Kitchen Table Economics
1.	Which of the following best describes your household's financial situation today? Select one.
		Getting ahead
		Having just enough to get by
		Falling behind
2.	How has the economic downturn affected your household in the past year? Select one.
		It hasn't
		Not very much
		Quite a bit
		Very much
Health Care and You
3.	Do you and members of your household have health care coverage? Select one.
		Yes
		No
		Some in the household do, some do not
3.	a.	If yes: (Check all that apply.)
		Coverage provided through employer (yours, spouse's, partner's or parents')
		Medicare
		Medicaid, VA or other public coverage
		Coverage purchased by you or someone in your household
		None
3.	b.	Do any of the following people in your household NOT have health coverage? (Check all that apply.)
		Self
		Spouse/partner
		Children younger than 18
		Children ages 18-24
		Children ages 25 and older
		Other household members (parent, sister, brother, etc.)
4.	In the past year, have you or has someone in your household lost health coverage because of losing a job or changing jobs? Select one.
		Yes
		No
5.	How big a concern is health care when you think about changing jobs? Select one.
		A big concern
		Some concern
		Not too much concern
		Not a concern at all
6.	Thinking about health care for you and your family, are you generally satisfied or dissatisfied with:
		Satisfied Dissatisfied Cost Access to care when you need it Quality Insurance coverage
6.	a.	Thinking about health care in America overall, are you generally satisfied or dissatisfied with:
		Satisfied Dissatisfied Cost Access to care when you need it Quality Insurance coverage
7.	Are you able to get the health care you need at a price you can afford? Select one.
		Yes
		No
8.	How have your overall health care costs changed in the past year? Select one.
		Increased a lot
		Increased some
		Stayed the same
		Decreased some
		Decreased a lot
9.	How much did you and your household spend out of your own pockets for health care in the past year?  (Include premiums, deductibles, co-pays, prescription costs.)   Select One.
		0
		$1 – $100
		$100 – $1,000
		$1,000 – $5,000
		More than $5,000
10.	Are any of the following health expenses not affordable for you today? Check all that apply .
		Prescription drugs
		Preventive care and checkups
		Tests
		Specialists
		Catastrophic health problems
		Chronic disease treatment
		Surgery
		Other:
11.	In the past year, did you or a member of your household experience any of the following problems with health care costs? Check all that apply .
		Did not visit doctor when sick because of cost
		Skipped medical test, treatment or follow-up recommended by doctor because of cost
		Did not fill a prescription or skipped doses because of cost
		Had serious problems paying or were unable to pay medical bills
		None
12.	In the past year, did you or a member of your household experience any of the following problems with health care coverage? Check all that apply .
		Was denied coverage because of a "pre-existing condition"
		Insurer refused to pay for treatment or tests the doctor recommended
		Insurer denied a claim you believe should have been covered
		Insurer paid less than you believe it should have for a claim
		None
13.	If you are insured, how much do you know about what your insurance covers and what it doesn’t?  Select one.
		A lot
		Some
		Not very much
		Hardly anything
14.	If you have insurance, how easy or hard is it to talk to someone at your insurance company about what is covered or coverage decisions?   Select one.
		Easy
		Not too hard
		Pretty hard
		Very difficult
15.	If you have had to call your insurance company for information or help, how many calls did you or your doctor have to make?  Select one.
		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		More than 10
16.	If you could change one thing about the way health care insurance works, what would it be?
	Limit: 150 words
17.	Do you think your health insurance provider has too much influence, too little influence or the right amount of influence on decisions about your health care and treatments?   Select one.
		Too much influence
		Too little influence
		The right amount of influence
Health Care in the Future
18.	Are you worried about you or someone in your household losing health care coverage in the next year?    Select one.
		Very worried
		Somewhat worried
		Not too worried
		Not worried at all
19.	Are you worried about you or someone in your household having trouble paying for health care in the next year? Select one.
		Very worried
		Somewhat worried
		Not too worried
		Not worried at all
20.	With the current economic crisis, how urgent do you think it is for the government to address health care reform?  Select one.
		Very urgent
		Somewhat urgent
		Not that urgent
		Not urgent at all
21.	Which one comes closer to your way of thinking? Select one for each grouping.
		Government should have stronger rules and standards for health insurance companies.
OR		Health insurance companies work best without too many government rules and standards.
		Premium, co-payment and deductible costs required by insurers should be limited.
OR		Insurers should be able to base premiums, co-payments and deductibles on market factors without interference.
		Health insurers should provide a standard package of benefits.
OR		Health insurers should cover benefits based on the policy you can afford and choose to buy.
		Health care reform should let people choose to have private insurance or a public health insurance plan.
OR		Health insurance should remain in the hands of private insurance companies.
About You
22.	Are you :  Select one.
		Currently employed
		Retired
		Not currently employed and not retirement age
23.	What age group are you in?  Select one.
		18-29
		30-39
		40-49
		50-64
		65 or older
24.	What was the last year of schooling you completed?  Select one.
		Grade 1-11
		High school graduate
		Non-college program after high school (technical school, for example)
		Some college
		College graduate
		Post-graduate school
25.	Are you :  Select one.
		Male
		Female
26.	Are you: (Check one that best applies.)
		Hispanic/Latino
		White/Caucasian, non-Hispanic
		African American, non-Hispanic
		Asian Pacific American/East Asian
		Native American
		Biracial/multiracial
27.	Please check all that describe you:
		Student
		Married
		Domestic partner
		Have children younger than 18 living with me
		Have children older than 18 living with me
		LGBT
		Union member
		Someone in my household is a union member
Tell Us Your Health Care Story
28.	Tell us your health care or health insurance story.    (Optional)
	Story Title:
	Story Category: Select one: ------------------- Health care costs Insurance issues Quality of care Access to care Health care reform Other
	The comments you submit here may be published on this website (see guidelines) and in other materials with your first name, city, state and union (if you're a union member). No other answers or comments you've provided in this survey will be published.
	Please do not name a company or individual. If necessary, we will edit posts to remove specific names.
	Limit: 300 words
	May we share your story with the press, using just your first name, city and state?
		Yes
		No
	To submit your story as a video, please enter the YouTube link here:
Submit Your Response
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