Ben Costiloe and Coral Zalusky never intended to marry. Costiloe was only 22 when they met, and Zalusky had already been married twice. They were happy cohabiting and enjoying their status quo.

But in 2005, Costiloe, who has Type 1 diabetes and was uninsured, began to see his health decline. His free, clinic-provided insulin changed its formula rendering it ineffective at managing his low blood sugar. He began having brain fog, night sweats, and episodes of paralysis. Sometimes, he’d experience incontinence. Once, he crashed his car. Every day became “a nightmarish existence,” Costiloe, now 61, said.

In 2006, they moved from Texas to Nevada, and Costiloe lost access to the subsidized insulin he relied on to survive. He was forced to pay more for a product that wasn’t working for him. And by 2007, he and Zalusky had enough, and decided Costiloe needed health insurance—fast. So they did what they otherwise might not have: They married at Chapel of the Bells in Reno, Nevada. “It was a sweet little ceremony,” Costiloe remembered.

Costiloe enjoyed the benefits of being insured for two weeks before Zalusky lost her job, leaving both of them without coverage. Four years after that, they divorced.

Costiloe and Zalusky made up just one of the more than 2 million couples that married in the United States that year. At least some of them—though it’s unclear exactly how many—factored insurance coverage into their decisions around when, how, and even whether to wed at all. Though improvements in insurance access have been made in the decades that followed Costiloe and Zalusky’s nuptials, Donald Trump’s reelection has rekindled uncertainty around the future affordability of health care. The widely-anticipated cuts to Medicaid and the Affordable Care Act, coupled with threats to anti-discrimination protections and marriage equality have some thinking about moving up their wedding plans. And while for some couples the stakes are low—changing the wedding date, scaling down the guest list, or hosting a smaller event—for others, a hasty marriage could come with significant consequences.

“People are compelled to make life-altering decisions … just to access the medications they need to survive,” said Merith Basey, the executive director of Patients for Affordable Drugs, a nonprofit patient advocacy organization.

Some 50 million Americans have been able to secure access to health insurance through the Affordable Care Act since it was passed in 2010. But more than a decade after it was fully implemented, Americans are still worried about affording care. Almost three-quarters of Americans said they’re worried about being able to pay unexpected medical bills, according to a 2024 survey by KFF. The health care policy research nonprofit also found health care is the expense Americans worry about most—”more than gas, food, and rent.”

Concerns about affordability are even more pronounced among certain groups of Americans—particularly people of color, members of LGBTQ+ communities, and those of lower income—who are less likely to be insured, research found. Pay disparities may also contribute to insurance access issues.

Insurance coverage doesn’t just influence when and how people get married. Researchers have found insurance access may be a factor in separations too. When people have to worry about health insurance, they get divorced at lower rates, a 2015 article published in the Journal of Marriage and Family found. The phenomenon was even stronger when separated by gender, wrote the paper’s author, Dr. Heeju Sohn, an assistant professor of sociology at Emory University. Women dependent on men for insurance coverage were less likely to divorce them than men who relied on women for the same. Sohn attributed the finding to differences in economic independence and gender norms.

And a 2019 paper by Dr. Tianxu Chen, a professor at the University of Connecticut, discovered links between age, insurance coverage, and divorce. When people become eligible for Medicare at 65 and no longer need a spouse to access private health insurance, she wrote, divorce rates in the United States begin to climb.

And for some like Costiloe, entering and exiting a marriage borne of insurance proved an acceptable solution to a difficult problem—emotional turmoil and heartbreak for both parties notwithstanding. But for others, like Jupiter Dior of Springfield, Massachusetts, the decision to enter into a legally-binding contract led to significant harm.

‘Trapped’

When Jupiter Dior, 31, began experiencing a series of abrupt and frightening symptoms including pelvic bleeding, weight gain, pain, and more, they didn’t know what to do. Dior, a low-income, nonbinary Black woman, couldn’t afford to see a doctor. In a period of eight months between 2015 and 2016, they lost four teeth, gained 135 pounds, suffered pelvic bleeding that soaked through multiple pairs of incontinence underwear daily, and developed a tumor that eventually required surgery. The experience, they said, was “horrifying.”

So when Dior’s insured boyfriend proposed, they said yes despite their misgivings about his character. Though they said they cried on their wedding day, they went through with the ceremony at a county courthouse in Columbiana, Alabama. Soon after, Dior alleged their husband became abusive, beginning with emotional and financial abuse, but later escalating to other claims of mistreatment. Still, Dior needed the health care their husband’s insurance provided. So they stayed in the relationship, all the while feeling “trapped.”

Dior later divorced their husband—a move they said was due, in part, to being able to access health care through Massachusetts, where Dior resides. It is one of 17 states (plus D.C.) with its own health insurance program and 41 states with expanded Medicaid.

“I would not have been in that relationship as long,” Dior sighed, “if not that my health care was tied to him.”

Crystal Justice, the chief external affairs officer for the National Domestic Violence Hotline (NDVH), said the hotline, which is currently experiencing its highest demand for services ever, frequently hears from survivors like Dior who feel they have no choice but to remain in their partnership. That’s especially true for people with disabilities, chronic illnesses, or other conditions requiring higher-maintenance care. “Your literal survival is dependent on you having adequate health care coverage,” she said, and “that is going to be one of the barriers to you seeking safety and leaving an abusive relationship.”

Justice added that, since the Supreme Court ruling that overturned Roe v. Wade in 2022, the hotline has experienced more than double the reports of reproductive coercion—survivors calling in to report a partner using control or intimidation strategies to wield influence over their victim’s reproductive health or autonomy.

That trend may get worse under President Donald Trump. Trump and politically-aligned state lawmakers have signaled restrictions to abortion, contraception, and even no-fault divorce could be imminent.That means domestic violence victims, 85 percent of whom are women, could be trapped in relationships with their abusers with limited options for escape. And pregnancy, planned or not, increases the risk of intimate partner violence.

Insurance ‘made the decision for us’

Even when a relationship is healthy, the need for insurance coverage may push couples like Kate Lindsay and Tyler Miller to wed in less-than-ideal circumstances.

Lindsay, 32, is a freelance writer who spent a year on Miller’s health insurance as his domestic partner. But Miller switched jobs in the summer of 2024, and his new policy only allowed for spouses to be covered. (This stipulation commonly varies by state and by health insurer.)

Lindsay tried to find her own coverage, but the options available to her through the Affordable Care Act didn’t work for her. She said the monthly premiums started at $400, and none of the plans allowed her to keep her existing providers and prescriptions. At the same time, Lindsay said, she was waiting to hear back about a job she had interviewed for that offered benefits. But the days kept passing. And time was running out. Lindsay paused therapy and postponed other medical appointments to save money.

On August 13, they ran out of time. Miller had to meet an enrollment deadline for the employer-sponsored insurance plan. So two weeks later, the pair married at New York City Hall. They were one of 92 couples who were wed that day by “a weird guy in a conference room,” Lindsay said.

But, “I really liked it,” she added. All the brides smiling and complimenting each other made it feel “like the Barbie movie.”

When asked about their wedding, the couple explained it’s not that they were disappointed, exactly. “I got to get married, eat dumplings, and get drunk with all of our friends,” Miller said. But Lindsay admitted annoyance that their hands were forced by insurance.

“It made the decision for us,” Lindsay said of having to consider health care affordability in the timing of their marriage. Their lives were identical before and after the wedding, she said—except now, she can go to the doctor.

“The joke I used when we first talked about it was that it’s a shotgun wedding,” Lindsay said. “But our health insurance was holding the gun.”

If you or someone you know is a victim of domestic violence, you can reach the National Domestic Violence Hotline 24 hours a day, seven days per week, via phone, text message, or browser life chat.