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Same-sex marriage, human rights and affordable healthcare

May 1st, 2014

by Jonathan H. Burroughs

Our country's 237-year history is marked by a long and slow advocacy for human rights of all kinds.

In 1859, shortly before the civil war, 23 percent of all Americans were slaves. On Aug. 26, 1920, the 19th constitutional amendment was signed into law giving women the right to vote. In 1964, Title VII of the Civil Rights Act passed barring federal discrimination based upon race, color, national origin, religion or sex. In February 2014, Congress struck down the Defense of Marriage Act (DOMA), which gives federal recognition to same-sex marriages or civil unions in states that permit them.

What do human rights have to do with healthcare? Legally disenfranchised groups typically have little access to protections under law, employer-based healthcare plans or tax advantages/credits for being legally married. Thus, human rights have social, economic and healthcare implications that affect all of us through: cost shifting and our country's ability to provide high-quality, low-cost care.

How does this work?


Cost shifting

Prior to the Patient Protection and Affordable Care Act of 2010, more than 50 million Americans lacked health insurance and almost 100 million had inadequate coverage. Today, there's a growing number of individuals with high-deductible healthcare policies, which may result in bad debt or failure to pay the deductible for services rendered.

These costs must shift to those who can afford to pay, which drives up healthcare costs for everyone. For instance, last year Johns Hopkins Hospital in Baltimore reported more than 500 percent in cost shifting due to charity care, bad debt and negative margin services. For every dollar of services provided, individuals with good healthcare coverage paid more than $5 for that care.

The United States is one of only three industrialized nations (along with Mexico and Turkey) in the world that does not offer universal healthcare coverage for its citizens. This is both unfair and unsustainable. The reason for the "universal mandate" in the PPACA is to expand the insured pool with low-cost, low-risk beneficiaries to dilute the high-risk pool and reduce the cost for everyone.

Sixty percent of Americans live in the 33 states that currently do not permit same-sex couples the right to marry. Therefore, they have significantly less access to employer-sponsored health insurance as they are not considered a family member or spouse of an employee. In addition, same-sex parents in the United States raise 220,000 children, and these individuals may not be eligible for health insurance if they do not qualify for the Children's Health Insurance Program (CHIP) under Medicaid.

As a result of all this, everyone else pays for these individuals when they don't have access to healthcare coverage, which makes no sense economically or legally.

Access to affordable care

Cost shifting impacts everyone and unaffordable healthcare costs inhibit an individual from seeking care. A National Health Interview Survey found 10 percent to 17 percent of adults choose not to seek necessary healthcare services due to lack of coverage or high-deductible policies. They either seek healthcare services when they are sicker with exponentially higher costs or don't seek it at all.

Same-sex couples pay higher taxes if they live in the 33 states that don't permit legal marriages or civil unions (due to a lack of standard deductions and tax benefits of employer-based insurance for spouses). That, coupled with a lack of access to insurance and a higher incidence of physical and psychological issues due to social stigmatism, restricts access to preventive and cost-effective healthcare services--which drives up the cost for everyone else.

Cost and quality of healthcare services

Quality cannot be optimized unless individuals seek healthcare early to enjoy the benefits of primary, secondary and tertiary prevention. Costs are significantly impacted when individuals seek low-cost care in low-cost venues (physician or nurse practitioner's office) and not when they wait and go to the emergency department after hours.

Restricting discriminated groups from access to healthcare and affordable healthcare coverage undermines quality outcomes, raises the costs for everyone, and creates bottlenecks and shortages in critical coverage areas (e.g., the ED) when we most need them.


Many struggle with the notion of equal rights to all Americans based upon personal religious, ethical or moral beliefs that may conflict with deeply held values handed down through generations. It is important to understand that we are all inexorably interdependent on one another whether we wish to acknowledge it and that how we treat discriminated groups has a moral, economic and health related impact on us all.

It is difficult to give up cherished silos of personal beliefs; however, high-quality, low-cost healthcare will only be available to ourselves when it is available to everyone.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.


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