Medical Debt Survey
1.
What is your ethnicity?
American Indian or Alaska Native
Asian
African American
Hispanic
Native Hawaiian or Pacific Islander
White
2.
What is your age?
18-25
26-35
36-46
46-55
56-65
Over 65
3.
What is your zip code?
4.
What is your gender?
Male
Female
Gender non-conforming
Prefer not to say
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
6.
Do you currently have health insurance, or not?
Yes, I do
No, I do not
I don't know
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
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
9.
Have you ever had to delay treatment due to cost?
Yes
No
I don't know
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
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
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
13.
Have you ever been denied medical care due to unpaid medical bills?
Yes
No
I don't know
14.
Do you have a hard time understanding your medical bills
Yes
No
Maybe
15.
Are you interested in receiving more information or about understanding medical debt? If so, please leave your email address or phone number below.
Current Progress,
0 of 15 answered
