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League of Women Voters of La Plata County - Health Questionnaire
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GENERAL
This purpose of this questionnaire is to gather opinions and information about healthcare in La Plata County. The questionnaire is anonymous and the results will be used to provide information to local governments, health care providers and the public.
What is your age?
(Required)
Under 20
20-29
30-39
40-49
50-59
60-69
70 or over
Hidden
What is your age?
(Required)
In general, how would you rate your overall health?
(Required)
Poor
Fair
Very Good
Excellent
Hidden
In general, how would you rate your overall health?
Excellent
Very good
Fair
Poor
What is your total annual household income?
Under $50K
$50K - $100K
$100K - $200K
Over $200K
Hidden
What is your total annual household income?
Under $50K
$50K - $100K
$100K - $200K
Over $200K
What is your race? (Check all that apply.)
White
Black or African American
Asian
Hispanic
Native American
Other
Hidden
What is your race? (check all that apply)
White
Black or African American
Asian
Hispanic
Native American
Other
What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
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What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
HEALTH INSURANCE
What type of insurance coverage do you currently have? (Check all that apply.)
(Required)
Individual plan
Employer-sponsored health insurance
Medicare
Other public plan (IHS, VA, CHIP, Federal Employee, Medicaid)
None - I don't have health insurance
If you have Medicare, which options do you have? (Check all that apply.)
Traditional (Parts A & B)
Medigap (Supplemental)
Medicare Advantage (Parts A, B & Supplemental)
Hidden
XWhat type of insurance coverage do you currently have?
(Required)
Individual plan
Employer-sponsored health insurance
Medicare
Other public plan (IHS, VA, CHIP, Federal Employee, Medicaid)
None – I don’t have health insurance
Hidden
XWhat type of insurance coverage do you currently have?
Individual plan
Employer-sponsored health insurance
Medicare
Other public plan (IHS, VA, CHIP, Federal Employee, Medicaid)
None.I don’t have health insurance
Do you receive a subsidy or financial assistance to lower your premium amount?
Yes
No
Not sure
XDo you receive a subsidy or financial assistance to lower your premium amount?
Yes
No
Not sure
What is your level of satisfaction with each of the following?
(Required)
Not Applicable
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
The amount I pay for my health insurance premium
The co-payment I am responsible for paying
The deductible amount I must pay before my health insurance covers 100% of my medical costs
My health insurance coverage
How would you rate the level of difficulty in working with your health insurance company?
(Required)
Not applicable
Very difficult
Difficult
Neutral
Easy
Very easy
Following a visit to your health care provider, the process of receiving, reviewing and paying claims
Signing up for or renewing your health insurance policy
What is your reason for not having health insurance? (Check all that apply.)
Can't afford it
Don't need or want it
Ineligible
Don't know how to get it
Other
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XWhat is your reason for not having health insurance? (Check all that apply.)
Can't afford it
Don't need or want it
Ineligible
Don't know how to get it
Other
If you answered "Other" from above, please explain:
Hidden
XIf you answered "Other" from above, please explain:
Has cost ever prevented you from seeking medical care?
(Required)
Yes
No
Hidden
XHas cost ever prevented you from seeking medical care?
(Required)
Yes
No
If yes to above, please explain:
XIf yes to above, please explain:
Further clarification or comments about your experience(s) with health insurance:
Hidden
XFurther clarification or comments about your experience(s) with health insurance:
HEALTH CARE PROVIDERS
What is your level of satisfaction with each of the following?
(Required)
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
The availability of physicians in La Plata County
The availability of hospitals in La Plata County
The quality of physicians in La Plata County
The quality of hospitals in La Plata County
The length of time it takes to get an appointment with a physician in La Plata County
The length of time it takes to get an appointment for a procedure at a La Plata County hospital
Further clarifications or comments:
Hidden
XFurther clarifications or comments:
Have you experienced receiving bills for unforeseen costs you didn’t anticipate that came after your interaction with a provider or hospital?
(Required)
Yes
No
Hidden
XHave you experienced receiving bills for unforeseen costs you didn’t anticipate that came after your interaction with a provider or hospital?
(Required)
Yes
No
If yes from above, please explain.
Hidden
X If yes from above, please explain.
PRESCRIPTION DRUGS
What is your level of satisfaction with the amount you pay for prescription drugs?
(Required)
Not Applicable
Not at all satisfied
Slightly satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
Has your doctor ever changed your prescription because your insurance won’t cover a medication that has worked well for you in the past but is no longer covering that drug?
(Required)
Yes
No
Don't know
Hidden
XHas your doctor ever changed your prescription because your insurance won’t cover a medication that has worked well for you in the past but is no longer covering that drug?
(Required)
Yes
No
Don't know
Further clarification or comments about your experience(s) with prescription drugs:
Hidden
Further clarification or comments about your experience(s) with prescription drugs:
HEALTHCARE IN THE US
Please rate your level of support for each of the following approaches to US healthcare reform:
(Required)
Strongly oppose
Oppose
Neutral
Agree
Strongly agree
Establish a tax-payer funded, universal healthcare system (e.g. like Medicare) where every citizen receives government-financed insurance that covers all essential healthcare costs from birth to death. The government would pay for healthcare delivery, but providers would remain private.
Expand the current Medicare system to be available to all citizens aged 50 and over.
Create a government-financed insurance “public option" that citizens can purchase that covers all healthcare costs from birth to death. Private insurance plans would remain and the public option plan would compete with them for customers.
Maintain the existing private healthcare system but implement federally-mandated regulations to control pricing of healthcare insurance, services and prescription drugs.
Maintain the existing private healthcare system without additional government regulations.
Please rate your level of agreement with the following statements:
(Required)
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Healthcare is a human right
Healthcare should be a non-profit industry
The US government should finance healthcare for all citizens
The Affordable Care Act is reducing health care costs, increasing accessibility and improving outcomes
The government should be allowed to negotiate drug prices for Medicare
Comments or clarifications:
Hidden
XComments or clarifications:
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Name
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