More than a year ago, I attended Josh and Adeleigh’s wedding. I watched them promise lifelong love to each other and celebrated with them at the reception. But Josh and Adeleigh never legally married, as I recently discovered while interviewing a dozen people in Ohio for Marriage, Penalized, a new Institute for Family Studies (IFS) and American Enterprise Institute (AEI) report about marriage penalties in public assistance programs.

Why didn’t they legally marry?

Adeleigh, age 26, has diabetes, which requires at least $1,500 worth of insulin and diabetic supplies a month. Josh and Adeleigh are not poor; they both work full time and recently bought a charming and cozy one-story, three-bedroom home. But their about $40,000 combined annual income means a tight budget for the couple and her toddler daughter, so Adeleigh and her child are on Medicaid. A pharmacy technician at a pharmacy retail store, Adeleigh could get insurance through her employer, but it would require the couple to pay the $18,000 annual price tag—almost half of their combined annual income—for her diabetic supplies out of pocket. Plus, after about a roughly $5,000 deductible, their healthcare costs would be even higher.

Before their wedding, Adeleigh learned that she might no longer qualify for Medicaid after marriage. She called the county office responsible for her Medicaid benefits to better understand their options, but she was told no one would be able to personally help her. They asked her to mail a bunch of documents and await their reply. Frustrated, she resorted to her own research and concluded that the choice probably boiled down to a marriage license or Medicaid.

It wasn’t a hard choice. As Josh put it, “As much as I thought it would be nice to have the [marriage] license, it didn’t seem wise to put her health potentially at risk.”

As the IFS/AEI report noted, 47 percent of American families with children five and under receive some form of means-tested assistance, like Medicaid or food stamps. (Full disclosure: my family is one of them. My wife is receiving Medicaid during her pregnancy, and we also receive some assistance through the Women, Infants, and Children program.) And like between 77 percent and 87 percent of lower-middle-class couples with a child two or younger, Josh and Adeleigh would suffer a financial penalty if they get married. And while in the 1960s and 1970s it was poor people who were most affected by marriage penalties within public assistance programs, today it is lower-middle-class couples like Josh and Adeleigh—a dual-earner, homeowner couple—who are most penalized. (Even so, 66 percent of the poorest couples face a marriage penalty.)

In a sentiment that we heard repeatedly in our interviews, Josh and Adeleigh are not trying to mooch the system. In fact, when they learned about the potential marriage penalty, they repeatedly tried to contact the county so they could sit down with a person and discuss their options, but to no avail. They were just trying to be organized and future-minded, only to encounter what seemed to them like disorganization at the county office.

Today, it is lower-middle-class couples like Josh and Adeleigh—a dual-earner, homeowner couple—who are most penalized.

“That’s the only thing we use as far as government benefits,” noted Josh. “We really don’t like to use it, as much as possible.”

But the bottom line is that Adeleigh needs insulin—and it’s the reason they’re not legally married. And they’re not alone. As the Marriage, Penalized report found in an analysis of a nationwide sample, those who are closest to the income cut-off for receiving benefits are about 2 to 4 percentage points less likely to be married if they face a marriage penalty with Medicaid or food stamps. However, in a separate sample of urban parents who recently had a baby, the report found that marriage penalties had no effect on marriage patterns.

In the dozen interviews my wife and I conducted, only three couples reported that the prospect of losing public assistance had any effect on their decision to marry. Josh and Adeleigh were one of them.

Similarly, their friend Katie, a stay-at-home mother, worried about losing Medicaid for herself and her child if she married her fiancé. He earns about $15 an hour at a factory, but his employer-based health insurance already costs the family about $90 a week, and she doesn’t see how they could afford to add more people to his insurance.

Finally, Eddie, age 26, who works part-time at a big-box store but is looking for full-time work, said that his girlfriend, a recovering drug addict, has voiced concern about potentially becoming ineligible for programs like Medicaid if they got married. Medicaid has helped her get access to important drug recovery treatments, but it is also fickle: for reasons that Eddie and his girlfriend couldn’t understand, she had already inexplicably lost Medicaid a few times. If they got married, would they lose it again? (Eddie was quick to add, though, that the prospect of becoming ineligible for benefits wasn’t a factor for him because he eventually wanted to be in a place where they wouldn’t need public assistance when they get married.)

“Once I became a ‘single mother’ I was able to get food stamps”— a 28-year-old married mom.

Another person we interviewed, Miranda, age 28, said that getting married didn’t affect her eligibility for public assistance, but it did hurt her family years later. Her husband had lost his job and enrolled in a job training program, while she worked full-time at a daycare center. After taxes, though, she only made about $1,000 a month. But when she applied for Medicaid and food stamps, she was denied. Her family needed assistance badly—two of her children suffered from asthma—and they tried to survive for two months. Finally, with an eviction notice on their door and their water and electric about to be shut off, Miranda did something she didn’t want to do: she re-applied for aid, but this time lied and said that her husband no longer lived with them.

“Once I became a ‘single mother’ I was able to get food stamps. It wasn’t a lot, but it was enough to feed my children,” she said. “[Taking] care of my kids is my first priority. And if that means I’m going to spend jail time to make sure my kids are taken care of, then I’ll do it.” She added that she feels like the choice to get married has sometimes “punished” her family.

Three other couples said that they would be affected by marriage penalties, but would still get married. And the remaining six couples either believed that getting married would not affect their eligibility for public assistance or believed that it would positively affect their eligibility. Taken together, our dozen interviews suggest that while marriage penalties do prevent a minority of couples from marrying, they are not a factor for most people—and some couples even believe that they would receive more benefits by marrying.

Indeed, many poor couples—as opposed to lower-middle-class couples—actually gain a marriage bonus by marrying. As the IFS/AEI report notes, “a couple with one child where the father and mother each earn $10,000 annually can receive more generous food stamps if they marry than if they are cohabiting and the woman applies for food stamps as a single mother.” They also point to one study’s finding that “a majority of cohabiting couples with children who had a combined income under 200 percent of the poverty level would receive more money through the EITC [Earned Income Tax Credit] if they married.”

For instance, Sean and Callie, both 23, were typically relying only on Callie’s less than $20,000 annual income before they got married. So when they thought about getting married, the prospect of losing assistance wasn’t a factor at all.

“It’s no longer affected by marriage,” Callie said to me, “it’s affected by income. So it didn’t matter if I married him or not.” In fact, it was only after getting married that Sean also began receiving food stamps (prior to marriage, only Callie and their two young children received food stamps).

So, in some cases, welfare may actually encourage marriage. And when we think about couples putting off marriage because of marriage penalties, we shouldn’t necessarily envision jobless people trying to maximize their share of public assistance.

We should think about individuals like Eddie’s girlfriend, who wonders if gaining marriage means losing an indispensable weapon in her fight against drug addiction: affordable healthcare. We should also think about stay-at-home parents like Katie, who worry about losing affordable health insurance for their children if they marry.

Finally, we should think of dual-earner couples, like Josh and Adeleigh, and her about $18,000 annual cost for diabetic supplies without Medicaid—and then ask ourselves, “What would I do?” Josh and Adeleigh’s choice is not a decision between responsibility and welfare; it’s a choice between civil marriage and insulin for a diabetic.