Required
Prefix:
Required
First Name:
MI:
Required
Last Name:
Required
Address Line 1:
Address Line 2:
Required
City:
Required
State:
Alabama
Alaska
America Samoa
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
Delaware
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Zip:
Required
Email:
Required
Phone:
Required
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Required
What is your current employment status?
Employed Full-time
Employed Part-time
Unemployed
Student
Retired
Unable to work
Required
What type of insurance do you currently have?
Medicaid
Medicare
Dual Eligible (Medicare and Medicaid)
Employer-provided insurance
Marketplace / ACA Plan
Private individual plan
TRICARE/VA
I am currently uninsured
Other (please specify)
Required
Do you have children or dependents on your insurance plan?
Yes
No
Required
How will your healthcare insurance be impacted in 2026?
No longer able to afford health coverage
Increased monthly premiums
Higher out-of-pocket costs or co-pays
Difficulty meeting work/eligible requirements for Medicaid
No impact on my health insurance costs
Required
If your monthly premiums increase, by how much will they increase?
What is your current monthly premium for 2025?
Required
What will your monthly premium be in 2026?
Required
Do you receive care from a community clinic or rural hospital?
Yes
No
Sometimes
If you answered yes, how concerned are you about potential closures or reduced services?
Very concerned
Somewhat concerned
Not concerned
Required
If your health insurance is impacted, will you have to choose between paying household needs (rent, utilities, food) and paying for health insurance or medical care?
Yes
No