Association for Public Policy Analysis & Management

Background: In 2015, same-sex marriage became legal across the United States and allowed more lesbian, gay, bisexual, and transgender (LGBT) people to marry the person they love. However, very little research has examined the impacts of same-sex marriage laws on health and wellbeing among LGBT people. This study estimated the impact of same-sex marriage laws on short-term marriage rates, health insurance coverage, and health outcomes for LGBT people in the United States.

Data: This study used data from the 2012-2016 Gallup-Healthways Well-Being Index (WBI), a cross-sectional telephone survey of adults aged 18 years and older in the United States. The final sample included 11,067 adults aged 25-64 years who personally identified as lesbian, gay, bisexual, or transgender (LGBT) and 326,442 non-LGBT adults aged 25-64 years. All analyses were restricted to observations in the 41 states implementing same-sex marriage during or after 2013, which allowed for ample pre- and post-implementation data.

Methods: This study took advantage of the natural experiments that occurred when same-sex marriage laws were implemented in different states at different times. A difference-in-differences approach was used to compare changes in each outcome between the treatment group (LGBT adults) and the comparison group (non-LGBT people). Linear probability models estimated the impact of legalizing same-sex marriage on LGBT adults while adjusting for age, race and ethnicity, educational attainment, residence in a Metropolitan Statistical Area (MSA), and state and year fixed effects. 

Results: 41 states legalized same-sex marriage between 2013 and 2016. Compared to the underlying trend for non-LGBT men and women, legalizing same-sex marriage increased the likelihood that LGBT men and women were married by more than 7 percentage points (8.1 percentage points for LGBT men and 7.4 percentage points for LGBT women). Legalizing same-sex marriage was associated with a 3 percentage point reduction in the likelihood that LGBT men were uninsured and a 2.9 percentage point reduction in the probability that LGBT men reported poor/fair health compared to non-LGBT men. Meanwhile, legalizing same-sex marriage was associated with a 3.8 percentage point reduction in uninsurance for LGBT women compared to non-LGBT women. Implementing same-sex marriage was not associated with significant reductions in psychological distress, depression diagnoses, or smoking rates for LGBT adults versus non-LGBT adults. 

Conclusions: This study found that many LGBT people married following the legalization of same-sex marriage in the United States. Legalizing same-sex marriage was associated with some improvements in health insurance coverage and self-reported health status for LGBT people, but results varied by gender. Meanwhile, same-sex marriage laws were not associated with significant improvements in behavioral health—a major health concern for LGBT people. This research is especially timely given the recent implementation of same-sex marriage in the United States and ongoing policy debates on additional nondiscrimination protections for LGBT people, such as employment non-discrimination acts (ENDAs) and religious freedom restoration acts (RFRAs). To achieve LGBT health equity, policymakers and health care providers should work together to address LGBT-based bias in public policy and health care settings.