Share Your Health Care Story

Health Access California and the #Fight4OurHealth coalition want to hear from you!

Our health care is under threat from Congress and the Trump administration. Whether it's through cuts to Medicaid in the federal budget, or actions such as pulling cost-sharing discounts for low-income families, it's more important than ever that we take action to protect our care.

Particularly as open enrollment season begins, we want to know what your experience is with health insurance. Whether or not this is your first time getting it, or if you have a story from before the Affordable Care Act was passed, we want to hear from you!

It's because of stories like yours, that we were able to defeat the many attempts at ACA repeal or other cuts or caps to our health care. And with your continued advocacy, we hope to build on the progress of the ACA to improve our health care system.

Thank you for sharing your story!

First Name

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* 1. First Name

Middle Initial

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* 2. Middle Initial

Last Name

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* 3. Last Name

How did you hear about this survey?

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* 4. How did you hear about this survey?

Age

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* 5. Age

Phone Number (XXX-XXX-XXXX)

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

E-mail Address

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* 7. E-mail Address

Address

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* 8. Address

Zip Code

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* 9. Zip Code

County

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* 10. County

Occupation

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* 11. Occupation

Do you have children? (currently 0-18)

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

Gender (optional)

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* 13. Gender (optional)

Race or ethnicity (optional)

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* 14. Race or ethnicity (optional)

What type of health insurance coverage do you have?

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

Has coverage saved your life (or someone in your family’s)?

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* 16. Has coverage saved your life (or someone in your family’s)?

Has coverage kept you (or your family) from financial ruin or even bankruptcy?

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* 17. Has coverage kept you (or your family) from financial ruin or even bankruptcy?

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?

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* 18. 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?

If you are a physician, nurse, clinic employee, home care worker or other health provider, please tell us how the ACA has benefited you or your patients:

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* 19. If you are a physician, nurse, clinic employee, home care worker or other health provider, please tell us how the ACA has benefited you or your patients:

Are you willing to speak further with Health Access staff or the Fight4OurHealth coalition about sharing your story?

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* 20. Are you willing to speak further with Health Access staff or the Fight4OurHealth coalition about sharing your story?

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

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

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

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

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

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

Are you comfortable with sharing your story with an audience at a Community meeting or Town Hall?

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* 24. Are you comfortable with sharing your story with an audience at a Community meeting or Town Hall?

Share a photo

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* 25. Share a photo

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Share your social media profile (optional)

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* 26. Share your social media profile (optional)

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