Healthcare Price Impact Survey
Help us understand how healthcare costs affect you and your household. Your responses are confidential and will be used for research purposes only.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
State or Region of Residence
*
Please Select
Northeast
Midwest
South
West
Other
Do you currently have health insurance?
*
Yes, through employer
Yes, private plan
Yes, government program (e.g., Medicare, Medicaid)
No
How would you rate your satisfaction with your current healthcare coverage?
*
1
2
3
4
5
How much have rising healthcare prices impacted your household budget in the past year?
*
No impact
Minor impact
Moderate impact
Major impact
Please indicate how healthcare prices have affected the following aspects of your life:
*
Rows
No Impact
Minor Impact
Moderate Impact
Major Impact
Ability to afford prescriptions
1
2
3
4
Ability to seek medical care
5
6
7
8
Mental health and stress
9
10
11
12
Ability to pay other bills
13
14
15
16
Access to preventive care
17
18
19
20
Have you delayed or avoided medical care due to cost in the past year?
*
Yes, delayed care
Yes, avoided care entirely
No
How do you feel about the transparency of healthcare pricing in your area?
*
Very transparent
Somewhat transparent
Not transparent
Unsure
Please share any additional comments or experiences regarding healthcare prices and their impact on you or your family.
Submit Survey
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