We want to hear about your experiences with health care in California

Health care has been a hot topic of debate, but we know at the center are real people with real stories. We want to hear from you about your experience with California's health care system. 

Do you have a pre-existing condition? Do you face high health care bills or prescription drug costs? Did you have a life-saving experience thanks to the ACA? It's because of stories like yours that we were able to fight back against many attempts to repeal or cut our health care and with your continued advocacy, we hope to build on this progress and improve our health care system while also lowering costs.

Thank you for sharing your story!

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* 1. First Name

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* 2. Middle Initial

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* 3. Last Name

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* 4. Age

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* 5. Phone Number (XXX-XXX-XXXX)

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* 6. E-mail Address

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* 7. Address

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* 8. Zip Code

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* 9. County

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* 10. Occupation

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* 11. Do you have children? (currently 0-18)

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* 12. Gender (optional)

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* 13. Race or ethnicity (optional)

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* 14. What type of health insurance coverage do you have?

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* 15. Do you have trouble affording health care insurance for you or your family? Or do you currently face high health care or prescription drug bills?

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* 16. share your story
Please describe your health care story
(take as much room as necessary). For example, tell us: about a time when you weren’t able to afford health coverage. Do you have a pre-existing health condition (examples include everything from childhood asthma, to having had surgery, or a life-threatening illness)?  What will happen to you and your loved ones if your health coverage is taken away? Has having coverage saved your life or saved you from financial ruin?

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* 17. Are you willing to speak further with Health Access staff about sharing your story?

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* 18. What is the best time to reach you and preferred method of communication?

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* 19. Would you be comfortable sharing your story with the media, such as a reporter or local TV station?

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* 20. Are you interested in sharing your story directly with lawmakers through a meeting or phone call?

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* 21. Would you like to receive regular communication from Health Access?

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