Health Insurance

Affordable health care and the lack thereof are important issues in black America—over 20 percent of us are uninsured. Real Health wants to know whether or not you and your children are covered and how you are covered.

We’re giving away five copies of Starz Home Entertainment’s "Dance Off the Inches: Fat Burning Belly Dance" (a $15 value), which offers fun, dance-inspired fitness routines. For more info, visit starzhomeent.com. To enter our drawing, take the survey at realhealthmag.com/survey or fill out the following and mail it to Real Health, c/o Smart + Strong, 500 Fifth Avenue, Suite 320, New York, NY 10110 or fax it to 212.675.8505. For the official contest rules, visit realhealthmag.com/survey/rules.
 
1. Name:
 
2. Organization (if you represent one):
 
3. Street address:
 
4. City & state:
 
5. ZIP code:
 
6. E-mail:
 
7. Phone:
 
8. Are you employed?
Employed, full-time
Employed, part-time
Freelance/contractor
On disability
Retired
Student
Unemployed
 
9. Do you have health insurance?
Yes, I have private insurance/Health Maintenance Organization (HMO)
Yes, I have private insurance/Point-of-Service Plan (POS)
Yes, I have private insurance/Preferred Provider Organization (PPO)
Yes, through Medicaid or Medicare
No, I am not insured
 
10. If you don’t have health insurance, for long have you lacked it?
1–6 months
7–12 months
1–2 years
2–3 years
3 or more years
 
11. Do you have a primary-care physician or OB/GYN whom you use as your primary doctor? (If no, skip to question 13.
Yes
No
 
12. How many times a year do you visit him/her?
0-1 time
2-3 times
4-5 times
6 or more times
 
13. How many children do you have under the age of 18? (If none, skip to question 18.)
0
1
2
3
4
More than 5
 
14. How many of those children are insured through private health insurance or the Military Health System?
0
1
2
3
4
More than 5
 
15. How many of those children are insured through Medicaid?
0
1
2
3
4
More than 5
 
16. How many of those children are insured through a State Children’s Health Insurance Program (SCHIP)?
0
1
2
3
4
More than 5
 
17. How many of those children are uninsured?
0
1
2
3
4
More than 5
 
18. How many young-adult children (between the ages of 18 and 25) do you have? (If none, skip to question 25.)
0
1
2
3
4
More than 5
 
19. How many of your young-adult children have health insurance through your private insurance?
0
1
2
3
4
More than 5
 
20. How many of your young-adult children have health insurance through their own private insurance?
0
1
2
3
4
More than 5
 
21. How many of your young-adult children have health insurance through their college/university?
0
1
2
3
4
More than 5
 
22. How many of your young-adult children have health insurance because they are in the Armed Forces?
0
1
2
3
4
More than 5
 
23. How many of your young-adult children have health insurance through Medicare?
0
1
2
3
4
More than 5
 
24. How many of your young-adult children are uninsured?
0
1
2
3
4
More than 5
 
25. What year were you born?
 
26. What is your gender?
Male
Female
 
27. What is your household income?
Under $15,000
$15,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 and over
 
28. What is your marital status?
Single, never married
Single, divorced or separated
Married
Unmarried, living together
Widowed