More than 40% of American adults under age 65 don’t have sufficient health insurance and struggle to pay for health care, and the coronavirus pandemic could make health care even more unaffordable, according to a new report by the Commonwealth Fund.

Previous research has found that the unprecedented rise in unemployment due to the pandemic has not meant an equally dramatic rise in the number of people who are uninsured. That’s because many people who lost their job during the pandemic never had insurance to lose in the first place. Many got covered under a spouse’s plan, while others became poor enough that they could qualify for Medicaid.

But health-care affordability is about more than insurance — ask anybody who is insured and still can’t afford health care. The pandemic will just aggravate family budgets, said Sara Collins, vice president of the Commonwealth Fund, a national health-care policy organization.

“So much with this pandemic has exposed vulnerabilities in our health-care system, and cost exposure is one of them,” Collins said. “The affordability problem in U.S. health care is just persistent and we don’t see a lot of change. Those issues are continuing to happen at pretty high levels and they are disproportionately affecting people with low income, people of color — people who were affected by the pandemic.”

According to the Commonwealth Fund’s Biennial Health Insurance Survey, 21% of adults were “underinsured” in the first half of 2020, meaning they had health insurance but spent more than 10% of their household income on health-care costs beyond plan premiums.

About 12.5% of working-age adults were uninsured and 9.5% suffered a gap in coverage, according to the report.

The survey, among the first to evaluate insurance coverage during the pandemic, found that insured rates are about the same as previous years. But researchers worry that the pandemic’s long-term effect on the economy will have an outsized impact on people who are already struggling more to pay for health care:

  • 40% of Latino people and 24% of Black people were uninsured at some point in the last year, compared to 17% of white individuals.

  • 38% of people who work for a business with fewer than 20 employees were without insurance at some point during the year, compared with 12% of workers at companies with 100 or more employees. Under the Affordable Care Act, businesses with fewer than 50 full-time employees are not required to offer health insurance.

  • 34% of families earning less than 133% of the federal poverty level (about $28,300 for a family of three) were uninsured at least part of the year, compared with 10% of families with incomes above 400% of the poverty level (about $86,800 for a family of three).

More than a quarter of adults who were insured all year said they had trouble with a medical bill or medical debt in the last year, according to the Commonwealth Fund survey. Among those paying off medical debt, half said they owed more than $2,000.

Rising deductibles that outpace wage growth are among the main drivers of high out-of-pocket costs, according to the report. A deductible is what an individual must spend before the plan begins to cover health expenses at a higher rate.

The share of adults with a deductible greater than $1,000 has doubled since 2010, when high-deductible plans became a popular way to deal with the soaring cost of insurance. In 2020, 46% of privately insured adults have a deductible greater than $1,000, compared with 22% in 2010, according to the study.

“Unless there’s a significant drop in deductibles in private coverage, many households are going to face health-care costs that are going to take up a larger share of shrinking household budgets,” Collins said.

In the early months of the pandemic, analysts feared that a surge in unemployment would escalate the number of people who are uninsured, because employer-sponsored health plans are the most common type of health insurance for working-age adults.

Yet a July study by the Urban Institute and the Robert Wood Johnson Foundation found that the uninsured rate has risen during the pandemic, but not in proportion to historic increases in unemployment. About 60% of people who lost a job due to the pandemic already had insurance from another source, that report found.

Many people who did lose insurance due to a layoff were able to get covered under a family member’s plan, while others were newly eligible for Medicaid. Some signed up for an individual health plan through the federal insurance marketplace or their state’s marketplace.

But still others may not have known they were eligible for a special enrollment period — a 60-day window permitted to anyone who loses insurance through a layoff.

Analysts will be watching how the pandemic affects the upcoming fall open enrollment period for the Affordable Care Act marketplaces, Collins said.

Loss of employer-sponsored coverage could draw more people to the individual marketplace, but whether more people actually sign up could depend on whether the plans are affordable.

In the Commonwealth Fund’s new report, 42% of people who sought an individual health plan through the marketplace in the last three years did not end up purchasing one. The most common reason was that the plans were too expensive.