THE ATTORNEY GENERAL OF TEXAS
September 15, 1988

W. 0. Shultz II opinion No. J&j-953 GeneralAttorney and Associate General Counsel Re: Circumstancesunder The University of Texas System which a county or public 201West 7th Street hospital or hospital disAustin, Texas 78701 trict is responsible for payment formedical services rendered to patients at M.D. Anderson Hospital (RQ-1392)

DearMr. Shultz:
You ask whether a county, a public hospital, or a hospital district is responsible for payment for services rendered at the University of Texas M.D. Anderson Hospital and Tumor Institute at Houston (hereinafter "M.D. Anderson").
M.D. Anderson is ,governed by chapter 73 of the Education Code. It is devoted to the "diagnosis, teaching, study,prevention, and treatment of neoplastic and allied diseases." Educ. Code 5 73.102. Each application for admission to M.D. Andersonmust be accompaniedby a written physician's statementthat the patienthas, or is suspected of having, a neoplasm or allied disease. Educ. Code s 73.108. Article 3196a,V.T.C.S.,which governs hospitals under the management and control of the Texas Department of Mental Health andMental Retardation, is also applicable to M.D. Anderson, except to the extent of any conflict with section 73.101 of the Education Code. Educ. Code 5 73.106. Article 3196aprovides, inpart:

Section 1. Patients admitted to State hospitals under the management and control of the Texas Department of Mental Health and Mental Retardation shall be of two classes, to wit: Indigentpatients: J

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Won-indigentpatients;
oent watients are thosewho oossess no prowertv of anv kind nor have anyone leaallv resvonsible for their suvvort. and who are le unab **U** shall be suwworted at the exoense of th: &&g. Non-indiaent vatients are those who possess somewrowertv out of which the State mav be reimbursed. or who have someone leaallv liable for their suvvort. This class shallbe kept and maintained at the expense of the State, as in the first instance, but in such cases the State shallhave the right to be reimbursed for the support, maintenante,and treatment of suchpatients.
Sec. 2. Where the patient has sufficientestate of his own, he shall b"z maintained at the expense: Of the husband orwife of suchperson, if able to do so; Of the father ormother of suchperson, if able to do so, provided suchperson is less than 18years old. Child supportpayments for the benefit of a patientpaid or owingby a parent pursuant to a divorce decree or other court order shallbe considered to be the property and estate of the patient, and charges may be made against such child support obligations. The parent who is obligated to pay child support on behalf of the patient shall be given a credit against charges forwhich he or she would otherwise be liable based on ability to pay for the amount of child support the parent actually pays for the benefit of the patient. The parent who receives the child supportpayments is liable for the charges based on the child support obligation to the extent suchpayments are actually received in addition to the liability of suchparent based on ability to pay. The department may, upon the failure of a parent to pay child support in accordance

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with the child support obligationor upon the failureof a parent to pay chargesbased on the child support obligation, file a motion to modify the court order to require the child support to be paid directly to the State hospital or facility in which the patient resides for the patient's support, maintenance, and treatment. The court may, in addition, order all past due child support to be paid to the Statehospital or facility to the extent that chargeshave been made against the child support obligation. (Emphasisadded.)
In summary,non-indigentpatients includepersons who have "someone legally liable for their support.11 The state is entitled to seek reimbursement for care rendered to non-indigents. You first ask whether the Indigent Health Care and Treatment Act, article 4438f, V.T.C.S., makes counties and public hospitals *'legally liable for We1 supportql

of certain individualso that those individualscan be considered "non-indigents" for purposes of article 3196a.l The IndigentHealth Care and TreatmentAct was enacted in 1985 to clarify the obligations of counties and public hospitals for indigenthealth care. Section 2.02 of the IndigentHealth Care and TreatmentAct provides:

(a) Each county shallprovidehealth care assistanceas prescribed by this title to each eligible resident of that county who does not residewithin the area that a hospital or hospital districthas a obligation to serve: (b)The county is the payor of last and shall provide assistance only if

1. The IndigentHealth -_ _ __. . _ .Care and Treatment

. _ _. . public legal

resort other

Act does not affect the ObligatiOnS Of nOSpitS diStrlCtS. see V.T.C.S. 443Sf, 55 11.02, 12.01(b). (Hospital.districts'obligations in regard to indigent health care are governed by constitutionaland statutory provisions governing hospital districts.) Therefore,we will consideryour question about hospital districts separately.

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adequatepublic or private sources ofpayment are not available.
Se al Q f 2.03 (providingthat eligibility depends on inzomesandresources). Section 10.02(a)provides, inpart:

Each public hospital shallprovide health care assistanceas prescribedby this title to each eligible resident of the area that the hospital has a legal obligation to serve. See also 9 10.02(b) (providing that eligibilitydepends on income and resources). Section 12.01(e)provides:

A public hospital is the payor of last resort under this title and is not liable for payment or assistance to an eligible resident of the area that the public hospital has a legal obligation to serve if any other public or private source of payment is available.
We conclude that public hospitals individual.
InAttorney those provisions do not make counties and

"legally liable for [the]supportI' of any

General OpinionJM-705 (1987),we addressed an issue related to your question. The issue there was whether an indigent'scounty of residence or the University of Texas Health Center at Tyler (hereinafter the "Tyler hospital")was liable for the indigent's treatment for a heart disease at the Tyler hospital. The statutes governing the Tyler hospital contain a provision that tracks section 1 of article 3196a:

Patients admitted to State chest hospitals shall be two (2)classes: (1)Indigentpublic patients and (2)Non-indigentpublic patients. (a) Indigentpublicpatients are those who possess no property of any kind nor have anyone legally responsible for their support, and who are unable to reimburse the State. This class shallbe supported at the expense of the State. V.T.C.S. art. 4477-11, 9 9 (TexasTuberculosis Code). The opinion concluded that the countywas responsible for the

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indigent'streatment. The basis of the decision, however, was that the provisions of article 4477-11 apply only to the care and treatment of personswith tuberculosis. Therefore, a personwith a heart disease is not among the persons to be supported at the expense of the statepursuant to section 9 of article 4477-11. Despite the conclusion that the county was responsible for the health care of the individual in question,however, the opinion indicated that the state would be responsible if the indigent had been treated for tuberculosis. Implicit in that is that the Indigent Health Care and TreatmentAct does not make the county someone "legallyresponsible for [the]support" of its indigent residents forpurposes of article 4477-11, section 9.
We think that implication is correct and that it applies to article 3196a as well as article 4477-11. The IndigentHealth Care and TreatmentAct requires counties and public hospitals to provide "healthcare assistance" under specified circumstances. Ordinarily, "supports* includes much more than "health care assistance." Parents are responsible for the "supportl* of their children, and spouses are responsible for the "support"of each other. Fam. Code 5 4.02. l%upportlt in that context includes food, clothing, shelter, as well as medical attention. Woodruff **V.** Woodruff, 487 S.W.2d 791, 793 (Tex. Civ.App. - Texarkana 1972, Do writ). Because article 3196a specifically identifies spouses and parents of minors as persons from whom reimbursementmay be sought,we think it as clear that the word N1supportll in article 3196ameans someone such as a parent or spouse who has an obligation to provide the necessitiesof life. The IndigentHealth Care and Treatment Act creates a much narrower obligation,not an obligation to *lsupport.ll

Therefore,persons forwhom counties and public hospitalsmust provide health care under the IndigentHealth Care and TreatmentAct are not "non-indigents"for purposes of article 3196a.2

2. You do not ask about article 2351(6),V.T.C.S, which provides that each commissionerscourt shall:

Provide for the support of paupers and such idiots and lunatics as cannot be admitted into the lunatic asylum, residents of their county,who are unable to support themselves. A county is obligated to provide health care assistance to eligible residents only to the (FootnoteContinued)

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Sections 2.02**(b)** and 12.01(e)of the Indigent Health Care and Treatment Act bolster our conclusion. Those provisions state that counties and public hospitals are payors of the last resort and are not responsible if other adequatepublic or private sources of payment are available. Those provisionsmake clear that the IndigentHealth Care and TreatmentAct was not intendedto relieve other public entities of any obligationsto provide health care. You also ask whether a hospital district is liable for the support" "legally of itsneedy inhabitants. Article IX, section 9, of the Texas Constitutionprovides inpart:

The Legislaturemay by lawprovide for the creation, establishment, maintenance and operation of hospital districts providing that any district so created'

. shali assume full responsibility for medical providing

and hospital care for its needy inhabitants

. . . . Again, a responsibilityto providemedical and hospital care is not the equivalent of an obligation to "supportt' someone. Therefore, article IX, section 9, of the Texas Constitution does not make needy inhabitants of hospital districts %on-indigents" forpurposes of article 3196a.3

(FootnoteContinued)

extentprescribedby the IndigentHealth Care and TreatmentAct. See aenerallyAttorney General Opinion JW-815 (1987). In any case,we think that the specificprovisions of article 3196a and chapter 73 of the Education Code would control over the generalprovision of article 2351(6). See State v. Jones, l!lri&)

. 570 S.W.2d 122, (Tex. Civ.App. - Austr1978, no Article 2351(6) also indicatesthatmedical care z only one aspect of l%upport.VV

3. Although you do not raise the issue, it has been suggested that article IX, section 9, prohibits the state from spendingmoney for medical care forneedy inhabitants of a hospital district. We point out, though, that article IX, section 9, prohibits othermunicipalities and political subdivisions,not the state, from taxing to provide medical care.

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All hospital districts are subject to theprovisions of the statutesunder which they are created. Although we have not reviewed all the statutes that create or allow the creation of hospital districts,we are aware of none that make hospital districts liable for the l'support*l of its needy inhabitants.
SUMMARY

The Indigent Health Care and Treatment Act, article 443Sf,V.T.C.S.,makes counties and public hospitals responsible for health care for certain indigents: it does not make counties orpublic hospitals liable for the llsupportl'

of indigents. Therefore, article 4438f does not make indigents for whom counties or publichospitals are obligated to provide health care "non-indigents" for purposes of article 3196a,V.T.C.S. Article IX, section 9, of the Texas Constitution makes hospital districts responsible formedical care for their ~needy inhabitants: it does not make hospital districts responsible for the llsupportl' of their needy inhabitants. Therefore, article IX, section 9, does notmake needy inhabitants of. hospital districts "non-indigents" for purposes of article 3196a,V.T.C.S.

JIM MATTOX Attorney General of Texas
MARY KELLER FirstAssistantAttorney General
LOU MCCREARY ExecutiveAssistantAttorney General
JUDGE ZOLLIE STEAKLEY SpecialAssistantAttorney General
RICK GILPIN Chairman, opinion Committee Preparedby SarahWoelk AssistantAttorney General

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