Q01
Message
All templatesHealthcare & Clinical
Healthcare Costs & Financial Burden Survey
Measures how much people actually pay for healthcare, how financially burdensome those costs feel, and whether cost causes them to delay or skip care. Built for health plans, providers, employers, and benefits teams tracking affordability; the AI follow-up interview reconstructs the real story behind a specific delay-or-skip-care decision instead of a checkbox answer.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
Multiple ChoiceRequired
Which of these best describes your current health insurance coverage?
- Employer-sponsored insurance
- Marketplace/individual plan
- Medicare
- Medicaid
- Uninsured
- Other
Q03
Number
Roughly how much did you personally pay out of pocket for healthcare in the last 12 months — premiums, copays, deductibles, and prescriptions combined (in USD)?
Q04
Opinion ScaleRequired
Overall, how much of a financial burden have your healthcare costs been over the past year?
Scale: 1 – 7
Min:No burden at allMax:Overwhelming burden
Q05
Multiple ChoiceRequired
In the past 12 months, did you delay or skip any medical care because of the cost?
- No, I got all the care I needed
- Yes, I delayed care but eventually got it
- Yes, I skipped care entirely
- Not sure / can't recall
Q06
MatrixRequired
How concerned are you about affording each of the following, if you needed it in the next year?
6 rows × 5 columns
- Prescription drugs
- Doctor or specialist visits
- Dental care
- Mental health services
- Emergency care
- +1 more
Columns: Not at all concerned · Slightly concerned · Moderately concerned · Very concerned · Extremely concerned
Q07
Best–Worst Trade-off (MaxDiff)Required
Which of these changes would do the most, and the least, to ease your healthcare financial burden?
- Lower monthly premiums
- Lower deductibles before coverage kicks in
- Clear pricing shown before treatment
- Lower cost telehealth options
- Cheaper prescription drugs
- Simpler, easier-to-understand bills
- More in-network provider choices
Pick best & worst per setBest:Would ease my burden mostWorst:Would ease my burden least
Q08
Price Sensitivity (Van Westendorp)Required
Think about a routine, in-network visit to a primary care doctor, before any insurance reimbursement.
- At what price for that visit would you start to question the quality of care being provided?
- At what price for that visit would you consider it a bargain — great value for the money?
- At what price for that visit would you start to feel it's expensive, though still worth paying?
- At what price for that visit would you consider it too expensive to pay at all?
Q09
AI Interview
Focus on the respondent's answer about delaying or skipping care due to cost. If they delayed or skipped care, reconstruct exactly what care was involved, what it would have cost, what happened to their health or plans as a result, and whether they've since gotten that care. If they said they got all needed care despite cost concerns, probe how they made that possible (borrowing, cutting other spending, payment plans) and whether that felt sustainable. Anchor on their reported financial burden level and their top-ranked cost-reduction change, and ask which single change would most have altered their actual decision.
Q10
Rating ScaleRequired
How satisfied are you with how your insurance provider handles your healthcare costs (claims, coverage clarity, billing)?
Range: 1 – 5
Min:Very dissatisfiedMax:Very satisfied
Q11
Multiple Choice
What is your age range?
- Under 25
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q12
Multiple Choice
What is your total annual household income?
- Under $25,000
- $25,000-$49,999
- $50,000-$74,999
- $75,000-$99,999
- $100,000-$149,999
- $150,000 or more
- Prefer not to say
Q13
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q14
Message
Thank you for sharing this — it's genuinely useful. Your responses will be combined with others (never shared individually) to help identify where healthcare costs are creating the most real-world strain, and what changes would actually help.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes a dedicated AI follow-up interview that probes the specific delay-or-skip-care decision a respondent reports, reconstructing the real story instead of stopping at a checkbox
- Combines hard cost data (out-of-pocket spend, Van Westendorp pricing on a routine primary care visit) with subjective burden and concern measures (opinion scale, matrix of concern-if-needed items)
- Uses a MaxDiff exercise to rank which cost-relief changes would matter most/least, giving benefits teams and health plans prioritized, actionable levers rather than just descriptive stats
- Automated per-response quality scoring and an auto-generated report mean health plans, providers, and employer benefits teams get analysis-ready output without manual coding of open-ends
SurveyMonkey
Healthcare Expenses Survey TemplateA directly comparable, fielding-ready template focused on healthcare expenses, likely covering similar ground on out-of-pocket costs and coverage. It's a static questionnaire built on SurveyMonkey's established survey infrastructure and benchmarking tools, not an interview-style instrument. Good for quick deployment but leaves follow-up probing to manual analysis.
What it does well
- Established, well-known survey platform with broad respondent panel and distribution options
- Likely benefits from SurveyMonkey's built-in benchmarking and reporting dashboards
- Purpose-built specifically around healthcare expenses, so questions are topically aligned
Where it falls short
- Static question set with no adaptive AI follow-up to dig into why someone delayed or skipped care
- No voice AI interview or guided screen-share task option
- No published methodology on how questions were validated or scored, unlike a transparent-prompt approach
Jotform
500+ Healthcare Assessment FormsThis is a broad category/library page listing hundreds of healthcare-related form templates (intake, assessment, consent, etc.), not a single fielding-ready cost-and-affordability survey. It's useful as a form-builder starting point but requires the researcher to assemble or heavily customize a cost-burden instrument themselves. The page itself does not demonstrate a purpose-built financial-burden or delay-of-care survey.
What it does well
- Large library of pre-built healthcare form templates covering many use cases
- Drag-and-drop form builder makes customization accessible to non-researchers
- Supports general data collection features like conditional logic and integrations
Where it falls short
- No template specifically designed to measure cost burden, delayed/skipped care, or affordability
- Static form fields only — no adaptive AI interview or voice AI follow-up to probe individual decisions
- No automated quality scoring or narrative report generation from open-ended responses
Frequently asked questions
What questions are in the “Healthcare Costs & Financial Burden Survey” template?
The template includes 14 ready-to-use questions, starting with: “Thanks for taking a few minutes to talk about healthcare costs — your own experience, not general opinions. Nothing here…” · “Which of these best describes your current health insurance coverage?” · “Roughly how much did you personally pay out of pocket for healthcare in the last 12 months — premiums, copays, deductibl…”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 14 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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