Health Care is a Human Right Survey Health Care is a Human Right Survey (Fluent Forms One Page Version)Thank you for taking our health care survey! The only chance we have to change the healthcare system is to take action together. At the end of the survey, we ask that your share your contact information so we can stay in touch. We will not publish your survey responses in connection with your name without your permission.Do you have health insurance? Yes NoWhat kind of insurance or assistance do you have? (check all that apply) Medicaid Medicare Medicare Supplement / Medigap Medicare Advantage Employer provided health insurance VT Health Connect plan with or without subsidy I rely on hospital financial aid My children are on Dr. Dynasaur OtherMore details (please describe)Are you concerned about losing Medicaid when paperwork and eligibility hurdles return in April, 2023? Yes, I'm currently on Medicaid, and I'm concerned I will lose it No, I'm currently on Medicaid but I'm not worried about losing it I'm not currently on MedicaidHow does the cost of health care affect you and your family? (check all that apply) Premiums/copays/deductibles/medical bills are too expensive I have medical debt I purposely limit my income to stay on Medicade I or someone I know has stayed in a relationship for healthcare I could not afford a $500 medical bill if I got one I or someone I know have stayed in a bad job just for healthcare My health insurance costs have risen over the years I have had to choose between medical care and other necessities OtherMore details (please describe)Do you struggle to access all the care that you need? Always Sometimes NeverWhat care do you struggle to access (check all that apply) Prescriptions Dental Vision or Hearing Mental health Services for people with disabilities Reproductive health Recovery treatment Difficulty finding providers in my area Gender affirming care Transportation to receive health care "Alternative" care (e.g. acupuncture, herbalist) OtherMore details (please describe)What barriers have you experienced in the healthcare system? (check all that apply) Gender identity Disability Language Age Poverty Race Body size History of substance use Formerly incarcerated Immigration status OtherMore details (please describe)Are there other challenges you and/or your family are facing in meeting your needs? Yes NoIf yes, how are these challenges impacting your health?Do you know other people struggling with access to health care? Is there anyone else we should talk to?Do you agree that healthcare is a human right? Yes NoFirst NameLast NameEmailPhoneAddressTownStateSubmit Form
