Ohio Consumers for Health Coverage is collecting data to learn what the barriers are to the access of health care by people with a chronic illness. If you are a person with a chronic illness or you are a care-giver for a person with a chronic illness, please answer the questions below.  If you are answering as a caregiver, please answer the questions as if you are the person for whom you are caring.

Even though we are exploring barriers that exist for people with a chronic illness who have health coverage, please continue to fill out the survey even if you answer question 1 that you “don’t have any coverage.”

Your answers will help us approach health insurance companies to seek more affordable cost sharing.  Please answer as accurately as you can.  If you aren’t sure that you have a chronic illness, assume that you do if there is some condition for which you take a regular medication or regular treatment of some kind.

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* 1. What health coverage do you have?

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* 2. How would you rate your health?

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* 3. Do you have any of the following chronic illnesses or conditions?

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* 4. Do you have a disability?

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* 5. If you answered “yes” for Question 4 (“Do you have a disability?”), please check all that apply:

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* 6. In the last twelve months, have you ever had difficulty paying for the medications you need to manage your chronic illness or condition?

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* 7. In the last twelve months, have you done any of the following pertaining to your medications because of the cost?

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* 8. In the last twelve months, have you not filled a prescription that pertains to your chronic illness or condition due to the cost?

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* 9. In the last twelve months, have you skipped or delayed going to the doctor that treats your chronic illness because of cost?

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* 10. In the last twelve months, was there any specialist your doctor referred you to that you did not see because of the cost of that specialist?

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* 11. In the last twelve months, was there any other treatment that your doctor referred you to that you did not go for because of the cost of that treatment?

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* 12. In the last twelve months, are there any medical supplies to monitor your chronic illness that you did not purchase in the quantity that you needed because of cost? (such as test strips, needles/syringes, glucose monitor, nebulizer, etc)

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* 13. How many prescription drugs do you take on a regular basis? (every day, every week, not just when you are sick, such as cold or flu)

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* 14. For you to take all the medications prescribed for your chronic illness as prescribed, what is the maximum monthly co-pay you could afford for each medication?

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* 15. Identify all of the following that get in your way in taking care of your chronic illness

Please answer the following questions about yourself to help us draw the most accurate conclusions from the survey:

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* 16. What is your age?

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* 17. What is your gender?

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* 18. What is your race?

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* 19. In what county do you live?

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* 20. What language do you prefer to speak when you are talking with your doctor?

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