California High Health Care Bills Survey Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Phone number Question Title * 4. E-mail Address Question Title * 5. Zip Code Question Title * 6. What type of health insurance do you have? Private insurance through Covered California Private insurance purchased directly from an insurance company Private insurance purchased through an independent broker Employer-sponsored insurance Medi-Cal Medicare Uninsured Other Question Title * 7. If you have insurance purchased through Covered California, do you receive financial subsidies to help lower your premiums or other costs? Yes No I don't know Did not purchase insurance through Covered California Question Title * 8. Do you have trouble affording any of the following (choose all that apply): Monthly premium Deductible Co-Pays Co-Insurnace Prescription drugs Question Title * 9. Have you ever had an expensive/outrageous health care bill? [From a doctor, hospital, or other health care setting] Yes No Question Title * 10. Please tell us more about your experience with high health care bills: Question Title * 11. Are you willing to speak further with Health Access staff about sharing your story? Yes No Maybe Question Title * 12. What is the best time to reach you? Question Title * 13. Are you interested in sharing your story directly with lawmakers through a meeting or phone call? Yes No Maybe Question Title * 14. Are you comfortable sharing your story with the media, such as a reporter or local TV station? Yes No Maybe Done