President-elect Joe Biden campaigned on supporting and building upon the Affordable Care Act (ACA), better managing the coronavirus pandemic and lowering prescription drug costs. However, with the political balance of the Senate uncertain, some Biden proposals, like creating a new public option and lowering the Medicare age to 60, are less likely to be enacted. Even so, as president, Biden could exercise executive branch authority to move forward on a variety of policy changes he has advocated through administrative action without Congress.

The table below includes potential administrative actions under the incoming Biden Administration, based on campaign pledges, and actions that would reverse or modify controversial regulations or guidance issued by the Trump Administration. The table also describes actions Biden could take as president that have received a great deal of attention from other prominent Democrats or are generally consistent with his campaign proposals, and that may therefore be priorities in Biden’s Administration. This table is not an exhaustive list of possible Biden Administration actions and does not include potential administrative actions pertaining to all health policy areas, including Medicare and prescription drug costs, where there is no clear indication of whether or how the Biden Administration would modify Trump Administration policies. If Biden’s health proposals are stymied by a divided Congress, he may look to use administrative actions beyond what’s detailed here to advance his health care agenda.

In this table, we note whether executive actions require regulatory change, as an indication of how much time it may take the Biden Administration to implement these changes. For some regulatory changes, the Biden Administration will need to issue a new Notice of Proposed Rule Making (NPRM) and allow a public comment period before revising the regulation. Rules made through annual payment notices, such as the Notice of Benefit and Payment Parameters (NBPP) may be revised annually.

By contrast, the Biden Administration may more quickly be able to reverse Trump Administration regulations that are proposed but not yet final as well as policies made through sub-regulatory agency guidance or executive order. Some sub-regulatory actions, such as renewing the COVID-19 Public Health Emergency Declaration that is currently set to expire on Inauguration Day, will require attention on Biden’s first day in office. Biden would also likely rescind pending rules that would sunset HHS regulations if not reviewed every 10 years (which could increase administrative burden for the agency and result in regulations with beneficiary protections expiring).

COVID-19 Response

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Affordable Care Act – Exchange Markets

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Affordable Care Act – Other Private Insurance

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Medicaid

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Women’s Health Policy

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Mental Health and Substance Use

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Immigration and Health

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Long-term Care

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HIV/AIDS Policy

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LGBT Health

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Introduction

The COVID-19 pandemic has had a profound impact on health care access and delivery. While patients’ other health care needs have generally not declined, providers have been tasked with figuring out how to address these needs while mitigating risk to both patients and staff related to the COVID-19 pandemic. Many providers have altered their practice models dramatically, including the rapid adoption of telehealth and reconfiguring practice workflows. While obstetrician-gynecologists (OBGYNs) do not represent the entirety of sexual and reproductive health (SRH) care providers, their experiences offer us insight into the field at a time of great change and adaptation.

At the time the novel coronavirus had started to spread widely within the U.S., KFF was underway fielding a national survey of OBGYNs to understand SRH care provision across the U.S. Realizing that practice patterns had likely changed due to the pandemic, we took the opportunity after the initial survey release to add a subset of questions related to provision of care during the COVID-19 pandemic. A nationally representative sample of 855 office-based U.S. OBGYNs answered the COVID-19 supplemental questions from July 8, 2020 to September 1, 2020. In this brief, we report on how the COVID-19 pandemic has impacted the provision of SRH care by U.S. OBGYNs.

The margin of sampling error for these questions is +/-6 percentage points at the 95% confidence level. All comparisons noted in this brief are statistically significant (p <0.05). A summary of physician and practice characteristic definitions can be found in the methodology section.

Declines in Visit Volume

At the time of the survey, more than half (54%) of OBGYNs said they had seen a decrease in the number of patient visits since the COVID-19 pandemic started in March 2020. Approximately a third (35%) saw about the same number of patients, while a minority (10%) saw more patients since the beginning of the pandemic (Figure 1). Those who were in small practices, defined as ≤ 3 full-time equivalent (FTE) doctors or advanced practice clinicians, appear to have been hit the hardest, with 73% of OBGYNs at small practices reporting a decrease in patients compared to 46% and 48% of OBGYNs at medium (4-10 FTE) and large practices (>10 FTE). Also, more OBGYNs age 65+ reported seeing declines in patient visits, compared to all younger age groups (80% for age 65+, 59% for age 55-64, 58% for age 45-54, 38% for age <45); this is also the age group that had the largest share of OBGYNs who did not utilize any telehealth in June 2020 (Table 2).

When those who reported a decrease in patient volume were asked to identify the primary driver of the decline, most attributed the decline to fewer patients seeking care (45%) or practice specific limitations (37%). State restrictions on health care services was less commonly (7%) cited as the primary reason for declines in patient volume (Figure 1).

Telehealth Utilization

During the COVID-19 pandemic, the use of telehealth grew rapidly among OBGYNs. Prior to the start of the COVID-19 emergency in the U.S. (March 1, 2020), the vast majority (86%) of OBGYNs said they did not conduct any telehealth visits. By June 2020, however, almost all (84%) reported conducting telehealth visits (Figure 2).

The average share of overall practice visits that OBGYNs reported conducting via telehealth grew from 1.5% before the COVID-19 emergency to 18% in June 2020. Physicians who had been using telehealth before the pandemic reported using telehealth for a significantly higher share of visits on average in June 2020 compared to those with no prior experience (35% vs. 16%). The average share of total visits conducted via telehealth also differed by physician characteristics, with higher shares of telehealth visits reported among female physicians and those under age 54. There were also differences by practice location, with those practicing in urban locations, the West and Northeast (areas initially hit hardest by the pandemic) and in Medicaid Expansion states reporting a higher share of telehealth visits (Table 1). No differences were identified by practice size.

When looking at how often OBGYNs utilized telehealth for patient visits, most did so for a minority of visits in June 2020; few (9%) were using telehealth for >50% of their total visits (Figure 3). Therefore, while the majority of OBGYNs have used some telehealth during the COVID-19 pandemic, most continued to deliver the bulk of their visits via in-person care.

While there was a major spike in telehealth adoption by June 2020, a small but sizable share of OBGYNs (14%) did not conduct any telehealth visits. A higher share of male OBGYNs compared to female, and older doctors compared to younger doctors reported no telehealth use in June 2020. Additionally, while there has been much discussion about the potential for telehealth to expand access in rural regions where transportation barriers can be a limiting factor in obtaining care, OBGYNs in rural areas were more likely than those in urban and suburban areas to have not adopted telehealth during the pandemic. About 1 in 4 OBGYNs practicing in rural areas, small practices and in states without Medicaid expansion reported no telehealth use (Table 2).

Telehealth Challenges

Among OBGYNs who provided telehealth care in June 2020, nine in ten (90%) experienced a telehealth-related challenge. The most cited challenge was the limitation in conducting physical exams (76%), followed by their patients having trouble using telehealth (63%), the inability to conduct diagnostic testing via telehealth (51%), lack of guidance on telehealth best practices (29%) and lack of training on how to use telehealth effectively (26%). A small minority cited high financial costs associated with establishing a telehealth program as a challenge (6%) (Figure 4).

For OBGYNs who had not been using telehealth prior to the pandemic, a higher share reported telehealth challenges (93%) compared to those who had used telehealth prior (75%). Those without prior telehealth use more often cited lack of training (29% vs. 5%), lack of guidance on best practices (32% vs. 14%) and limitations in conducting a physical exam (80% vs. 54%) as challenges, compared to those with prior telehealth use (Figure 5).

When thinking about the sustainability of telehealth beyond the COVID-19 emergency in the U.S., reimbursement was an issue cited by many. About half of OBGYNs (52%) reported they would need to be reimbursed at the same rate for telehealth compared to in-person care to continue conducting telehealth visits (Figure 6). About one in four (28%) said they would need to be reimbursed at 75-99% compared to in-person care to continue to offer telehealth. Few (11%) would accept <75% reimbursement for telehealth compared to in-person care, and 7% said they would not offer telehealth at all after the resolution of the COVID-19 emergency. Notably, a larger share of OBGYNs practicing in public clinics said they would not offer telehealth in the future, compared to those in private practice (16% vs. 5%).

Financial and Staffing Challenges

Four in five (81%) OBGYNs said their practice experienced at least one financial or staffing challenge as a result of the COVID-19 pandemic. The most commonly cited experiences were reducing operating hours (56%), reducing pay for clinicians (39%) and furloughing or laying off non-clinical staff (37%). Fewer reduced pay for non-clinical staff (17%), furloughed or laid off clinicians (16%) or closed the practice temporarily (13%) (Table 3). Half of OBGYNs reported that their practice experienced more than one of these challenges.

Financial and staffing challenges affected different shares of OBGYNs depending on practice type and setting (Figure 7). Temporarily closing their practices was reported by a higher share of OBGYNs in the Northeast (26%) compared to the West (10%), Midwest (9%) and South (10%); this was also the case for OBGYNs in small practices (22%) compared to those in medium (11%) and large practices (6%). Reducing operating hours was more common among OBGYNs in urban (59%) and suburban (71%) practices compared to those in rural practices (41%), as well as OBGYNs working in private practice (60%) compared to public clinics (37%). Additionally, a higher share of OBGYNs in private practice than public reported reduced pay for clinicians (42% vs. 22%).

Delivery of Reproductive Health Care

mode of Delivery

Despite the rapid growth in telemedicine visits, the vast majority of OBGYNs continued to provide basic contraceptive services and STI testing during the COVID-19 pandemic via in-person care. This includes LARC placement (92%), IUD removal (95%), contraceptive injections (93%), prescription of hormonal contraceptive pills (75%) and STI testing for symptomatic patients (94%) (Table 4).

Some OBGYNs reported utilizing telehealth to deliver these services. Nearly half (51%) of OBGYNs report prescribing OCPs via telehealth since the COVID-19 pandemic began. Younger OBGYNs age <45 (64%) and 45-54 (63%) were about twice as likely to provide OCPs via telehealth than older OBGYNs age 55-64 (34%) and 65+ (28%). Prescribing OCPs via telehealth was also more common among female OBGYNs compared to male (61% vs. 33%), OBGYNs in urban locations compared to rural (55% vs. 35%), and those in large practices compared to small (64% vs. 44%). Providers in the West (67%) reported higher rates of providing OCPs via telehealth compared to those in the Midwest (45%) and South (44%), as well as those in states with Medicaid expansion compared to states without Medicaid expansion (57% vs. 39%) (Table 5).

Despite innovations in telehealth for use in STI care and contraception, very few OBGYNs reported utilizing telehealth for STI testing (9%), or for providing instruction on self-administered contraceptive injections (3%) or IUD removal (2%) (Table 4). Providers who were using telehealth for >25% of their patient visits in June 2020 reported higher use of telehealth for STI testing (20% vs. 6%), contraceptive injections (8% vs. 1%) and OCP prescription (63% vs. 48%) than providers using telehealth for ≤25% of their visits.

Very few OBGYNs reported that they were not providing the aforementioned services at all at the time this survey was fielded (July 8 to September 1, 2020). In the Northeast (14%), the region hit particularly hard early on in the COVID-19 pandemic, a higher share of doctors reported they were not providing LARC placement at the time of the survey compared to those in the West (4%), Midwest (2%) and South (3%). Similarly, a somewhat higher share of OBGYNs in the Northeast were not providing contraceptive injections (8%) compared to the Midwest (1%) and South (1%) [no statistically significant difference was found from the West (3%)]. It is possible that practices have resumed provision of these services since the fielding of this survey.

Access and Delays in Care

The majority of OBGYNs said it was more difficult to address their patients’ needs during the COVID-19 pandemic; this was true for both reproductive preventive care needs (71%), like STI and cervical cancer screening, as well as chronic gynecological conditions (77%), like addressing fibroids, endometriosis and menopausal symptoms (Figure 8).

Most OBGYNs expressed concern that patients who experience delays in SRH care as a result of the COVID-19 emergency will face negative health consequences. At least six in ten OBGYNs reported being very or somewhat worried about delays in contraceptive care, prenatal care, follow-up care for abnormal pap smears, STI treatment, and obtaining an abortion (Figure 9).

Negative health consequences due to delays in obtaining an abortion were of particular concern to certain groups of OBGYNs. A higher share of female compared to male, urban and suburban compared to rural, and younger compared to older OBGYNs said they were very or somewhat worried about delays in abortion care. Additionally, a higher share of OBGYNs who provide abortions said they were very or somewhat worried about delays in abortion care, compared to OBGYNs who do not provide abortions (Figure 10).

Conclusions and Implications

Since the onset of the COVID-19 pandemic, OBGYNs across the country have been faced with the challenge of how to provide quality sexual and reproductive health (SRH) care to patients during a public health emergency. Our survey finds that most OBGYNs are continuing to provide SRH services, however not without great adaptation. Almost all have changed the way they deliver care, including quickly adopting telehealth, and most have changed, at least temporarily, the way their practice operates, including reducing operating hours and staffing. This rapid response has likely put stressors on both patients and providers. While we were not able to elicit the patient perspective in this survey, we saw that OBGYNs reported declines in patient volumes, largely attributed to fewer patients seeking care, and that OBGYNs worry about the negative health consequences that may result from delays in care. This suggests that patients are facing heightened barriers to accessing care, and that OBGYNs are facing new challenges to providing that care.

While our study provides a snapshot into how OBGYNs adapted their care provision during the Summer of 2020, we recognize that in a rapidly changing environment much has likely evolved since this survey was fielded, and will continue to evolve in the months to come. As the pandemic surges in much of the country, practices may need to reevaluate how they are providing care. OBGYNs, as well as other health care providers, will need to continue to make decisions about how best to meet the sexual and reproductive health care needs of their patients, at a time when patient need for these services has not diminished.

Summary

The 2020 KFF National Physician Survey on Reproductive Health obtained responses from a nationally representative sample of OBGYNs practicing in the United States who provide sexual and reproductive health care to patients in office-based settings. The survey was designed and analyzed by researchers at KFF (the Kaiser Family Foundation). An independent research company, SSRS, carried out the fieldwork and collaborated on questionnaire design, pretesting, sample design, and weighting. KFF paid for all costs associated with the survey. Survey responses were collected via paper and online questionnaires from March 18 and September 1, 2020, from a random sample of 1,210 OBGYNs. All OBGYNs included in the sample were sent an invitation letter encouraging them to participate as well as an incentive, described below. The initial sample release in March 2020 corresponded with the emergence of the COVID-19 pandemic. As such, after the initial sample release, additional questions were added related to how the COVID-19 pandemic impacted providers. Among the 1,210 OBGYNs, 855 OBGYNs completed the additional questions related to COIVD-19. The samples were weighted to match known demographics. Taking into account the design effect, the margin of sampling error for the total sample is +/-4 percentage points at the 95% confidence level. The margin of error for the sample who completed the COVID-19 supplemental section +/-6 percentage points. All statistical significance testing was set at p <0.05.

Sample Design

The sample of OBGYNs was procured from IQVIA via their OneKey Database. The OneKey database integrates provider information from various sources (e.g., IMS Health, SK&A, and Healthcare Data Solutions) and is continually updated through telephone and desktop research. The IQVIA OBGYN population universe is about 46,815 and a sample of 6,288 records were selected for this study. Using the survey questionnaire, the sample was then further screened to include only those who are board certified, spend at least 60% of their time providing direct patient care, and provide sexual and reproductive health care to at least 10% of their patients in an office-based setting.

A two-wave sample release design was used for this study to enable adjustments to the sample release and improve representativeness as a result of non-response. In Wave 1, the sample included an oversample of OBGYNs who work in rural areas, work in a public setting and those that had 25% or more of their patients covered by Medicaid, in order to obtain a reliable sample of these key groups of interest. ZIP code of the office, profit status of the facility and median income of the practice location were used as proxies to target these groups respectively. After the initial sample release, SSRS reviewed the productivity of the sample to model the second release. The number of OBGYNs working in a public setting was lower than anticipated, therefore Wave 2 again included an oversample of OBGYNs in public practice.

Contact Design

In an effort to maximize the survey completion rate, OBGYNs were contacted by multiple modes (mail, email) and offered the opportunity to complete the questionnaire either on paper or online. Those who completed the paper survey mailed back their responses using a prepaid reply envelope. OBGYNs were sent an up-front cash $2 bill incentive as well as an incentive check for $75 in the first two mailings to encourage respondents to complete the survey. Respondents received up to five communications for the main survey, four postal mailings and one email. The Wave 1 release corresponded with the emergence of the COVID-19 pandemic. As such, after the initial sample release, additional questions were added related to how the COVID-19 pandemic impacted providers. Wave 1 completes were recontacted and asked to complete these questions, with up to two additional communications, one postal and one email. The Wave 2 release was sent the main survey as well as the COVID-19 questions to complete.

Response Rate

The response rate for the OBGYNs was 22.1% and was calculated using AAPOR’s RR3 (53% completes by web, 47% by mail).

Weighting

The sample was weighted in stages. The first stage of the weighting was the application of a base weight to account for the disproportionately-stratified samples and response rates across sample strata. In the second stage of weighting, the OBGYN sample was post-stratified to match the IQVIA frame on key variables. In the final stage, self-reported sample demographics were matched to population parameters from the AMA database. Qualified respondents’ weights were then rebalanced to the total complete sample size. Because a selection of questions about COVID-19 were added to the survey after the first wave of sample had been released, a second weight was calculated based on respondents who received the supplement and was used for analyses of those questions.

Analysis

A series of data quality checks were run, including removing duplicate cases (n = 32). We compared survey responses by key physician and practice demographics. Gender, age and race were determined by physician self-report. Practice type was determined by physician self-report; those who indicated they work in private practice or a health maintenance organization were classified as “private,” while those who indicated they work in a community health center, a family planning clinic or a government operated health department were classified as “public.” Practice size was determined by the number of full-time equivalent (FTE) physicians or advance practice clinicians (small ≤ 3, medium 4-10, large >10). Urbanicity and region were determined by the ZIP code of the practice, using U.S. census definitions and breaks.

Demographics of Survey Respondents for the COVID-19 Supplement

Background

The legal and policy landscape regarding protections based on sexual orientation and gender identity in health care and other areas has shifted markedly in the last decade. Most recently, on June 15, 2020 in Bostock vs. Clayton County, the Supreme Court of the United States ruled that, under Title VII of the Civil Rights Act of 1964, it is unlawful sex discrimination for an employer (with at least 15 employees) to fire an employee because of their sexual orientation or gender identity. It is likely that this ruling will have implications for employers’ decisions regarding health insurance coverage for employees with same-sex spouses, among other areas of employment.

Using the latest data from our annual Employer Health Benefits Survey (EHBS), we assessed access to employer sponsored health insurance (ESI) coverage for same-sex spouses during the first half of 2020 (prior to the Bostock decision), as well as trends over time; ESI remains the primary way people in the U.S. receive health coverage, either directly or as a spouse or other dependent.^1 ,2  We find that, as of mid-2020, while employer offer of same-sex spousal coverage has increased over time, it remains less common than opposite sex spousal coverage.³  These increases follow two other Supreme Court rulings (United States v Windsor and Obergerfell v Hodges) which guaranteed the right to marriage nationwide and paved the way for wider access to health insurance through the workplace (see Appendix).⁴ 

Findings

Firms Offering

In 2020, about three-quarters (74%) of firms offering health insurance coverage to opposite-sex spouses also provided coverage to same-sex spouses, a substantial increase from 43% in 2016 (see Figure 1).⁵  Of the remaining 26% of firms, 5% reported that they do not offer this benefit (similar to the share in 2018) and 21% reported they had not encountered this as a benefits issue, a finding driven by small employers (those with fewer than 200 workers), who represent the majority of employers overall (97%).⁶  It is becoming less common for employers to report not encountering this benefits issue.

The likelihood of employers offering both opposite-sex spousal coverage and same-sex spousal coverage increases with firm size (see Figure 2). Among firms offering opposite sex spousal coverage, large firms (those with 200 or more employees) were more likely to offer coverage to same-sex spouses compared to smaller firms (89% vs 73%). Almost nine in ten (89%) large firms with opposite-sex spousal coverage offered such coverage, 9% did not, and 2% reported they had not encountered this benefits issue. Among the largest firms (those with a 1,000 or more workers), 95% offered coverage to same-sex couples. By contrast, just 73% of small employers (3-49 workers) offered coverage to same-sex spouses. Four (4%) percent did not and 23% said they had not encountered it.

 

Covered Workers

While the majority of firms in the United States are small, the majority of covered workers are employed by large firms (200 or more workers) (see Figure 3).⁷  In 2020, among employees who worked at firms offering opposite-sex spousal health benefits, 91% also had access to same-sex spousal coverage, up somewhat from 88% in 2018 and 84% in 2016 and 2017 (see Figure 4). Five percent (5%) did not have access to this benefit, and 4% worked at firms who reported they had not encountered this benefits issue.

As with firms offering same-sex spousal coverage, the share of employees with access to this benefit increases with firm size (see Figure 5). Most covered workers (96%) at large firms (those with 200 or more employees) who have access to opposite-sex spousal coverage also have access to same-sex spousal coverage. Just 4% did not, and less than1% worked at firms that reported they had not encountered the issue. Among workers at the largest firms (1,000+ workers), nearly all (98%) had access to same-sex spousal coverage. Those least like to have access were employees at firms with 50-199 workers, 15% of whom did not have same-sex spousal coverage when opposite sex coverage was available.

Workers at small firms offering opposite-sex spousal coverage were less likely to have access to health insurance benefits for same-sex spouses, though a majority did (77%). Nine percent (10%) did not have access to this benefit and another 13% worked at firms that report they have not encountered this issue.

Conclusion

These findings indicate that access to employer coverage for same-sex spouses is increasing in the U.S., though it still is less than access to opposite sex spousal coverage. Coverage varies substantially by employer size, with employees at small firms having less access while those at the largest firms have almost uniform access to this benefit. In some cases, lack of access could be a policy decision, though that appears to be on the decline, with smaller shares of firms saying explicitly that they do not offer same-sex spousal coverage. Moreover, it is likely that the Bostock decision will have further implications for same-sex spousal coverage, with more firms being required to offer this benefit under the sex protections in Title VII. However, Title VII nondiscrimination protections do not apply to the 5% of employees at firms with less than 15 employee. Further, the Bostock court cautioned that employers could potentially secure religious liberty exemptions from extending sex protections to encompass sexual orientation and gender identity and it is yet to be seen how such exemptions interact with Title VII.

This work was supported in part by the Elton John AIDS Foundation. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Supreme Court Marriage Cases – Background

Prior to the Windsor and Obergefell decisions, same-sex couples faced limited options for obtaining spousal coverage through an employer and when they did, this benefit was treated differently under federal law from benefits received by heterosexually married couples. While some employers offered domestic partner benefits for same-sex partners⁸  and a growing number of states began to recognize same-sex marriage⁹ , in 2012, less than half of all workers with health coverage had access to same-sex health benefits.¹⁰  In addition, because the federal government did not recognize same-sex marriages, where such benefits were offered, they were not considered tax exempt which meant that same-sex couples faced higher tax burdens compared to heterosexual counterparts.

In June 2013, in Windsor, the Supreme Court overturned a major portion of the Defense of Marriage Act (DOMA) which had, for federal purposes, defined marriage as between a man and a woman. The Windsor decision required federal recognition of same-sex marriages, even if a couple lived in a state that did not recognize same-sex marriage. As a result, employer-sponsored health benefits provided to legally married same-sex couples were now considered tax exempt.¹¹  Windsor, however, did not require states to issue same-sex marriage licenses or recognize those performed elsewhere, leading to a patchwork of recognition across the U.S. and lack of access to legal same-sex marriage for many couples where they lived. In 2015, the Supreme Court’s ruling in Obergefell legalized same-sex marriage nationwide, requiring all states to recognize same-sex marriages and issue marriage licenses to same-sex couples. While neither decision required private employers to offer same-sex spousal coverage if they offered coverage to opposite-sex spouses¹² , it was expected that wider access to marriage would lead to greater access to coverage. In fact, one study found that the legalization of same-sex marriage in New York was associated with an increase in employer-sponsored insurance among same-sex couples.¹³  In addition, an increasing number of states (22 states and DC as of 2019) have protections in place that prohibit employers from discriminating against individuals based on sexual orientation, and presumably would require employers offering opposite-sex spousal coverage to extend that benefit to same-sex spouses.¹⁴  Furthermore, employers who refuse to offer same-sex spousal coverage while providing coverage to opposite-sex spouses could face legal challenges. Still, employers are not required to provide same-sex spousal coverage parity to their employees.

1. Virtually all employers offering health benefits offer spousal coverage, allowing over half those covered by an employer plan to be covered as a dependent. ↩︎
2. Kaiser Family Foundation. Health Insurance Coverage of the Total Population, 2019. State Health Facts. https://modern.kff.org/other/state-indicator/total-population/ ↩︎
3. Note: the survey was largely fielded prior to the Bostock decision, see Methods. ↩︎
4. Additional detail about these Supreme Court cases is available in the Appendix. ↩︎
5. This increase was driven by the smallest firms so this finding may have some year-to-year volatility based on the mix of small firms sampled. ↩︎
6. Distribution of Employers, Workers, and Workers Covered by Health Benefits, by firm size, 2020 from The KFF 2020 Employer Health Benefits Survey (2020). Exhibit available here: https://modern.kff.org/report-section/ehbs-2020-survey-design-and-methods/#figurem6 ↩︎
7. Distribution of Employers, Workers, and Workers Covered by Health Benefits, by firm size, 2020 from KFF 2020 Employer Health Benefits Survey (2020). Exhibit available here: https://modern.kff.org/report-section/ehbs-2020-survey-design-and-methods/#figurem6 ↩︎
8. The first employer to do so was the Village Voice in 1982. (Appleby, J. May 14, 2012. “Many Businesses Offer Health Benefits To Same-Sex Couples Ahead Of Laws.” PBS Newshour. Retrieved from: http://www.pbs.org/newshour/rundown/many-businesses-offer-health-benefits-to-same-sex-couples-ahead-of-laws/.) ↩︎
9. Massachusetts became the first state to recognize same-sex marriage in 2003. By June 2013, 12 states and the District of Columbia recognized gay marriage. (See Honan, E. June 26, 2013. “Factbox: List of states that legalized gay marriage.” Reuters. Retrieved from: http://www.reuters.com/article/us-usa-court-gaymarriage-states-idUSBRE95P07A20130626.) ↩︎
10. Among Large Firms Offering Health Benefits, Percentage That Offer to Unmarried Opposite-Sex and Same-Sex Domestic Partners, 2008-2019, from The KFF 2019 Employer Health Benefits Survey (2019). Exhibit available here: https://modern.kff.org/report-section/ehbs-2019-section-2-health-benefits-offer-rates/#figure213 ↩︎
11. IRS Revenue Ruling 2013-17,  August 29, 2013. https://www.irs.gov/pub/irs-drop/rr-13-17.pdf. ↩︎
12. However, the Windsor decision ensures federal employees and contractor employees, have access to same-sex spousal coverage at parity with opposite-sex spousal coverage offerings and the Obergefell ruling means that spousal coverage benefits should be extended to state and municipal employees across the nation to the same degree as their heterosexual counterparts. ↩︎
13. Gonzales G. “Association of the New York State Marriage Equality Act with Changes in Health Insurance Coverage.” JAMA. 314(7). 2015. ↩︎
14. Human Rights Campaign. Map of State Laws and Policies- Statewide Employment Laws and Policies. Available at: http://www.hrc.org/state_maps. Accessed 10/15/20. ↩︎