The Age of the "Insurance Card Marriage"

Forget green cards. A growing number of Americans are getting hitched to get health insurance [1].

Some people marry for love, some for companionship, and others for status or money. Now comes another reason to get hitched: health insurance.

In a poll released today, 7% of Americans said they or someone in their household decided to marry in the last year so they could get healthcare benefits via their spouse.

"It's a small number but a powerful result, because it shows how paying for healthcare is reflected not only in family budgets but in life decisions," said Drew E. Altman, president of the Kaiser Family Foundation, which commissioned the survey as part of its regular polling on healthcare.

...What surprised researchers was that such costs had become a factor in marriage decisions. "We should have asked about divorce," said Altman, joking.

Those who cited health insurance as a factor in deciding to marry tended to have modest incomes. About 6 in 10 were in households making less than $50,000 a year, said Mollyann Brodie, who directs Kaiser's opinion research. They also were younger, with 4 in 10 between 18 and 34.

Maybe they should have asked about divorce. They'd have found that at least some people stay married for the sake of health insurance [2].

Whether people get married or stay married for the sake of health insurance, who can blame them?

Health insurance is getting more and more expensive. Premiums have gone up 30% [3], compared to a 3% increase in wages. Co-payments for some prescriptions have shot up [4], as insurance companies change to a pricing system that charges patients a percentage of of the drugs' actual cost, instead of a fixed amount. And that percentage can range anywhere from 20% to 70% [5]. Plus, insurers are reimbursing less for out-of-network medical services [6]. If you've got cancer, you may have to pay cash up front before getting treatment [7].

And that's if you are insured, even under-insured. It's worse, much worse if you're uninsured. So, if people get married or stay (unhappily) married for the sake of having health insurance, I don't blame them one bit.

However, no matter which option these people choose, they all have one very important thing in common related to their access to health insurance: they can get married, to each other or to some other partner of their choosing. They might even marry someone they'd have married anyway. But, again, they can.

Do I need to say it? There's an entire class of people for whom marriage (getting married or staying married) isn't an option, because we can't marry each other. And the few alternatives don't really help much either. Just ask Robert Ryan and Ralph Martinelli [8], whose story I blogged about earlier [9].

What they didn't know before moving to Idaho could fill a house, and in many ways it does.

The kitchen table holds stacks of legal papers. Medication bottles litter a nearby countertop. The two-story home Robert Ryan, 42, shares with his partner, Ralph Martinelli, 53, overlooks a quaint suburb west of Boise, a rural landscape of ruddy hills that doesn't seem quite as welcoming as it once did.

A 2,400-mile move west that once seemed like a chance at a fresh start, has instead delivered some hard lessons -- especially about moving from a state that recognizes same-sex unions to one of the 21 states that don't.

The couple was stunned when Ryan was dropped from the company insurance plan the two shared in New Jersey, where they were able to register as domestic partners. Idaho does not formally recognize same-sex couples.

"It didn't even dawn on us that this would have an impact," Ryan said.

...A year after they started dating, they registered as domestic partners in New Jersey. Martinelli was told he could insure Ryan under his policy as a Konica Minolta Business Solutions sales manager.

Ryan used the policy to pay for medication to treat his depression, anxiety and the childhood asthma that resurfaced from severe smoke inhalation in the attack.

But he was dropped from the policy last October, shortly after the Konica Minolta company found the couple had moved to Idaho, where they couldn't register as domestic partners. In 2006, 63 percent of Idaho voters approved a constitutional amendment defining marriage as the union of a man and a woman, effectively outlawing same-sex unions.

Of course, if Robert and Ralph had been Robert and Rachel or Roberta and Ralph, it wouldn't have mattered. If they were married, they'd have been just as married in Idaho as they were in New Jersey. And if they were just shacking up and moved to a state that didn't offer the option of domestic partnership, they could just get hitched.

Boom. Done. Ralph (or Rachel) has health insurance. But they're not Robert and Rachel, or even Roberta and Ralph. So no health insurance for Ralph. Maybe. Robert pays $650 a month that he wouldn't have to pay if he and Ralph were married (and the amount deducted from his paycheck to cover his spouse would probably be a lot less), for a COBRA policy Ralph wouldn't need if they could marry, and that will expire in March 2009 anyway.

(Ironically, Robert's act of paying for Ralph's COBRA policy is a significant indication of their commitment to each other. If Robert weren't paying for the COBRA policy, Ralph wouldn't have coverage.)

A while back, I asked "Is Health Care a Gay Issue?" [10], and at the risk of repeating myself, it becomes one at the point where health insurance is linked to marital status, or at least it should.

Again, I have to go back to the Health Care for America [11] plan, and how it could apply to same-sex couples and our families.

At a stroke, then, no one with a direct or family tie to the workforce would remain uninsured.

…For the small share of people without direct or family ties to the workforce and ineligible for Medicaid, S-CHIP, or Medicare, the Health Care for America Plan would be available as an attractive new coverage option. Premiums would again be based on income, ranging from no premium in the case of those with incomes below the poverty line to the average actuarial cost of coverage for all enrollees in Health Care for America in the case of those with incomes above 400% of the poverty level. In other words, Health Care for America would allow higher-income individuals without workplace ties to buy into the program for a premium that did not vary with age, region, or health status (a so-called community-rated premium).

Meanwhile, Americans without ties to the workforce would be enrolled in the Health Care for America Plan through an individual buy-in, through state antipoverty and un-employment insurance programs, or through new efforts to reach the uninsured when they sought medical care without insurance.

It may not be obvious at first, but it's pretty easy to parse out if you consider how it would apply to couples like Ryan and Martinelli. Even without the benefit of legal marriage, a move from one state to another wouldn't cause Martinelli — someone without a direct or family tie to the workforce (because his partner, Ryan, is not legally considered "family")— to lose his health insurance.

For same-sex couples with children the benefit of a health care plan like this becomes even more obvious. A post by Daily Journalcolumnist Howard Ludwig [12] pointed me to a study recently published in the Journal of Economic Perspectives, titled "The Economics of Lesbian and Gay Familes," [13] and among the findings was this interesting tidbit.

Gay and lesbian couples with children are more likely to have a stay-at-home partner. Similar to heterosexual couples, the partner who stays home in a same-sex relationship usually has fewer years of formal education.

Again, the choices for a stay-at-home parent in a same-sex household when it comes to health insurance — in any state where our relationships are not legally recognized — are: (a) purchase an individual health insurance policy at a higher cost than, say, the married heterosexual stay-at-home parent next door who's carried on her husband's policy, which is underwritten by his employer and a paycheck deduction that's a lot less than the cost of an individual policy; or (b) end up doing without health insurance. (Children, under this plan, born with coverage.)

Something like the Health Care for America plan would "divorce" health insurance from marital status because, quite simply, no one would have to get married to get health insurance. And no one who can't marry their partner would face marital status as a barrier to getting health insurance, or pay a much higher price for health insurance as a consequence of not being able to marry.

Health care has cropped up in national political debate again, as Sen. John McCain debuted his health care plan, and the conventional wisdom is that the McCain plan would raise health care costs [14] and generally and already bad system worse. Bill Scher has posted a great blog round-up [15] that includes my favorite assesment of the McCain plan: "Oliver Willis and Masson's Blog sum up what McCain's plan means for you in one word: Pray."

You can bet that if it would make things worse for heterosexual couples, it would do our families even less good.

The Democratic presidential contenders, on the other hand, have plans that pretty much resemble the Health Care for America plan [16].

Hillary Rodham Clinton, Barack Obama and John Edwards have been sniping at each other for months over healthcare, but there's one thing the top Democratic presidential candidates agree on: Americans of all ages should have the choice of buying a government-run plan modeled on Medicare.

The idea, which would set up a competition between a new government plan and private insurance programs, has been overshadowed by the political horse race. But it's one of the most far-reaching and controversial proposals for making health insurance more affordable and more widely available.

The government now guarantees access to healthcare only for seniors and the disabled through Medicare and for the poor mainly through Medicaid. Under the proposals being advanced by Clinton, Obama and Edwards, the government would offer coverage for middle-class workers and their families, with benefits comparable to those now provided for federal employees and members of Congress.

Participation in the government plan would be voluntary, but the approach sparks widely differing reactions.

Equality, for our families is and may continue to be hard to come by much of the time, and hard won where it does exist, while we are in the process of building our lives and our families together; weaving our families' destinies together with those of our community and our country, much as we weave our own together as families. We can walk down the aisle just like any other couples, but may continue for some time walk back up the aisle with fewer benefits and protections than other couples.

But neither we nor they should need to walk down the aisle for the sake of having health insurance. Health Care for All isn't a "gay health bill," and it doesn't single out particular groups for inclusion or exclusion. It does, however, offer a way to provide all Americans with health insurance, married or not. It would treat my family the same as the family down the street, with two legally married parents, because its benefits are not conditional on the basis our marital status or anyone else's. We'd get them whether we're married or not, and whether we can marry or not.

Well, that's a kind of equality, and one that appears to be good for everybody.

Or, to put it another way, for all [17].