A new survey shows that 44% of Covered California policyholders find it difficult paying their monthly premiums for Obamacare coverage.
And a similar percentage of uninsured Californians say the high cost of coverage is the main reason they go without health insurance.
The issue of just how much people can afford will loom large as the state exchange prepares to negotiate with health insurers over next year's rates.
Many analysts are predicting bigger premium increases for 2016 in California and across the country. Insurers have more details on the medical costs of enrollees, and some federal programs that help protect health plans from unpredictable claims will be winding down.
This latest pulse on consumer attitudes is drawn from a Kaiser Family Foundation survey of 4,555 Californians from September to December 2014. It examined the experiences of people in Covered California, Medi-Cal, other private coverage and the uninsured.
Forty-four percent of exchange policyholders surveyed said it's somewhat or very difficult to afford their premiums. That's compared with 25% of adults who had employer-based or other private health insurance.
Peter Lee, executive director of Covered California, acknowledged that many Californians find it hard to fit health insurance premiums into their household budget, even when they qualify for generous federal subsidies.
"If you are making $25,000 a year that $70 premium is still a struggle," Lee said. "The Affordable Care Act is providing nobody with a free lunch. This issue of making healthcare affordable is not easy."
Anthem Blue Cross, Kaiser Permanente and other health insurers have submitted their proposed 2016 rates for individual policies to Covered California, and negotiations are expected to begin next month.
The final statewide rates should be announced in July, Lee said. For 2015, the average rate increase was 4.2%.
The consumer survey also delved into patient satisfaction with their health insurer and access to care.
Among Covered California members, 74% rated their coverage as excellent or good. It was 88% among people with other private coverage.
Ninety-one percent of exchange customers said it was easy to get to their usual source of medical care, matching the response among people with other types of private coverage.
And 59% of Covered California enrollees had a checkup or preventive care visit by the fall of 2014. But 18% of exchange policyholders said a medical provider would not accept them as a new patient.
Many consumers have complained about a shortage of participating doctors in narrower Covered California networks and problems getting accurate information from insurers' provider directories.