by citing studies showing that married people tend to be healthier than nonmarried individuals. Obviously there are many caveats to these studies, and not all marriages are necessarily good for mental or physical health. But to the extent this may be added benefit to marriage, it is certainly an important one.
