Health Care Rights and Access Questionnaire
Please share your health care story by filling out the questionnaire below. You can respond anonymously.

You story will help the Campaign for New York Health better understand the challenges New Yorkers face accessing health care and more effectively advocate for a health care system that guarantees equal, quality care for all New Yorkers.
1) Do you currently have health insurance? *
1a) If you answered yes, you do have health insurance, what type?
Clear selection
1b) What is your insurance company?
1c) If your insurance was purchased on the Health Insurance Marketplace, which tier did you select?
Clear selection
1d) What’s the longest period of time you have gone without health insurance?
Clear selection
1e) How much will your insurance costs go up in 2019?
Clear selection
2) Have you ever had problems getting the health care you need?
Clear selection
If yes, what were/are the reasons?
3) Have you ever had to forgo needed health care because of costs?
Clear selection
3a) Have you ever skipped any of the following?
3b) Have any of these costs have been difficult for you (check all that apply)
4) Have you, or someone in your family, ever experienced any of the following:
Stayed in a job only to keep your health insurance?
Clear selection
If yes, please describe:
Been discriminated against when trying to get healthcare because of your race, immigration status, gender, sexual orientation, age, or disability?
Clear selection
If yes, please describe
Developed more serious health problems or delayed treatment because of concerns around cost?
Clear selection
If yes, please describe
Have had problems paying medical bills?
Clear selection
If yes, please explain:
Had problems paying for home care?
Clear selection
If yes, please explain:
For those who work in health care settings
Do you work in a clinical setting?
Clear selection
Please describe
Have you ever observed different treatment for patients based on health insurance status?
Clear selection
If yes, please describe
Have you ever observed a patient delay or refuse health care because of cost?
Clear selection
If yes, please describe
Do you feel that a patient’s concern with cost of health care has affected your relationship with the patient?
Clear selection
If yes, please describe
Claiming Our Rights
Do you think we should make sure that everyone in New York can get the health care they need?
Clear selection
Do you believe that health care is a human right?
Clear selection
Do you believe our government has an obligation to protect the human right to health care?
Clear selection
Would you say that the human right to health care is protected here in New York?
Clear selection
Do you feel that you have a say in decisions about our health care system?
Clear selection
Responsibilities of Government: The Solution
What do you think of the idea of a universal health care system, which would be publicly funded from our taxes rather than paying premiums and deductibles to insurers and medical care providers? This type of coverage would allow for you to choose your doctor and hospital. It is often called a single-payer system or improved Medicare for All.
Clear selection
If you could change anything about our health care system, what would it be?
Any other comments you’d like to make?
About you (this will help us analyze the results of this survey)
Which New York county do you live in?
Gender
Clear selection
Your race or ethnicity
Clear selection
Your age
Are you a medical practitioner?
Clear selection
If yes, what field?
Are you a business owner?
Clear selection
If yes, would you be interested in learning about the Business for NY Health campaign?
Clear selection
Do you want to get involved?
It is not necessary to give your personal information to do the survey. You can choose to remain anonymous. However, if you would like to get involved in the Campaign for New York Health, for example by telling your story, we need some way to get in touch with you!
I would like to get more involved in the Campaign for New York Health
Name
Street Address
City
Zip code
Phone
Email
What's the best way to contact you to discuss your story?
Would you be willing to speak with the media, lawmakers, and others about your story?* *
Would you be willing to allow the Campaign for New York Health to share your story in letters, press releases, or social media campaigns? *
Thank you for sharing your story.
Submit
Never submit passwords through Google Forms.
This form was created inside of Physicians for a National Health Program NY Metro Chapter. Report Abuse