More than a plus-one: The cost of spousal coverage
While employers may focus on employee health needs, it’s important to also consider covered family members — who may be driving even greater costs.
When employees add a spouse or partner to their health plan, the move can feel straightforward — but its cost implications are anything but simple.
Spouses represent 17% of health plan membership yet account for 24.8% of total plan spend, according to the UnitedHealthcare 2026 Trends Report.1 This is a meaningful imbalance that far exceeds their proportional footprint. By contrast, employees and subscribers make up 51.3% of membership and 56.2% of spend, while dependents represent 31.8% of membership but just 19% of spend.1
That comparison should matter to employers. Dependents — children and other covered family members — actually cost less relative to their share of the population. Spouses, on the other hand, cost significantly more.
Spouses generated 36% higher per-member costs than employees1
So, why is this occurring? Age, health needs, gender and site of care preferences all play a role:
1. Age
The average age of covered spouses is 47, compared to an average employee age of 44 — a gap that carries real clinical significance.1 With age comes greater risk of chronic conditions and growing health needs, such as circulatory issues, digestive disorders and cancer, based on UnitedHealthcare data.1 “Married people are typically older than single people, and our health needs become greater as we age,” Kurtzweil says.
2. Greater health needs
Spouses account for twice as many hospital admissions and more than one-third of surgeries compared to covered employees — patterns consistent with an older, higher-need population.1 As Jim Winkler, chief strategy officer for Business Group on Health, has noted: “When a spouse joins their partner’s health plan, it’s likely due in part to the fact that the alternate plan has better coverage and/or is more economical.”
This becomes more the case when there is a particular medication or condition they are managing, or perhaps an upcoming known medical event to be planned. In short, spouses who opt into employer-sponsored coverage tend to be those with the greatest health needs — meaning the cost gap reflects a structural issue in how coverage is designed, not simply a difference in who is enrolling.
Cancer: a telling case study
Cancer data offers a particularly instructive lens on spousal utilization. UnitedHealthcare data shows that cancer prevalence is highest among covered spouses compared to both subscribers and dependents — consistent with the age-driven health differences noted above.1 However, the picture shifts when examining the share of total plan spend attributable to cancer: Subscribers or employees drive a greater proportion of overall cancer-related spend than spouses, even where spouses carry the higher prevalence.1
This reflects the reality that employees, as the largest membership group, absorb a larger share of aggregate costs even when their individual health risks are comparatively lower. For employers, it means that addressing spousal cost is not simply a matter of restricting access — it requires a nuanced understanding of where both utilization and spend are concentrated.
3. Gender differences
Gender differences matter: According to UnitedHealthcare data, 68.7% of covered spouses are female compared to 43.5% of covered employees. In general, women2 tend to utilize health benefits 14% more than their male counterparts.1
This may be attributed to reproductive health needs, higher instances of behavioral health needs and the fact that certain conditions affect women disproportionately.1 That’s why it’s critical to consider women’s health* when designing benefits for the workforce.
Compared to men, women:1
- Visit the emergency room (ER) and urgent care 32% more often
- Account for 67% more inpatient hospital admissions
- Undergo 22% more outpatient surgeries
4. Site of care preferences
Covered employees are 28% more likely to engage with the health system through virtual visits compared to covered spouses, who tend to favor in-person appointments.1 When appropriate, virtual care can reduce costs and improve access and adherence to treatment. Encouraging spouses — alongside employees — to visit effective sites of care is one practical lever employers can pull to manage total plan cost without narrowing coverage.
What this means for employers
The data points to a clear and actionable conclusion: Covered spouses are a meaningful, growing cost driver within employer-sponsored plans. They represent a smaller share of membership than employees yet consume a disproportionate share of resources, driven by older age profiles, greater health needs and a preference for in-person care.
None of this suggests spousal coverage is a liability to be eliminated. Supporting employees’ families is a proven driver of retention and engagement, and the value of extensive family benefits is real. The more productive question is not whether to offer spousal coverage, but how to offer it sustainably. Employers should examine their spousal population closely — understanding who is covered, what conditions they are managing and whether existing plan design, care navigation and virtual care tools are being fully utilized.
Some employers have also introduced a spousal surcharge to offset the added cost of covering a spouse who has access to coverage elsewhere. While effective as a cost-sharing mechanism, that approach warrants careful consideration given its potential impact on employee satisfaction and health equity. The goal is not to shift burden — it is to strike the right balance between supporting families and protecting the plan’s long-term viability.
Driving better utilization among spouses and offering benefits that support employees and their families can be a smart retention strategy. The key is holding the tension between doing that and protecting the bottom line.
Share
