If you don’t get health insurance through an employer and you’re not enrolled in Medicare or Medicaid, then you probably buy Affordable Care Act (ACA) coverage on your own. The health reform was fully implemented in 2014, ten years ago.

So, how’s it holding up?

To answer that question, we surveyed more than 300 ACA plan enrollees and here are our top-five takeaways:

1. The subsidy divide is real: Whether enrollees consider the ACA a success largely depends on if they’ve received federal subsidies: 66% of those receiving federal subsidies to lower their premiums consider it a success, while only 34% of unsubsidized enrollees feel the same way.
2. Healthcare is a major election issue: A significant majority (67%) of ACA enrollees who are likely voters rank healthcare among their top three voting issues; 56% specifically want to see reduced costs for premiums and out-of-pocket expenses.
3. Overall satisfaction remains strong: Despite the subsidy divide, more than two-thirds (68%) of all ACA plan enrollees report being satisfied with their health insurance coverage, suggesting the program is meeting many enrollees' needs.
4. Some would reconsider charging people more based on their health: A notable minority of ACA plan enrollees (29%) believe higher-risk individuals should pay more for coverage, challenging one of the ACA's foundational principles. Of these, 76% specifically target heavy drinkers and 73% point to smokers for higher premiums.
5. Affordability remains a key challenge: Among those receiving federal premium subsidies, 81% consider their coverage affordable, compared to only 46% of those not receiving subsidies. Cost remains a significant hurdle for those who don't qualify for federal assistance, even ten years after full implementation.

Read the full report. 

If you buy coverage on your own for yourself or your family, remember: the ACA’s nationwide annual open enrollment period is scheduled to begin on November 1 and run through January 15, 2025.