Are you (please click one):

Age 50-65 Older than 65

If You Are On Medicare...

Do you have difficulty accessing care? When or why?

Do you have supplemental Medicare insurance?

Yes No

Have your premiums increased in the last year? By how much? Are they affordable?

Do you have Medicare Part D (prescription drug coverage through Medicare)?

Yes No

If yes, what do you think about the program?

If You Are Under 65, Or Older Than 65 But Not On Medicare...

Do you:

Have medical insurance through your employer?

Yes No

Have medical insurance you purchase privately?

Yes No

Have medical conditions (pre-existing or chronic conditions) that have been excluded from coverage? Please tell us about them.

Has health care affordability affected whether or not you decided to retire? Will it affect that decison in the future?

Do you have children, grandchildren or other family members who are finding it difficult to meet their health care needs? If so, what difficulties have they faced?

Optional: Please enter your email address so that we may follow up with you regarding your comments

Thanks for taking the time to fill out the survey! To complete the process, please click the “Submit” button below. You will go to a page that includes a form for contacting your legislators to convey your health care concerns.