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Can't speak to the spouse situation as that is very personal, but 20k a year to go from Kentucky to BU is trivial, though you'd have to give an estimate of the total COA difference. The 2 specialties you're interested in are pretty competitive. If personal issues are too big, Kentucky makes sense and you gotta do what's best for your family.
 
Kentucky. You don't want to be separated from your spouse for an unknown amount of time and hoping things pan out. And she has a great job there. Not a lot of people match back to CA because not a lot of CA students go to UKCOM in the first place. Matching back shouldn't be a problem. And lastly, you can get into a competitive residency program anywhere, it's what you put into it. Also, gas isn't too competitive (unlike ortho).
 
Ophtho is pretty competitive. Do both schools have a decent amount of matches in it looking at the last few match lists?

Overall I’d say go to UK and then do a couple aways in California programs to demonstrate interest in whatever field it ends up being.
 
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