Last week, Alabama's Supreme Court Justice Roy Moore joined a long, pathetic line-up on the wrong side of history when he tried to defy the US Supreme Court by ordering Alabama court officials to continue denying marriage licenses to gay and lesbian couples. Some writers correctly compared the stand-off to a previous shameful chapter of Alabama history, when Governor George Wallace tried to defy US Supreme Court rulings about segregation. What I would like to add to all of this dialogue are the benefits to health justice when we recognize same-sex marriages. Given the network of mutuality in which we live, the health of our whole society improves when we uphold the rights for our LGBT brothers and sisters.
For many of us, access to health care depends on the legal recognition and standing of our relationships. When a person is covered by her or his spouse's employer-based health insurance, that coverage depends on the marriage being legally recognized in their state. Similarly, when a person wants to make medical decisions on behalf of an incapacitated spouse, having a legally recognized marriage supports the authority of patients and families. These are basic components of health care access and delivery for all of us, regardless of our sexual orientation. As a physician, I believe patients and their families have enough to deal with from illness and injury. It is an unjust and unnecessary burden to require couples and families to defend the validity of their relationships when seeking health care. I am not alone in this line of thinking. The American Academy of Pediatrics, the American Medical Association, the American Congress of Obstetricians and Gynecologists, and the American Psychiatric Association have all issued unequivocal statements of support for marriage equality for same-sex couples.
Regardless of our fields of expertise, health care providers should be glad to see the progress made at the federal level to build equality for same-sex married couples. For federally-funded health care programs (including all of the health insurance exchanges set up by the federal government in 30 states), the Affordable Care Act prohibits basing coverage eligibility, benefits, and insurance premiums on gender identity, sexual orientation, or sex stereotyping. The health insurance exchanges set up by state governments are similarly prohibited from discriminating based on sexual orientation. When the Supreme Court struck down the Defense of Marriage Act (DOMA) in 2013, there were a variety of positive outcomes for access to and delivery of health care. Since that ruling, same-sex spouses have been able to use benefits under Medicare Advantage and the Veterans Administration.
However, as Americans we are governed by an interplay of federal and state laws. Defeating DOMA was a major step in the right direction, but the journey is hardly over. The US Department of Health and Human Services must defer to state governments to recognize same-sex marriages when determining Medicaid eligibility. One can imagine how much harder it is for low-income LGBT Americans (almost 40 percent earn less than $30,000 per year) to get health insurance coverage when they live in a state that neither expands Medicaid nor legalizes their marriages. Additionally, for same-sex couples living in states that do not recognize their marriage, they can not readily use provisions of the Family Medical Leave Act (FMLA) to bond with a newborn, to welcome a newly adopted child to their home, or to care for a sick family member. This system of double standards contributes to disparities in health care for our LGBT brothers and sisters, especially when we look at HIV and mental health burdens.
When any of us live as second-class citizens, none of us can truly thrive. By taking such contrasting policy paths for marriage and health, our state governments are turning America into a place where access to basic equality and health rights depends on what we earn, who we love, and where we live. Crossing state lines can transform whether we are insured, whether we can participate in medical decisions for our families, whether we can take time away from our jobs to prioritize health needs, and so on. As a physician, these conditions are not part of the Hippocratic Oath I took, and as an American, this patchwork of discrimination undermines "liberty and justice for all." I do not have to be gay to realize that we are all vulnerable as individuals, but we can draw strength from communities united under common values of health justice. We can do better. We must do better. Let's start acting like Americans and manifest equality for all of us, regardless of who we love.