Open in a separate window Note. The number of medical and mental health care visits and total costs associated with the 3 most frequently billed ICD-9 codes during the 12 months before — and after — the legalization of same-sex marriage. When analyses included only patients with data at both time points, the results were similar; only medical care expenditures were no longer significantly lower in the 12 months after the law was passed.
HIV-positive men had no significant reduction in HIV-related visits results not shown , suggesting that the observed reduction in health care visits did not affect routine and other HIV-related care. Importantly, we were able to confirm that our results were not restricted to sexual minority men who were in partnered relationships, indicating that same-sex marriage policies may have a broad public health effect.
The magnitude of the overall effects, which corresponded to small and medium effect sizes, 30 were particularly striking given that policy-level changes are likely to be more distal determinants of health. One mechanism that may explain these findings is a reduction in the amount and frequency of status-based stressors that sexual minority men experience when institutionalized forms of stigma are eliminated. However, given the exploratory nature of these results, our findings on potential mechanisms should be interpreted with caution and require replication in future studies.
Limitations of the study included the possibility of unmeasured confounding. For example, changes in other health care policies in Massachusetts during this time could have been responsible for the results. However, an examination of health care policies in the state found no significant changes during the study period — Massachusetts initiated a comprehensive health care reform law, which required all residents to purchase health insurance coverage, but this did not go into effect until , 33 well outside the study period.
Furthermore, trends in health care costs in Massachusetts increased during the study period, 34 whereas we found evidence for decreased expenditures. One policy change did occur during that likely affected health care use. In , Massachusetts implemented significant cuts to their MassHealth insurance program for individuals with disabilities or living below the poverty line.
Removing this group from the analyses did not change the direction or magnitude of the results. Finally, although some same-sex couples lost their health care benefits if they chose not to marry 36 which could have led to a decrease in health care use , many couples obtained new health care benefits through their employers.
Although analyses indicated that this sample did not differ from other clinic attendees in terms of demographic variables, if this subsample differed in other respects e. Third, because the clinic is housed in a large metropolitan city, these results may not be generalizable to sexual minority men living in rural communities.
However, because rural sexual minority men confront additional stressors that are less common in urban environments, 38 the legalization of same-sex marriage may have a greater effect on their health, suggesting that our results could be interpreted as conservative estimates.
The use of a clinic-based sample also may restrict generalizability. For instance, sexual minority men who attend a clinic that focuses specifically on lesbian, gay, and bisexual health issues likely differ from other sexual minority men e.
However, men in our sample were higher educated e. Consequently, these results may not be fully generalizable to the general population of sexual minority men in Massachusetts. Finally, our measure of sexual orientation did not distinguish between same-sex attraction, behavior, and identity.
These dimensions of sexual orientation are highly correlated 40 but have been shown to define different population groups.
Although most studies rely on measures similar to the one we used, researchers have noted the limitations of single-item measures of sexual orientation and have highlighted the importance of including multiple dimensions of this construct to more accurately define the study population.
The prospective design also permitted a within-subjects approach, which affords a stronger test than do between-subjects designs, 45 particularly because subjects serve as their own controls, reducing the potential that factors other than the independent variable are responsible for group differences. The outcome measures were obtained via billing records, reducing the possibility for measurement error related to self-report.
Finally, the central explanatory variable in our study, changes in a state-level policy, occurred outside the control of the individual. Consequently, changes in this policy could not be caused by individual-level factors that also could affect the dependent variables of interest, which helps to minimize endogeneity. The ability of social policies to exert demonstrable effects on health has led to renewed interest in designing policy-level interventions to improve health at a population level.
Additionally, previous research has found substantial economic benefits of same-sex marriage policies that are accrued to businesses e.
Taken together, our study therefore makes an important contribution to an emerging body of research on the social, economic, and health benefits of same-sex marriage. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Human Participant Protection This research was approved by the clinic's institutional review board.
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