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What Is Payer Mix In Healthcare?

What Is Payer Mix In Healthcare
What is payor mix? Payor mix measures patients who have federal health insurance, such as Medicaid and Medicare, compared to patients who pay themselves or have private medical insurance. Accordingly, payor mix tracks which payor funds healthcare costs.

What is the payer mix in the US?

Payer mix refers to the percentage of patients with government health plans — Medicare and Medicaid — vs. commercial or ‘private’ insurance.

What is patient mix?

From Wikipedia, the free encyclopedia Case mix, also casemix and patient mix, is a term used within healthcare as a synonym for cohort ; essentially, a case mix groups statistically related patients. An example case mix might be male patients under the age of 50, who present with a myocardial infarction and also undergo emergency coronary artery bypass surgery,

At a local level, such as a single hospital; the data within a case mix may relate to the activity of an individual consultant, a specific speciality or a particular unit (such as a ward). On a wider level; it is possible to compare the case mix of hospitals, regions, and even countries. Whilst a case mix will often include a condition or diagnosis, as well as any treatment received; it can also include demographics, such as gender or age, and a specific time range.

Conditions and treatments are often captured using a medical classification system, such as ICD-10, in a process called clinical coding, The practice of coding, essentially groups patients using statistical codes. The coded data can be grouped further into Diagnosis-Related Groups (DRGs), which are used in the billing process by hospitals and practices; as the “cost per item” of healthcare is based on the casemix.

Is the UK a single-payer system?

Description – Within single-payer healthcare systems, a single government or government-related source pays for all covered healthcare services. Governments use this strategy to achieve several goals, including universal healthcare, decreased economic burden of health care, and improved health outcomes for the population.

In 2010, the World Health Organization ‘s member countries adopted universal healthcare as a goal; this goal was also adopted by the United Nations General Assembly in 2015 as part of the 2030 Agenda for Sustainable Development. A single-payer health system establishes a single risk pool, consisting of the entire population of a geographic or political region.

It also establishes a single set of rules for services offered, reimbursement rates, drug prices, and minimum standards for required services. In wealthy nations, single-payer health insurance is typically available to all citizens and legal residents.

Why a single-payer system would not work in the US?

Single-Payer Would Be Bad for Doctors – A single-payer system—government-run healthcare for all—sounds like a noble ideal, but things quickly fall apart in the execution, according to its critics. Michel Accad, MD, a cardiologist in San Francisco, says that because a single-payer system makes healthcare virtually free, “demand is almost unlimited,” and the government has to set limits on what will be provided.

  • Dr Accad writes a blog called “Alert & Oriented,” which provides alternative views on healthcare systems.
  • Because the offer is so open-ended, Dr Accad says that single-payer systems in Canada, the United Kingdom, and other developed countries have to impose strict central planning.
  • Rather than leave healthcare choices up to individual physicians, their patients, and free-market forces that could balance supply with demand, the government sets the rules.

These rules, Dr Accad says, are usually based on large quantities of data—comparing costs against probable outcomes—or on political considerations, such as the need to balance budgets without raising taxes. This approach, he says, will inevitably misallocate services.

  • When central planning allocates care, there will be shortages of some services and gluts of other services.
  • In particular, central planners will have a difficult time keeping up with cutting-edge technology and improvements in practice patterns.
  • Centralized systems also underpay physicians.
  • In a single-payer system,” Dr Accad says, “planners decide arbitrarily what the payments should be, and payments fall because there are no competitors and no choice for providers to bid up payments.” Indeed, a 2011 study found that reimbursements to US primary care physicians from public payers, such as Medicare and Medicaid, were 27% higher than in countries with universal coverage, and their reimbursements from private payers were 70% higher.

Meanwhile, reimbursements to US specialists were 70% higher from public payers and 120% higher from private payers.

How do you calculate patient mix?

Case Mix Index | The Case Mix Index (CMI) is the average relative DRG weight of a hospital’s inpatient discharges, calculated by summing the Medicare Severity-Diagnosis Related Group (MS-DRG) weight for each discharge and dividing the total by the number of discharges.

  • The CMI reflects the diversity, clinical complexity, and resource needs of all the patients in the hospital.
  • A higher CMI indicates a more complex and resource-intensive case load.
  • Although the MS-DRG weights, provided by the Centers for Medicare & Medicaid Services (CMS), were designed for the Medicare population, they are applied here to all discharges regardless of payer.

Note: It is not meaningful to add the CMI values together. : Case Mix Index |

What are P’s in healthcare?

When it comes to marketing to a potential or future client, it is commonly assumed that it is a one size fits all scenario: that one set of skills can apply to all industries. Unfortunately for marketing professionals, that is not the case. Healthcare marketing is even more unique, and marketing to providers of healthcare is even more challenging, requiring its own particular focus and strategy that differs immensely from other industries.

  1. When it comes to b2b marketing as is the process here at ReportingMD, you have to both market to your client, while assisting them with their patients and consumers.
  2. What is healthcare marketing? WebMD defines healthcare marketing as “a process of strategic outreach and communications designed to attracted healthcare consumers, guide them through their healthcare journey, and keep them engaged with the health system”.

To successful achieve this, competent healthcare marketers must incorporate multiple tools and strategies. This involves an omnichannel approach to create and maintain a loyal client base. This is where the 5 P’s of Healthcare Marketing (Product, People, Place, Price, and Promotion) come into play and the order that I find to be the most important and beneficial to any healthcare organization.

Product: The first key to any successful healthcare marketing campaign is to firmly establish the product at hand. Establishing the core selling point to clients and prospective clients kick starts the rest of the 5 P’s of Healthcare Marketing and establishes the marketer as the voice of the product.

ReportingMD’s product focus is our Total Outcomes Management (TOM) platform with the aim being to best serve their clients and their clients’ patients so that these patients are receiving the post possible care to remain a healthy population, which includes offerings in MIPS, HCC codes, Care Gap Management, and eCQM/CQM measures just to name a few.

People: Almost as important as the product itself comes the people to which your organization is serving, Establishing your ideal client base is a key step in establishing the rest of the marketing process and how your campaigns will be orchestrated. ReportingMD is “proud to work with some of the finest health care organizations from independent practices to multi-specialty to rural and regional medical centers to academic health systems in the country”.

Not only are our healthcare organization clients vital to our success, but through our services we aim to establish a healthy patient population by better providing for our clients’ patients. Place: “Place” encompasses where clients and prospective clients find the product.

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A company’s website is an obvious answer but establishing the place for a product is much more than the homebase. The competition is taking this into account as well: looking for other areas where to best broadcast their product, whether that be through online ads or promotion on other industry websites.

This is where the marketer steps in. By utilizing SEO skills with tools such as Google Analytics and Google Search Console help establish new jumping off points for your product and help outstep the competition. Price: Price, although appearing self-explanatory, is more complicated than just establishing the price of the product.

  • Price plays a huge part in the marketing efforts that are utilized, deciding what is ultimately used as a tactic and what is tossed to the side.
  • Research is essential to establish what is worth the price when it comes to marketing the product.
  • Promotion: Promotion is the culmination of the rest of the 5 P’s of Healthcare Marketing.

By combining Product, People, Place and Price, we are truly able to create a successful marketing campaign for a healthcare organization. Cementing the product, establishing/focusing on the audience population, creating the places for the product and deciding on pricing will not only sell a well valued and useful product but will maintain a happy, content client base.

What is case mix groups in medical terms?

By definition, a case-mix is a cohort, a group of individuals sharing a defining characteristic. The term is used in the healthcare sector to identify a group of patients that are somehow related, either by statistics, marketing or demographics. The term was created in the UK to signify the sum of diagnoses in a given population and the therapies to manage them, for resource analysis and planning.

Case-mix can also refer to the characteristics of all patients of a specific hospital or healthcare facility, classified by disease, diagnosis or therapy. Generally speaking, in the healthcare sector, a case-mix is a group of patients, treated at a particular hospital or healthcare centre, that require similar tests, diagnostics, equipment, procedures, exams and resources: this way it defines the hospital’s production and focus, and it can actively contribute in analyses that will lead to funding and administrative or financial decisions.

In Australia, the universal health insurance system caters for public funding destined to the population’s admittance to healthcare services. Private health insurance covers the costs of access to private health care and allied health or supplementary services such as physiotherapy, psychotherapy, specialist care and more.

  1. These two forms of insurance aim to minimise the costs for their contributors and they often involve payments based on case-mix to private hospitals, as decided by the current Australian Health Care Agreements.
  2. Public hospitals are funded by the commonwealth and the local state or territory government.

The responsibilities get shared between these two parties, causing some challenges within the organisation of healthcare in Australia. Case-mix funding, often associated with Activity-Based funding, started in the 1990s in Victoria and soon other states followed its guidance.

  • They started by adopting case-mix measures as the foundation for the allocation decisions of public hospital budgets.
  • Case-mix funding promotes equity, efficiency and patient experience while allocating funds according to the amount and types of patients, and classifying patient’s care episodes into clinical statistics and demographic groups.

The hospital’s funding is based on the cost of every single patient’s care event; the entire model relies on the classification of patients with similar conditions into Diagnosis Related Groups (DRGs), on the count of the number of patients treated and on the calculation of all costs involved in the treatment.

Who is called payer?

Understanding a Payee – In any type of transaction, there will be a party that provides the goods or services and the party that receives the goods or services. To receive goods or services a payer must provide an exchange of value, which is most often money, to the payee.

In a banking situation, the payee must have an active account that is in good standing through which funds can be transmitted by the payer. This is, of course, if the transaction is not done in cash. In the case of a promissory note, through which one party promises to pay another party a predetermined sum, the party receiving the payment is known as the payee.

The party making the payment is known as the payer. For coupon payments from bonds, the party receiving the coupon is the payee and the bond issuer is referred to as the payer. Payees have the ability to accept or reject amounts being paid to them, based on an agreement or contract.

Investment management transactions frequently have payee accounts that receive payments for the benefit of a client’s separate account. For example, in contributing to an individual retirement account (IRA), a customer (e.g., John Smith) may write a check from their checking account to their investment management company, with the payee being the company’s name receiving the funds “For the Benefit of” (FBO) the client.

This would appear as “XYZ Management FBO John Smith.” The funds will ultimately be deposited into John Smith’s account as the payee, with XYZ Management being the custodian. Payees may also be more than one party. This typically happens in electronic transfers when a person withdraws money from the payer’s account and splits it into a variety of payee allocations.

  1. Depending on the banking institution, these types of transactions may have approval requirements for numbers, percentages, and types of accounts.
  2. Sometimes, the payee and payer may be the same party.
  3. This can occur when a person writes checks, makes withdrawals and deposits, or electronically transfers funds from one of their accounts to another.

It is a good practice to ensure that the payer and the payee are in agreement on the amount being transferred between parties to avoid disputes.

Is Germany a single-payer healthcare system?

Insurance systems – Total health spending per capita, in US$ PPP-adjusted, of Germany compared amongst various other developed countries Germany has a universal system with two main types of health insurance. Germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.

Accident insurance for working accidents ( Arbeitsunfallversicherung ) is covered by the employer and basically covers all risks for commuting to work and at the workplace. Long-term care insurance ( Pflegeversicherung ) is covered half and half by employer and employee and covers cases in which a person is not able to manage their daily routine (provision of food, cleaning of apartment, personal hygiene, etc.).

It is about 2% of a yearly salaried income or pension, with employers matching the contribution of the employee. There are two separate types of health insurance: public health insurance ( gesetzliche Krankenversicherung ) and private insurance ( private Krankenversicherung ).

  1. Both systems struggle with the increasing cost of medical treatment and the changing demography.
  2. About 87.5% of the persons with health insurance are members of the public system, while 12.5% are covered by private insurance (as of 2006).
  3. In 2013 a state funded private care insurance was introduced ( private Pflegeversicherung ).

Insurance contracts that fit certain criteria are subsidized by €60 per year. It is expected that the number of contracts will grow from 400,000 by end of 2013 to over a million within the next few years. These contracts have been criticized by consumer rights foundations.

Is Denmark single-payer?

Hover over Click on a tile for details. What is single-payer healthcare? Single-payer healthcare is a type of universal healthcare that is publicly administered and is financed by taxes. Single-payer healthcare covers the costs of essential healthcare for all of a country’s residents with costs paid for by a single public system.

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Single-payer healthcare is different from universal healthcare even though the terms are used interchangeably. Universal health care refers to a healthcare system where every individual has health coverage; however, many countries have achieved universal healthcare coverage without using a single-payer system.

In the United States, Medicare and the Veterans Health Administration are examples of single-payer systems. The United States healthcare system faces several problems, such as spending much higher amounts on healthcare than other countries, using a complicated and wasteful network of insurance plans, and inequality.

  • Proponents of a single-payer healthcare system argue that it would address these problems, such as helping the uninsured and underinsured Americans receive quality healthcare.
  • They also suggest wasteful expenses could be controlled through cost control and lower administrative costs.
  • Furthermore, single-payer systems can direct healthcare spending to public health measures, such as funding obesity prevention programs.

Opponents of single-payer healthcare argue that the system causes lengthy wait times and restricted availability of certain services and procedures. Opponents also argue that taxes, whether income, sales, or corporate, will be significantly higher in order to fund the single-payer system.

  • There are currently 17 countries that offer single-payer healthcare: Norway, Japan, United Kingdom, Kuwait, Sweden, Bahrain, Canada, United Arab Emirates, Denmark, Finland, Slovenia, Italy, Portugal, Cyprus, Spain, and Iceland,
  • The United Kingdom has both universal healthcare and a single-payer healthcare system.

Funding for the country’s National Health Service (NHS) comes from taxes. The United Kingdom’s healthcare system can also be called socialized medicine since a majority of hospitals are owned by the government, which also employs the medical providers.

  • The U.K. citizens have the option to buy private health insurance, which grants them the option to receive faster access to care.
  • Healthcare in Canada is also a single-payer system, with most funds coming from income tax.
  • Canada’s healthcare is mostly free at the point of use and most services are privately provided.

Canada’s single-payer system is funded by income, corporate, and sales taxes. Unfortunately, long wait times plague the Canadian healthcare system, with some people waiting up to six months to receive surgery and up to two weeks to receive diagnostics tests such as MRIs and CT scans.

  1. The United States is divided on the idea of a single-payer system.
  2. Some have suggested that the best course of action is a hybrid system, such as that seen in the United Kingdom, allowing people to choose a private insurance option if they wish.
  3. Several states in the U.S., including California, Colorado, Hawaii, and Vermont, have proposed single-payer state referendums and bills, all of which have failed except for in Vermont.

Vermont canceled its plans for a single-payer system in December 2014.

Are there free hospitals in the US?

There is no universal healthcare. The U.S. government does not provide health benefits to citizens or visitors. Any time you get medical care, someone has to pay for it. Healthcare is very expensive. According to a U.S. government website, if you break your leg, you could end up with a bill for $7,500. If you need to stay in the hospital for three days, it would probably cost about $30,000. Most people in the U.S. have health insurance. Health insurance protects you from owing a lot of money to doctors or hospitals if you get sick or hurt. To get health insurance, you need to make regular payments (called “premiums”) to a health insurance company. In exchange, the company agrees to pay some, or all, of your medical bills. Learn more about health insurance. You will get most of your care from your “primary care provider” (PCP). After you buy health insurance, you can choose a PCP who is part of your insurance company’s network. If you buy an MIT health insurance plan, you will choose a PCP at MIT Medical, Your new PCP could be a nurse practitioner or a physician. You will see your PCP when you need a physical exam or lab test, when you are sick, or if you need care for an ongoing condition, like diabetes or high blood pressure. Learn more about PCPs. You will usually need an appointment to get medical care. If you want to see your PCP, you will need to call your PCP’s office to make an appointment. When you call, you need to explain why you need the appointment. If you are sick or hurt, you will get an appointment very soon. If you just need a routine physical exam, you might have to wait several weeks or even a month. Learn more about appointments.

NOTE: If you have a medical emergency or urgent need, you can get care immediately. Read more.

What are the two major payer types in us?

In healthcare, a payor is a person, organization, or entity that pays for the care services administered by a  healthcare provider, This term most often refers to private insurance companies, which provide customers with health plans that offer cost coverage and reimbursements for medical treatment and care services. There are three different types of healthcare payors:

Commercial Private Government/public

A “commercial payor” refers to publicly-traded insurance companies like UnitedHealth, Aetna or Humana, while “private payor” refers to private insurance companies like Blue Cross Blue Shield. A “public payor” refers to government-funded health insurance plans like Medicare, Medicaid, and the  Children’s Health Insurance Program (CHIP).

Does California have free healthcare?

I previously was denied Medi-Cal due to owning a car. Do I qualify now? – The Affordable Care Act simplified financial eligibility requirements for Medi-Cal program eligibility. Under these simplifications, “property” such as a car, is no longer counted.

What are the two major payer types in us?

In healthcare, a payor is a person, organization, or entity that pays for the care services administered by a  healthcare provider, This term most often refers to private insurance companies, which provide customers with health plans that offer cost coverage and reimbursements for medical treatment and care services. There are three different types of healthcare payors:

Commercial Private Government/public

A “commercial payor” refers to publicly-traded insurance companies like UnitedHealth, Aetna or Humana, while “private payor” refers to private insurance companies like Blue Cross Blue Shield. A “public payor” refers to government-funded health insurance plans like Medicare, Medicaid, and the  Children’s Health Insurance Program (CHIP).

Is the United States primarily a multi payer system?

Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section Peter D. Donnelly is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Paul C. Erwin is with the School of Public Health, University of Alabama at Birmingham. Corresponding author. Correspondence should be sent to Paul C. Erwin, MD, DrPH, Dean and Professor, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, RPHB 140B, Birmingham, AL 35294-0022 (e-mail: ). Reprints can be ordered at by clicking the “Reprints” link.

  • CONTRIBUTORS All authors were involved in concept development, writing, reviewing, and finalizing of the editorial.
  • Accepted August 15, 2019.
  • © American Public Health Association 2019 The purpose of the articles and editorials in this AJPH special section is to clarify the complexity and significance of the issues involved in moving from the current multiple-payer system of financing health care in the United States to the variety of single- and multiple-payer systems currently advocated by candidates for public office and their allies.

Each contributor to the section exemplifies the value of analytic rigor in arraying and assessing evidence about the history, current politics, strengths, and weaknesses of payment systems in the United States and other industrial democracies. All of them ground rigorous analysis in their own research and immersion in relevant literature.

  1. Several of them, moreover, have extensive personal experience with the politics of making and implementing health policy in single- or multiple-payer systems.
  2. As an introduction to these articles and editorials, our first task is to provide a clear set of definitions.
  3. Single payer refers to a health system that is financed by a single entity; in its common usage, that single entity is government.
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Government is the payer for services, and such payments are financed by taxes, but there is no implication that government employs the providers or actually owns or operates the health system. There still may be intermediaries between the government as payer and the provider, such as exists now with Medicare and health insurance intermediaries.

  • In its “purest” form, in a single-payer system, health care services are paid for only by the government; in the case of Medicare, beneficiaries also contribute to payments through premiums.
  • Multiple payer refers to a health system that is financed through more than a single entity, one of which may include government.

Private health insurance companies participate in multiple-payer systems, with financing through individual premiums paid directly by beneficiaries, employers, and, in some cases, government. Whether a health care system is single or multiple payer does not in and of itself define the system in terms of coverage.

Universal coverage means simply that all people within a particular jurisdiction have health insurance, be it single or multiple payer. Universal coverage requires governmental mandate; however, the form of that mandate may be through either single or multiple payer or a hybrid model. Health care in the United States is currently a unique hybrid, multiple-payer system, but with elements of single payer (i.e., Medicare, although beneficiaries also contribute through premiums), publicly subsidized private payers (e.g., employer-sponsored health insurance), socialized medicine (e.g., Department of Veterans Affairs, in which government is both the payer and the employer), and self-pay (i.e., out of pocket).

Greer et al. (p.1493) lead off this special issue of AJPH with “Lessons for the United States From Single-Payer Systems.” The authors address these questions: What is a single-payer system, and how much does the term help us? How are single-payer systems established? How are single-payer systems maintained? While exploring the conditions for maintaining single-payer systems, Greer et al.

  • Focus on the risks to the health care system if the middle class exits.
  • The middle class, in their view, is the key to political sustainability of a single-payer system.
  • Oberlander (p.1497) entreats us to learn from history in his commentary, “Lessons From the Long and Winding Road to Medicare for All.” He offers four major lessons: (1) single-payer models have been a part of the political debate for at least 75 years; (2) with the exception of Medicare, proposals to establish a federally run national health insurance program have consistently failed in Congress; (3) in the absence of national health insurance, we have adopted a patchwork of private and public arrangements, which themselves are now major impediments to reform; and (4) since 1975, the political fortunes of single-payer health reform have faded.

The recent resurgence in interest may only keep us on a long and winding path of incrementalism. In her analytic essay, “Political Accommodations in Multipayer Health Care Systems: Implications for the United States,” Tuohy (p.1501) provides additional perspectives on definitions while examining the history and current state of multiple-payer systems.

  1. What aspects of multiple-payer systems elsewhere might be applicable to the United States, as alternatives to the single-payer approach? Tuohy describes how health care systems in Germany, the Netherlands, Switzerland, and Israel have been shaped by political circumstances.
  2. She suggests that a multiple-payer system may be the most feasible path to achieve universal coverage in the United States.

In “Single-Payer Health Care in the United States: Feasible Solution or Grand Illusion?,” Brown (p.1506) explains why the balance of power thwarts a single-payer system. Almost all reform efforts of the past 20 years have only strengthened the role of private actors in the health care system, most notably the for-profit insurance industry.

  1. A conceptual barrier also must be overcome, because polls show widely disparate responses about people’s views of single-payer health care, depending on the questions asked.
  2. Moreover, large institutional factors must be overcome, including declining trust in the federal government.
  3. With the challenges of federal-level approaches to single-payer health care, what is possible and can be learned from state-level efforts? Two articles address this question.

In “States as Policy Laboratories: The Politics of State-Based Single-Payer Proposals,” Sparer (p.1511) describes recent events in Vermont, Colorado, California, and New York to exemplify obstacles to state reform. These include the need to obtain a federal waiver, the limits imposed by the federal Employee Retirement Income and Security Act, and the difficulty of any single state action in “an interconnected 50-state economy.” In a second state-focused article, “Medicaid for All? State-Level Single-Payer Health Care From a Public Health Perspective,” Wiley (p.1515) discusses the advantages of expanding Medicaid rather than Medicare for All.

A Medicaid-for-All approach may maximize opportunities for integration of systems at the state level, creating a path to universal coverage that may be more politically feasible and palatable to the American public. Glied’s commentary (p.1517) on “Options for Dialing Down From Single Payer” calls for a renewed focus on the Affordable Care Act (ACA) as a realistic approach to achieving some of the same goals as single-payer health care—namely, increasing the number of people covered by health insurance on the way to universal coverage.

Post-2016 changes to ACA could be restored, beginning with the individual mandate. Expanding Medicaid in the 14 states that have not done so could result in lowering the US uninsured rate to less than 5%. More generous coverage for people with middle incomes would fill another gap.

  1. In addition, returning to the original proposal for a public option in the ACA could result in lower premiums and lower subsidy costs to government.
  2. In his editorial, “Enacting Medicare for All: Balancing Ambition With the Needs of Statecraft,” Peterson (p.1521) reflects on the failed efforts in health care reform since the early 1990s.

Alluding to Mario Cuomo, and paraphrasing Will Rogers, Peterson surmises that “Medicare for All is motivational poetry for many, to fulfill the opportunity for prose, however, candidates and advocates with the shared commitment to universal coverage must,

avoid forming a circular firing squad, both on the campaign trail and once in office.” As the editors of this special section, we hope that these articles and editorials help readers of AJPH to become better informed about issues that will be debated intensely as we approach the 2020 presidential election.

We thank the authors and reviewers of these articles and editorials for sharing their knowledge and Alfredo Morabia, MD, PhD, editor-in-chief of AJPH, for making this special issue possible. The authors have no conflicts of interest to disclose. : Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section

What is the major third party payer in United States?

Private health insurance : For those who are regularly employed, private insurance is the most common third-party payer for healthcare needs.

What are several types of payers exist in the United States?

Several types of ‘payers’ exist in the United States, including private insurance, government programs, and military programs.