Healthcare access through marriage

The largest source of health insurance in the U.S. is employer-sponsored coverage, which insures roughly half the population. Most employer plans offer coverage for the worker, the worker's spouse, and the worker's children. Employer subsidies of family coverage vary — some employers pay most of the spousal premium, others charge the worker the full incremental cost — but family coverage is almost always less expensive per person than two separate individual-market plans. This makes employer plans the central mechanism by which marriage delivers health insurance. A non-working or self-employed spouse of an employed worker can gain comprehensive coverage at a marginal cost the employer subsidizes. The system was built around the assumption of a single-earner household with dependents, and although that household structure has receded, the insurance architecture has not changed accordingly. Spousal coverage remains the path of least resistance for millions of households.

A growing share of employers have introduced spousal surcharges or denied coverage to spouses who have access to coverage through their own employer. These policies aim to push spouses onto their own employer's plan, reducing the employer's costs. Spousal surcharges typically run $1,000 to $3,000 per year. Spousal carve-outs (denying coverage if the spouse has other access) are more aggressive but less common. These trends reduce the value of marriage as a health insurance vehicle for dual-earner couples in which both partners have employer offers. They do not affect single-earner couples or couples in which one spouse is self-employed or unemployed. The result is a stratification: marriage-as-insurance works best when one spouse lacks their own coverage, and increasingly poorly when both spouses are employed at large firms.

Medicare Part A (hospital insurance) is free for workers who have accumulated 40 quarters of Medicare-covered employment. Workers with fewer credits can qualify on a spouse's record, provided the spouse has the credits, the marriage has lasted at least one year, and the worker is 65. This derivative eligibility extends Medicare to non-working spouses (predominantly women) who would otherwise have to buy Part A at full premium — over $500 per month in 2024. The derivative rule also applies to divorced spouses (if the marriage lasted at least ten years) and surviving spouses. Medicare's marital architecture, like Social Security's, was designed in 1965 around assumptions about single-earner households. It has not been redesigned.

The Affordable Care Act of 2010 created subsidized individual marketplaces. For the first time, an adult earning between roughly the poverty line and 400 percent of the poverty line could buy comprehensive coverage with federal premium tax credits, regardless of marital status. The ACA partially decoupled health insurance from employment and from marriage. But the subsidy structure uses household income, which means marriage can reduce or eliminate the subsidy when a low-income person marries a higher-income one. The American Rescue Plan and Inflation Reduction Act expanded subsidies above 400 percent of poverty (through 2025), reducing the marriage penalty for moderate-income couples. The ACA also created Medicaid expansion in participating states, extending coverage to adults up to 138 percent of the poverty line on the basis of individual or household income, with state-by-state rules about how marriage affects eligibility.

Medicaid is jointly administered by the federal government and the states, and rules vary substantially. Most states use household income to determine eligibility, meaning marriage can change Medicaid eligibility in either direction depending on the spouses' incomes and the state's threshold. For couples near the eligibility line, marriage can be a Medicaid-disqualifying event for one partner — a phenomenon documented in disability advocacy literature as "the marriage penalty" in Medicaid, particularly for SSI recipients whose benefits are reduced or eliminated by marriage to a working spouse. The state has built health coverage rules that, in effect, discourage marriage for certain low-income populations, even as other federal policies promote marriage for the same populations.

When one spouse needs long-term nursing home care, Medicaid is typically the primary payer once private assets are depleted. The Medicare Catastrophic Coverage Act of 1988 created spousal impoverishment protections allowing the community spouse to retain a certain amount of assets (currently up to about $154,000) and a minimum monthly income, while the nursing home spouse qualifies for Medicaid. Without these protections, the community spouse would face destitution as marital assets were spent down on the nursing home spouse's care. The rules are complex, vary by state, and require sophisticated planning to navigate optimally. Elder law attorneys make their living on this complexity. Marriage matters profoundly for long-term care outcomes, and the choices made decades earlier (whose name is on which asset, when transfers occurred) determine the financial trajectory of a couple's final years.

When a patient is incapacitated, hospitals and physicians need a surrogate decision-maker. State default surrogate laws — present in nearly every state — designate a hierarchy: spouse first, then adult children, then parents, then siblings. The spouse default means a married incapacitated patient has an immediate, legally recognized decision-maker who can authorize treatment, withdraw care, and consent to surgery without needing court intervention. Unmarried partners must rely on healthcare power of attorney documents, which exist but are unevenly executed and sometimes contested. The 2010 CMS rule requiring hospitals receiving Medicare or Medicaid funds to permit visitation regardless of family relationship clarified visitation, but it did not change the surrogate decision-making hierarchy. Marriage remains the most reliable mechanism for ensuring your partner can speak for you when you cannot speak for yourself.

When a worker loses employment, COBRA allows continuation of employer health coverage for up to 18 or 36 months at the worker's expense. Spouses and dependents are also eligible for COBRA coverage when a "qualifying event" occurs, including divorce. A spouse losing coverage through divorce can elect COBRA for up to 36 months, providing a bridge to other coverage. This is a significant protection for spouses (predominantly women) who depended on a spouse's employer plan and then divorce. The protection is time-limited and requires paying full premium plus a 2 percent administrative fee — often expensive — but it provides continuity at a critical transition. Without COBRA, divorce would create an immediate insurance crisis for the dependent spouse.

Marriage is a HIPAA special enrollment event, allowing a spouse to be added to an employer health plan outside the annual open enrollment window. This means marriage immediately triggers the right to enroll, without waiting for the next enrollment period. Birth, adoption, and certain other events have similar special enrollment status. The architecture treats marriage as a discrete moment that justifies a coverage change, embedding the assumption that marriage and coverage move together. Unmarried cohabitation, no matter how long, is not a special enrollment event. The state has, in effect, designed health insurance enrollment around the marital ceremony.

The marital health-insurance pathway works for couples in stable, benefits-covered employment. It works less well, or not at all, for couples in gig work, part-time work, or low-wage service work without family coverage. Cahn and Carbone have documented how access to spousal benefits stratifies by class: college-educated couples are more likely to be in jobs offering family coverage, more likely to marry, and more likely to use marriage as a health-coverage strategy. Lower-income couples, even when they have stable employment, may face employer plans that do not offer affordable family coverage, or jobs that offer no health benefits at all. The marital health-insurance subsidy is therefore regressive in its effective distribution — accruing more to those with better jobs.

A foreign national who marries a U.S. citizen or permanent resident can gain access to employer health coverage through the U.S. spouse even before completing immigration adjustments. Conversely, undocumented spouses are excluded from most public coverage programs, even when their U.S.-citizen spouse qualifies for Medicaid or ACA subsidies. Mixed-status families face complex enrollment decisions, with U.S.-citizen children eligible for Medicaid or CHIP while undocumented parents are not. Margaret Stock has written about how immigration enforcement intersects with healthcare access, including the chilling effect of public-charge rules on benefit enrollment by mixed-status families. The state has built a healthcare system whose access points are mediated by both marital and immigration status, and the interaction of the two creates distinctive vulnerabilities for immigrant spouses.

The American healthcare system's marital architecture has proven remarkably stable. The ACA modified it at the edges. Marriage equality (Windsor, Obergefell) extended it to same-sex couples. Spousal impoverishment rules have been adjusted incrementally. But the central structure — employer-sponsored coverage as the dominant form, with spousal access as a default feature — has not changed since World War II, when wage controls pushed employers to compete on benefits. Reform proposals (single-payer, Medicare-for-all, public option) would decouple healthcare from both employment and marriage, but none has been enacted. The implication for couples is that healthcare considerations are likely to remain a significant background factor in marriage decisions for the foreseeable future. The state has built the system this way; for now, individuals make decisions inside it.

1. Cahn, Naomi, and June Carbone. Marriage Markets: How Inequality Is Remaking the American Family. New York: Oxford University Press, 2014. 2. Stock, Margaret D. Immigration Law and the Family. Washington, DC: American Immigration Lawyers Association, 2019. 3. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010). 4. Medicare Catastrophic Coverage Act of 1988, Pub. L. No. 100-360, 102 Stat. 683. 5. Centers for Medicare & Medicaid Services. "Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation to Ensure Visitation Rights for All Patients." 75 Fed. Reg. 70831 (November 19, 2010). 6. Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936. 7. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Pub. L. No. 99-272, 100 Stat. 82. 8. United States v. Windsor, 570 U.S. 744 (2013). 9. Obergefell v. Hodges, 576 U.S. 644 (2015). 10. Alstott, Anne L. A New Deal for Old Age: Toward a Progressive Retirement. Cambridge, MA: Harvard University Press, 2016. 11. Cahn, Naomi. "Test Tube Families: Why the Fertility Market Needs Legal Regulation." NYU Review of Law and Social Change 33 (2009): 1–55. 12. Kaiser Family Foundation. "Employer Health Benefits Annual Survey." Various years through 2023.