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Nearly three-quarters of Californians who didn’t have health insurance before the Affordable Care Act took effect in 2014 are now covered, but those still uninsured are increasingly difficult reach, according to a new released Thursday.

Some of those remaining uninsured are undocumented immigrants who don’t qualify for federally subsidized coverage. Others may be eligible but unaware of their options, and still others said they were worried about costs, according to the survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

There is a lingering perception “that it is not affordable for them,” said Bianca DiJulio, an associate director at the foundation.

Many of those still without coverage are Latino; one-third of all Latino survey respondents are still uninsured.

The Affordable Care Act allowed states to expand Medicaid coverage to single, childless adults and those with higher incomes than before. It also created insurance exchanges, where people could sign up for subsidized health insurance.

Since 2014, about 1.4 million residents enrolled in Covered California, the state’s health insurance exchange, and almost 5 million in Medi-Cal, California’s version of Medicaid. Not all were previously uninsured.

The percentage of those who were uninsured in 2013 and got coverage did not significantly change from last year. About 72 percent were covered after the third enrollment period, up slightly from 68 percent after the second open enrollment.

Of those who were previously insured and gained coverage, about one-third did so through Medi-Cal. One-fifth received employer coverage and about 1 in 10 purchased plans through Covered California, the survey found. A found this year that the uninsured rate in California among adults aged 18 to 64 dropped from 23.7 percent in 2013 to 11.1 percent at the end of 2015.

The Kaiser Family Foundation survey followed a random group of about 2,000 adult Californians from 2013 through 2016. By interviewing the same residents at four separate times, researchers were able to track changes in their insurance status and determine how health insurance affected their lives.

One of the participants, James Daniel, a 65-year-old website developer from Sylmar, said insurance companies wouldn’t even talk to him before the Affordable Care Act because he was taking antidepressant medication. “I was totally uninsurable,” he said.

In late 2013, Daniel had a heart attack. As soon as enrollment opened in 2014 and insurers could no longer deny coverage to people with preexisting conditions, Daniel signed up for a plan through Covered California. His premium cost about $50 a month, and he started seeing a cardiologist regularly.

“It saved my life,” said Daniel, who switched to Medicare once he reached 65. “It let me go see the doctor and it helped me pay for my meds, which I couldn’t have afforded.”

Maria Arreola, 38, said she became insured this spring through her husband’s job as a hotel chef. Arreola said she didn’t sign up earlier because the monthly premium costs were unaffordable.

The Santa Ana resident said she feels relieved that she no longer has to pay $200 for a doctor visit. “I finally have medical coverage,” she said. “If I get sick, I have something to help.”

About three-fourths of those now covered said their health needs are being met well, compared to about 50 percent in 2013. The vast majority of the recently insured said they have had good experiences with their insurers. They also reported being satisfied with their choice of doctors and hospitals, the survey found. Still, about 10 percent said they had been turned away by a doctor’s office or clinic in the previous year.

Survey participants who gained health coverage were also far less worried about paying medical bills in 2016 than when they were uninsured three years earlier. But some newly insured still are concerned about costs: About 20 percent said they didn’t get medical care sometime in the previous year because of the cost and more than half reported they worry about bills if they have a serious illness or accident.

Costs will remain a challenge — both for individuals and the health system as a whole, said Walter Zelman, a Cal State University, Los Angeles professor and longtime California health policy insider who helped educate and enroll students in new coverage. Prescription drug prices continue to climb, and premiums in Covered California plans on average will rise by more than 13 percent in 2017.

“We still have a very expensive healthcare system,” Zelman said. “That is an ongoing challenge that we have to work through.”

Although there is still some churn of people gaining and losing coverage, the majority of those who get insurance keep it, the survey found. More than 60 percent of survey respondents who were insured said they had coverage for at least a year, and nearly 50 percent had it for more than two years, according to the survey.

“Having a stable source of coverage and some continuity of care…could help people be more engaged with their health and the health care system,” DiJulio said.

The next challenge will be reaching those who still aren’t covered, DiJulio said.

Jacquelyn Catchings, 59, said she has been uninsured most of her life. If she needs to go to the doctor, she pays cash. Catchings said she has high blood pressure but isn’t generally worried about her health.

Catchings, who lived in Compton before recently moving to Las Vegas, said she didn’t sign up because she didn’t know that much about what is available and she is “lazy.”

“Right now, I don’t think it’s important because I am not a sickly person,” she said.

California is waiting for a decision from the federal government on whether to grant an exemption from current law and allow immigrants living in the state illegally to purchase health coverage through Covered California — although they wouldn’t qualify for federal subsidies.

It may take an intense and expensive outreach effort to educate California’s remaining uninsured that they may be eligible for free or nearly free health insurance, Zelman said. Nearly half of those without insurance said they believe that it is too expensive, even though many people have incomes low enough to qualify for help, according to the survey.

California “is a considerable success story,” Zelman said, “with the lingering problem that relatively few people are not accessing the system.”

–This story has been updated to explain more clearly California’s effort to open its state health insurance exchange to undocumented immigrants