Form CMS-10437 Consumer Survey of Marketplace Disenrollees

This is a national survey of adults being conducted on behalf of the U.S. Department of Health and Human Services. The U.S. Department of Health and Human Services is the government agency responsible for initiatives to improve the health of all Americans. It regularly sponsors research to help evaluate the healthcare Americans receive.

Your participation in this survey is anonymous and voluntary. Your individual answers will remain confidential and reported only in the aggregate.

ING1. Do you currently have health insurance coverage?

1. Yes

2. No

3. DK

4. REF

ING2. [If ING1 = 1] How do you currently get health insurance to cover your hospital expenses or doctor’s visits? Do you get it through:

1. Current or former employer

2. Spouse or partner’s current or former employer

3. Parent’s current or former employer

4. A plan you purchase on your own directly from a health insurance company

5. A plan you purchased through the Health Insurance Marketplace at Healthcare.gov

6. A COBRA health insurance plan

7. Medicare

8. Medicaid or State Assistance

9. VA or Veterans’ Health Insurance

10. Tricare

11. Indian Health Services

12. Other (specify)

13. DK

14. REF

ING3. [If ING1=2] For how long have you been without health insurance?

1. Less than 6 months

2. 6 months to less than one year

3. One year to less than two years

4. More than two years

5. DK

6. REF

ING4. [If ING1=2] What is the main reason you do not have insurance? (OPEN ENDED)

ING6. [If ING2 ~= 5] Did you sign up for health insurance through the Health Insurance Marketplace at any time?

1. Yes

2. No

3. DK

4. REF

HSG1. Do you have any disabilities?

1. Yes

2. No

3. DK

4. REF

HSG2. Do you have a chronic illness or health condition?

1. Yes

2. No

3. DK

4. REF

HSG3. How would you rate your overall health?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

6. Very poor

BG8. [If ING1=2] How likely is it that you will enroll in health coverage within the next year?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

BG8a. [If ING1=1 AND ING2~=5 or 7] If you become uninsured in the future, how likely is it that you will enroll in health coverage through the Health Insurance Marketplace at Healthcare.gov?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

PG6. In general, how favorable or unfavorable is your opinion of the Health Insurance Marketplace at Healthcare.gov?

1. Very favorable

2. Somewhat favorable

3. Somewhat unfavorable

4. Very unfavorable

5. DK

6. REF

DG1. What is your gender?

1. Male

2. Female

3. REF

DG2. In what year were you born? (OPEN ENDED)

DG3. Are you Hispanic or Latino?

1. Yes

2. No

3. REF

DG4. What is your race or ethnic background?

4. White

5. Black or African American

6. American Indian or Alaska Native

7. Asian

8. Native Hawaiian or other Pacific Islander

9. REF

DG5. What is the highest level of education you have completed?

1. Less than high school

2. High school graduate

3. Some college

4. College graduate

5. Post graduate

6. DK

7. REF

DG6. What is your marital status?

1. Single, never married

2. Married

3. In a committed relationship

4. Living with a partner

5. Separated

6. Divorced

7. Widowed

8. REF

DG7. Including you, how many people live in your household? (OPEN END)

DG8. How many children under the age of 18 live in your household? (OPEN END)

DG9. What is your current employment status?

1. Employed full time

2. Employed part time

3. Retired

4. Unemployed <and not looking/and looking>

5. Not in the labor force (student, homemaker, etc.)

6. Other (Specify)

7. REF

DG10. What is your household’s total annual income before taxes? <PROVIDE RANGES, SUCH AS>:

1. $0-14,999

2. $15,000-24,999

3. $25,000-34,999

4. $35,000-49,999

5. $50,000-74,999

6. $75,000-99,999

7. 100,000-149,999

8. $150,000 or more

9. DK

10. REF

DG11. In what state do you reside? (OPEN END)