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	First Unitarian Church of Portland Health Care Survey
	The Economic Justice Action Group (EJAG) of the First Unitarian Church of Portland is concerned with health care access and afforability. We have developed this survey for our congregation to find out if there is significant interest to improve the current health care system. We plan to make the results availalble to our members.   Please take a few minutes to express your opinions about the availability and cost of health care in our community. Your answers are important to the success of this study and will help raise an awareness in our community of this important issue which affects us all. Thank you so much for your time and your assistance.
	What kind of medical insurance coverage do you and your family have? Check all that apply.   None   Purchased individually   Employer-sponsored   Medicaid   Medicare   Oregon Health Plan   Oregon Medical Insurance Pool (OMIP)   Other    Internal Data Structure Error
	Quality and efficiency of the health care you and your family are receiving   Satisfied   Somewhat satisfied   Dissatisfied
	How much is your monthly cost for your household's medical insurance premiums? What are your average monthly out-of-pocket expenditures for health care, such as co-pays, prescriptions, lab fees, uncovered costs, etc.
	Your share of the cost of healthcare   More than we can afford   Barely manageable   Easily manageable   Not sure   Comments
	About how many times have you and members of your family been to a healthcare provider or medical facility in the past year? How would you describe your experience?
	Have you or a family member had to care for an elderly parent or spouse and was the health insurance coverage adequate? Please describe.
	Have you or a family member ever been denied coverage? Please check all that apply.   I (or family member) have never been denied coverage.   I (or family member) took a job based on the coverage offered or wanted to change jobs but was unwilling to do so because we did not want to lose our medical coverage.   I (or family member) was denied coverage or was exempted from coverage for a chronic condition.   I (or family member) was denied coverage due to a pre-existing condition.   I (or family member) wanted a treatment or medication that was not covered by the insurance plan we have/had.   I (or family member) wanted to use a type of provider or a method of treatment that our plan would not cover (such as a therapist, chiropractor, specialist, or acupuncture   I (or family member) had to use a healthcare provider that was not one we would have selected or was not of our own chosing.
	Do you have a health care or insurance coverage story that you would be willing to share with our congregation? Please check all that apply.   No   Yes, but anonymously   Yes, in writing   Yes, by talking within a small group   Yes, to a larger audience   If yes, please provide your name, email and/or phone contact information or contact info@ejag.org:
	How shall health care be paid for? Are you in favor of:   Universal single-payer system similar to the Canadian or European models   Mandated expanded employer-sponsored insurance coverage   Mandated individual private insurance coverage   A mixture of employer and government-sponsored insurance pools   Choice between private insurance and government-sponsored universal health care   Leave the system as is   I don't know yet   Other
	Yes No Don't know Do you support Measure 50 (tobacco tax to cover all Oregon children)?
	These questions will remain anonymous and are optional, but your response will help us establish the affordability of health care in our community. What was your total household income (approximately) from all sources before taxes for the year 2006.   $25,000 or less   $25,000-$49,999   $50,000-$74,999   $75,000-$99,999   $100,000-$124,999   $125,000-$149,999   $150,000 or over   Don't know
	Age of person completing this questionnaire: Number of family members aged 17 and under (not including yourself). Number of family members over 18 and under 65 (not including yourself). Number of family members over 65 (not including yourself).
	Thank you for taking the time to complete this survey. We appreciate your input!
	Please contact info@ejag.org if you have any questions regarding this survey.

 

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