Medical Debt Survey

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* 1. What is your ethnicity?

American Indian or Alaska Native

Asian

African American

Hispanic

Native Hawaiian or Pacific Islander

White

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* 2. What is your age?

18-25

26-35

36-46

46-55

56-65

Over 65

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* 3. What is your zip code?

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* 4. What is your gender?

Male

Female

Gender non-conforming

Prefer not to say

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* 5. What is your annual household income?

Under $10,000

$10,000-$25,000

$25,000-$50,000

$50,000-$75,000

$75,000-$100,000

$100,000-$125,000

$125,000-$150,000

Over $150,000

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* 6. Do you currently have health insurance, or not?

Yes, I do

No, I do not

I don't know

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* 7. In the past 12 months, did you have trouble paying medical bills, such as doctor, medications, emergency care?

Yes, I did

No, I didn't

I don't know

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* 8. Have you ever had to go without health insurance due to cost or availability?

Yes, I have

No, I haven't

I don't know

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* 9. Have you ever had to delay treatment due to cost?

Yes

I don't know

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* 10. Of all the medical bills you’ve had problems paying in the past 12 months, were these bills for. Select all that apply.

Your own medical care

Your spouse or child

A parent(s)

Another family member

I don't know

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* 11. How do you pay your medical bills? Select all that apply.

Financial Assistance

Payment Arrangement

Paycheck/Checking/Savings Account

Credit Card

Tax Refund

Loans(bank, family, friends)

HSA/Flex account

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* 12. Approximately how much medical debt do you owe?

Less than $250

$250 - $1,000

$1,000 - $5,000

$5,000-$10,000

Above $10,000

I don't know how much

None

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* 13. Have you ever been denied medical care due to unpaid medical bills?

Yes

I don't know

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* 14. Do you have a hard time understanding your medical bills

Yes

Maybe

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* 15. Are you interested in receiving more information or about understanding medical debt? If so, please leave your email address or phone number below.