[reaanb2]

In real life, insurance often doesn't pay for everything and service providers would need to support capturing both sets of info, not either one or the other. But that's beside the point.

Properly naming check constraints can go a long way towards providing better error messages, and then there are stored procs which can be used to ensure that multiple tables are updated as a single logical step. It would've been nice if SQL supported literal values in FK constraints, e.g. FOREIGN KEY (id, 'uninsured') REFERENCES patients(id, payment_type), as well as exclusion constraints, e.g. FOREIGN KEY (id) NOT REFERENCES insured_payment_info(id). As it stands, my preferred approach would be combining approach 4 with stored procs, except I would make id the primary key and (id, payment_type) a unique key.