Tell Congress to keep their hands off our health care.

Congress is, once again, trying to take away health care from seniors, children, poor families, people with disabilities, and those with pre-existing conditions.

The most horrific ACA repeal proposal we've seen -- from Senators Cassidy and Graham -- is within 2 weeks of a vote. It takes direct aim at California.

This proposal would gut Medicaid funding and eliminate the ACA's financial assistance for middle-class families. Our vulnerable populations would suffer, while the mega-wealthy would get huge tax breaks.

Congress needs to hear that their decisions have very real impacts on people, families, and communities. Our stories are the MOST effective way to get the message across loud and clear.

Please share your health care story here. Then forward this survey to everybody you know and post it on social media. 

The clock is ticking.

-Fight4ourhealth coalition, September 15, 2017

* 1. First Name

* 2. Middle Initial

* 3. Last Name

* 4. How did you hear about this survey?

* 5. Age

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

* 7. E-mail Address

* 8. Address

* 9. Zip Code

* 10. County

* 11. Occupation

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

* 13. Gender (optional)

* 14. Race or ethnicity (optional)

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

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

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

* 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?

* 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:

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

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

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

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

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

* 25. Share a photo

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* 26. Share your social media profile (optional)