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The right to marry in any state won’t be the only gain for gay couples from last week’s Supreme Court ruling. The decision will likely boost health insurance among gay couples as same-sex spouses get access to employer plans.

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.

New York legalized gay marriage in 2011. The next year, there was a big increase in same-sex couples covered by employer-sponsored health insurance, according to a study published Friday by JAMA, a journal of the American Medical Association.

Although the court found a constitutional right to same-sex marriage, lawyers gave mixed messages on whether employers must now offer health insurance to same-sex spouses if they offer it to opposite-sex spouses.

Edward Fensholt, a benefits lawyer with brokers Lockton Companies, expects most companies to cover same-sex spouses if they already offer benefits to opposite-sex spouses. But the decision doesn’t require them to, he said.

“Employers get confused about this,” he said. “They’ll see that ruling and they’ll start to think they have to offer coverage to same-sex spouses.”

But Lambda Legal, which advocates for gay rights, said employers refusing to offer health insurance to all married couples would violate federal law prohibiting sex discrimination.

“You should be able to add your [same-sex] spouse to your health insurance,” Lamba Legal and other civil rights groups wrote in an online FAQ.

Also, state laws may require equal benefits for same-sex spouses.

Big companies also like the simplification the ruling brings to their human resources departments.

“We’re relieved because this basically means you won’t have to do a state-by-state analysis” of how the law applies to same-sex couples, said Gretchen Young, senior vice president of health policy at the ERISA Industry Committee, which represents very large employers. “We always want uniform treatment.”

Weirdly, a constitutional right to same-sex marriage may harm some same-sex couples: those with domestic-partner benefits who don’t want to get married.

Last year Verizon told same-sex partners in states where gay marriage is legal they had to wed if they wanted to qualify for benefits. Now that the high court has placed same-sex and opposite-sex marriage on the same level, other companies are likely to follow, say benefits specialists.

“We would certainly expect to see a falloff in domestic partner benefits,” said J.D. Piro, a health benefits lawyer with Aon Hewitt, a consulting firm. “Given the decision, employers might want to be asking, do we still need to do that?”

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Melissa Mathis holds a container of freeze-dried placenta capsules. Carrie Feibel/Houston Public Media hide caption

itoggle caption Carrie Feibel/Houston Public Media

After giving birth, some women save the placenta in order to consume it in the following weeks. In fact, Texas just passed a law giving women the right to take the placenta home from the hospital, the third state to do so.

Science doesn’t support a lot of the claims of its purported benefits. But for Melissa Mathis, it’s about her rights. Last year she had her baby, Betsy, in a Dallas hospital. When Mathis took Betsy home, she wanted to take the placenta home, too.

“As far as I was concerned it was a part of my body that was in my body. So it wasn’t like something, it didn’t really feel that strange to me,” Mathis says.

Like many women, Mathis had heard through friends about eating a little placenta every day in the weeks after giving birth.

The placenta, sometimes called the afterbirth, is typically dehydrated, ground up and put into edible capsules. Many midwives and doulas believe that because the placenta grows along with the fetus, it contains hormones and nutrients that can help a woman recover from childbirth.

Some say it helps women breastfeed or can prevent postpartum depression.

Mathis took the capsules for six weeks.

“It’s hard for me to know what the effects were because I don’t have anything to compare it to,” she says, “But I had great success breastfeeding, I had no problems with emotional instability. I definitely feel that it helped me.”

Mathis says the hardest part was just getting her placenta in the first place.

Texas classifies placentas as medical waste. And hospitals have liability concerns because placentas could carry infectious disease. Mathis says she spent months during her pregnancy communicating with hospital administrators about arranging custody of her placenta when the time came, but she says the answers she got were too vague.

Melissa Mathis holding the cooler she used to smuggle her placenta out of the hospital. Carrie Feibel/Houston Public Media hide caption

itoggle caption Carrie Feibel/Houston Public Media

So when Betsy arrived, Mathis and her husband waited until nobody was looking.

“And we were able to grab it, and we got it and put it in a cooler and threw it in a backpack and my husband handed it off to the placenta handler in the lobby of the hospital and that’s not ideal. And, in my opinion, that’s not acceptable.”

Mathis talked about it with her state representative, Dallas Republican Kenneth Sheets.

“It seemed like an issue that involves freedom and liberty and just a basic right and we just decided we’d take it on,” he says.

Sheets wrote the new law that allows women to keep placentas, if they sign a waiver and don’t test positive for infectious disease.

Texas is the third state in less than a decade to put a placenta law on the books. The first were Hawaii and then Oregon.

And yet doctors say there’s no scientific evidence behind all the health claims. Some women say the placenta helped them, but researchers say it’s probably just a placebo effect.

“We don’t have any studies on this,” says Dr. Catherine Spong, deputy director of the National Institute of Child Health and Human Development.

Spong is much more interested in how the placenta functions during pregnancy, not after.

“The placenta is really the lifeline. It serves as the baby’s lungs, the baby’s kidney, it has functions of the liver, of the GI tract,” Spong says. “Interestingly, it also has immune functions and endocrine functions.”

Spong says her institute will spend $44 million on placenta research over the next few years. She says she doesn’t feel comfortable offering an opinion on moms who eat placenta, simply reiterating that science doesn’t support it.

But Mark Kristal does have an opinion.

Kristal is a behavioral neuroscientist with the State University of New York at Buffalo. He’s been studying placenta eating in mammals for 43 years.

“The overwhelming majority of mammalian placental mothers ingest afterbirth,” he says.

In fact, many women point to this fact as evidence that humans should do it too.

But Kristal says not so fast. The reason many mammals do it is because there’s a chemical he discovered in amniotic fluid and placenta that provides pain relief during birth.

“It boosts the effectiveness specifically of opioid or opiate painkillers,” he says.

So wouldn’t this work in humans?

Kristal says the chemical is also in human the placenta but it’s fragile. Cooking and encapsulating the placenta would actually destroy it.

Kristal says eating it raw isn’t a good idea either. Since placentas are also filters, there may be waste products in our placenta that are harmful or toxic.

In fact, he believes humans have evolved away from eating placenta.

“It’s not a routine human behavior. On the contrary, there are a lot of cultures that have developed taboos against doing it,” he says.

Kristal speculates evolution has provided women with something else to deal with the pain of childbirth. And that’s the company of other people.

Most mammals that eat placenta give birth unassisted. But humans don’t.

“The advantage of socially assisted birth is not only to help the mother but also to pass information about childbirth from older more experienced women to younger less experienced women who might be helping,” Kristal says. “The human data bank grows by this social experience.”

Dallas mom Melissa Mathis says she’s open to hearing more science about the placenta. But until then, she wants to decide for herself.

“I feel like it’s a personal liberty issue. It’s our freedom to choose what we’re going to do with our own bodies,” she says.

Texas hospitals will start releasing placentas in 2016.

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Drs. Mitchell Lunn and Juno Obedin-Maliver, both clinical fellows at the University of California, San Francisco, have spent the past decade studying the health problems of people who identify as lesbian, gay, bisexual, transgender and queer.

Their biggest challenge is the lack of population health data about LGBTQ people. The researchers hope that an iPhone app can change that.

The new app, called PRIDE, will ask LQBTQ participants about their health history and concerns. Their answers will inform a longer-term study, which kicks off in January 2016.

After downloading the app, participants are prompted to answer some basic demographic questions and post a topic they would like a researcher to study in the future. They can also see questions or topics that others have posed, which are tagged by category, such as “behavioral health” or “sexual health.”

Lunn said he views the first year of the project as a “community listening phase.” Next year, the researchers intend to kick off a more rigorous and in-depth study, which will include some of the questions posed by the community.

The app debuted in the App Store Thursday, just ahead of the much anticipated Supreme Court ruling that made same-sex marriage the law of the land.

“We know that there are health disparities, but we don’t have the data to drive clinical practice and public health priorities,” said Obedin-Maliver, who also practices as a resident physician in obstetrics and gynecology.

For example, about 1 in 3 people from the LGBTQ community smokes, which is a far higher rate than the average U.S. adult population. Therefore, scientists assume that a higher number of LGBTQ people die from cancer and other diseases that are linked to smoking — but they don’t have a way to prove it.

Progress has been slow on that front. The Institute of Medicine in 2011 issued a report finding that LGBT people “have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are.” It wasn’t until 2013 that the Centers for Disease Control and Prevention’s annual National Health Interview Survey included a question about sexual orientation.

Privacy and Security Concerns

The researchers found support for their app from Apple employees, who helped connect the team with a mobile design firm.

Apple CEO Tim Cook has emerged as an outspoken advocate of LGBTQ rights. In a Bloomberg BusinessWeek op-ed published last October, Cook said he doesn’t consider himself an activist but is “proud to be gay.”

The PRIDE app connects with Apple’s ResearchKit service, which makes it easier for clinical researchers and developers to develop mobile apps that gather data from participants — with their consent.

The first five ResearchKit apps focused on Parkinson’s disease, breast cancer, diabetes, asthma and heart disease. This is the first ResearchKit-powered app that aims to gathering data about population health, rather than a specific disease.

“When Apple launched ResearchKit [last month], we reached out to the team at Apple to ask whether we could think about modifying it to make it more of a tool to engage the community,” Lunn explained. “They were very excited.”

Some potential participants may be concerned about sharing their sexual orientation and gender identity with an app. Lunn said they built the app with security and privacy in mind — it is HIPAA-compliant and includes “military-grade encryption,” he said.

The data will only be available to researchers from UCSF for now. But it may later be shared with researchers in an “aggregate and de-identified way,” meaning first name, Social Security number and contact information won’t be visible.

Thrive, Not Just Survive

Lunn and Obedin-Maliver say this is the first national public health study focused on LGBTQ people.

Other researchers say this kind of data would help fill a void. National cancer registries, such as one called “SEER” for short, don’t include questions about sexual orientation and gender identity.

“I really need this data,” said Liz Margolies, founder and executive director of the National LGBT Cancer Network. “The federal government should be making sure this data is collected, but it takes years. In the meantime, it is very difficult to get funding.”

The UCSF study will also investigate some of the discrimination that LGBTQ people face during their treatment. Recent research found that 55 percent of lesbian and gay patients and 70 percent of transgender patients felt they had experienced discrimination or substandard care.

“In order for the community to thrive — not just survive — we need to incorporate LGBTQ people into all facets of life, including health and research,” said Obedin-Maliver. “We need to understand their needs in their own words and voices.”

Christina Farr is the editor and host of KQED’s Future of You blog, which explores the intersection of emerging technologies, medicine and health care. She’s on Twitter: @chrissyfarr

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Once a smoker always a smoker, right? Not quite.

As the number of smokers drops, the remaining smokers actually smoke less and are more likely to quit, according to a study published Wednesday in the journal Tobacco Control.

It supports the idea that smoking in the United States is heading down a “softening” curve. That means more people are trying to quit, and the number of people quitting compared to smokers is increasing as the number of total smokers declines.

Over in Europe, the researchers found, things are slightly different. The percentage of smokers who have quit remained constant even as fewer people smoked, while the number of cigarettes smoked per day dropped, as it has in U.S.

The study is based on population data collected by the Census Bureau in the U.S. over 18 years, while six years’ worth of public opinion surveys conducted by the European Commission were used for EU counterpart.

The researchers say their results bring into question the practice of harm reduction, a public health approach for tobacco control in use since the 1970s. Harm reduction was proposed as a way to minimize the exposure of smokers unable or unwilling to quit. More recently, e-cigarettes have been promoted as a replacement for the traditional cigarette.

“The fundamental thing is that harm reduction is wrong,” says Dr. Stanton Glantz, senior author of the study and director of the Center of Tobacco Control Research and Education at the University of California, San Francisco. “It’s not an irrational idea, but it’s just not happening.”

While Joanna Cohen, director of the Institute for Global Tobacco Control at Johns Hopkins Bloomberg School of Public Health, agrees that there’s a ‘softening’ trend, she thinks that e-cigarettes and harm reduction policies are not a black-and-white issue.

“In tobacco control, those words carry a log of baggage right now,” Cohen says. “Different experts have different opinions.” There’s no formal policy at the Centers for Disease Control and Prevention or other agencies that specifically has a harm reduction approach, she notees.

“Some people think that [e-cigarettes] are going to be the solution to the problem,” she continues, “Other people are more concerned that either they won’t make a difference or cause harm.”

Potential problems include e-cigarettes preventing people from quitting smoking altogether and tempting new users, since they are marketed as not as harmful as the traditional cigarette. Evidence isn’t clear either way at this point.

One reason for the shifting debate is that our attitudes and understanding have changed about nicotine, Glantz says.

People used to believe that nicotine kept people addicted to cigarettes but that it wasn’t dangerous itself. The smoke was thought to be the source of harmful toxins. So the idea was to introduce new ways to deliver nicotine such as e-cigarettes that could give people the nicotine they desired but didn’t involve burning tobacco.

Now we know better. The 2014 U.S. Surgeon General’s report concluded that nicotine is addictive, that a high-enough dosage can be very toxic in a short amount of time, and that exposure to nicotine during pregnancy and childhood can have serious adverse consequences. E-cigarettes deliver nicotine and other chemicals to users, but in vapor instead of smoke.

The study results suggest that current tobacco control policies already in place are working. Glantz says. He and first author Margarete Kulik, a postdoctoral fellow at UCSF, attribute the general decline in smokers to this success, which includes the debut of clean indoor air laws that ban smoking inside workplaces, restaurants and other facilities. National media campaigns that aimed to de-normalize smoking and raised cigarette taxes also helped.

“It certainly suggests that we need to keep doing what we’re doing,” says Dr, Vaughan Rees, director of the Center for Global Tobacco Control at the Harvard T.H. Chan School of Public Health, who was not involved in this study.

Since current policies work and data suggests that remaining smokers are more likely to quit and smoke less, then there really is no need to promote new recreational nicotine products like e-cigarettes under the name of harm reduction, Glantz says.

Cohen also points out that there are challenges when you look at population-level data and think about what that means for policy.

A governmental institution such as the CDC might make use of the same data in a different way than the average physician will. If you have a hard-core smoker sitting in front of you, you as a health care provider want to help that person as best as you can. Maybe an e-cigarette is the best choice for that particular patient.

“In the end, everyone’s heart is in the same place. Everybody wants to reduce death and disease from tobacco products,” Cohen says.

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