​Trapped by Coverage: How the US Healthcare System Ties Survivors to Abuse

Many people are nervously awaiting the fate of the Affordable Care Act, or ACA, under the new administration. If the ACA is repealed or restricted, countless women in abusive relationships could be forced to risk losing their spouse's healthcare coverage should they decide to leave.

For millions of Americans, healthcare is tied to jobs or marriages, creating dangerous dependencies. In 2023, over 60% of Americans under age 65 relied on employer-sponsored health insurance. Of these, one-quarter of women under 65 received their health insurance through a spouse’s plan.

I witnessed the devastating consequences of this firsthand during my 10 years working with a governmental agency dedicated to supporting individuals in “high-risk” domestic violence situations—cases where abuse was severe, frequent, and life-threatening. In this role, I provided crisis intervention, safety planning, and emotional support to survivors navigating unimaginable challenges. One woman I worked with called me from the doctor’s office one afternoon in tears. She had just been treated for a fractured eye socket. Her partner had thrown her against a wall the night before. While she hadn’t disclosed the cause of her injury to the medical staff, she had shared the truth with me.

Today, healthcare access is largely determined by employment and marital status, reinforcing economic inequality, gender-based harm, and rigid social roles.

Her distress, however, wasn’t about the medical care she received. It was about the idea of losing access to that very care if she ever left her partner. Ironically, the same healthcare that tended to her physical and emotional wounds was tied to her abuser’s job. Without him, she and her children would lose their health insurance entirely.

This tragic irony is the daily reality for countless individuals across the United States. For people in abusive, coercive, or manipulative relationships, healthcare tied to marriage gives abusers significant leverage. Leaving an abusive partner is never a simple decision, but the threat of losing health insurance—often for their children as well as themselves—makes it even harder. Survivors are forced to weigh their personal safety against access to life-saving care.

Employer-sponsored health insurance wasn’t always the norm. Before World War II, Americans typically paid out of pocket for medical procedures. But in the 1940s, wage controls during wartime prevented employers from raising salaries, so they began offering health insurance as a perk to attract and retain workers. Over time, this temporary solution became a default system, expanding to include dependent and spousal coverage as societal norms emphasized “family-centric” policies.

What began as a short-term fix has since created a web of unintended consequences. Today, healthcare access is largely determined by employment and marital status, reinforcing economic inequality, gender-based harm, and rigid social roles.

For survivors of domestic violence, this system compounds an already harrowing situation. The research shows that approximately 99% of domestic violence survivors experience financial abuse. Healthcare is often one of the financial tools used to exert control. Survivors may be blocked from accessing care, forced to remain in harmful relationships, or deprived of medical resources if they attempt to leave.

But the problem doesn’t end with domestic violence. The employer- and spousal-based healthcare system pressures people to conform to outdated family roles, leaving out millions who live outside traditional employment or family structures. For example, why shouldn’t someone be able to add a sibling, an elderly parent, or a close friend to their health insurance plan? Our narrow definitions of “family” exclude many from the support they need during life’s most challenging moments.

The good news is that change is possible. While we may not yet be at a point where we can fully separate healthcare from jobs and marriages, we are at a critical juncture where we can challenge the status quo and push for meaningful reform.

The Affordable Care Act was a significant step forward, but public options remain prohibitively expensive for many Americans. On average, employer-sponsored plans cost workers around $6,200 annually for family coverage, while public plans, without subsidies, can be more expensive. Closing this gap through expanded subsidies or premium caps must be a priority.

Current laws offer some protections. For example, domestic violence survivors qualify for health insurance enrollment outside standard open enrollment periods under the ACA and many private plans. But these policies are undermined by prohibitive costs and complex administrative processes, creating unnecessary barriers for those already in crisis.

Administrative barriers like these need reform. The ACA’s rollout was marred by technical issues, and today, many Americans still face confusing, inefficient systems that discourage participation. Streamlining the enrollment process and raising public awareness of available options would go a long way toward ensuring equitable access.

Long-term, we must move toward a system where healthcare access is no longer tied to employment or romantic relationships. Universal healthcare, or at least a robust public option, would give Americans the freedom to leave jobs or relationships without fear of losing coverage. No one should have to choose between their health and their safety, or between financial security and their autonomy.