THE ATTORNEY GENERAL 

OF TEXAS 

September 15, 1988 

W. 0. Shultz II opinion No. J&j-953 

General Attorney and 

Associate General Counsel Re: Circumstances under 

The University of Texas System which a county or public 

201 West 7th Street hospital or hospital disAustin, Texas 78701 trict is responsible for 

payment for medical services 

rendered to patients at M.D. 

Anderson Hospital (RQ-1392) 

Dear Mr. 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. Anderson must be accompanied by a written 

physician's statement that the patient has, 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 and Mental 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 3196a provides, in part: 

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: 

Indigent patients: 

J 

p. 4821 
W. 0. Shultz II - Page 2 (JM-953) 

Won-indigent patients; 

oent watients are those who 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 some wrowertv out of which the State 

mav be reimbursed. or who have someone 

leaallv liable for their suvvort. This class 

shall be kept and maintained at the expense 

of the State, as in the first instance, but 

in such cases the State shall have the right 

to be reimbursed for the support, maintenante , and treatment of such patients. 

Sec. 2. Where the patient has 

sufficient estate of his own, he shall b"z 

maintained at the expense: 

Of the husband or wife of such person, if 

able to do so; 

Of the father or mother of such person, if 

able to do so, provided such person is less 

than 18 years old. 

Child support payments for the benefit of 

a patient paid or owing by a parent pursuant 

to a divorce decree or other court order 

shall be 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 for which 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 support payments is liable 

for the charges based on the child support 

obligation to the extent such payments are 

actually received in addition to the liability of such parent based on ability to pay. 

The department may, upon the failure of a 

parent to pay child support in accordance 

p. 4822 
W. 0. Shultz II - Page 3 (JM-953) 

with the child support obligation or upon the 

failure of a parent to pay charges based 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 State hospital or facility 

to the extent that charges have been made 

against the child support obligation. 

(Emphasis added.) 

In summary, non-indigent patients include persons 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 individual so that those individuals can 

be considered "non-indigents" for purposes of article 

3196a.l 

The Indigent Health Care and Treatment Act was enacted 

in 1985 to clarify the obligations of counties and public 

hospitals for indigent health care. Section 2.02 of the 

Indigent Health Care and Treatment Act provides: 

(a) Each county shall provide health care 

assistance as prescribed by this title to 

each eligible resident of that county who 

does not reside within the area that a 

hospital or hospital district has a 

obligation to serve: 

(b) The county is the payor of last 

and shall provide assistance only if 

1. The Indigent Health - _ _ _ _ . . _ . 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 

constitutional and statutory provisions governing hospital 

districts.) Therefore, we will consider your question about 

hospital districts separately. 

p. 4823 
W. 0. Shultz II - Page 4 (JM-953) 

adequate public or private sources of payment 

are not available. 

Se al Q f 2.03 (providing that eligibility depends on 

inzomesand resources). Section 10.02(a) provides, in part: 

Each public hospital shall provide health 

care assistance as prescribed by 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 eligibility depends 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. 

In Attorney 

those provisions do not make counties and 

"legally liable for [the] supportI' of any 

General Opinion JM-705 (1987), we addressed 

an issue related to your question. The issue there was 

whether an indigent's county 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) Indigent public patients and 

(2) Non-indigent public patients. 

(a) Indigent public patients 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 shall be supported at the expense 

of the State. 

V.T.C.S. art. 4477-11, 9 9 (Texas Tuberculosis Code). The 

opinion concluded that the county was responsible for the 

p. 4824 
W. 0. Shultz II - Page 5 (JM-953) 

indigent's treatment. The basis of the decision, however, 

was that the provisions of article 4477-11 apply only to the 

care and treatment of persons with tuberculosis. Therefore, 

a person with a heart disease is not among the persons to be 

supported at the expense of the state pursuant 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 Treatment Act does not make the county someone 

"legally responsible for [the] support" of its indigent 

residents for purposes 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 

Indigent Health Care and Treatment Act requires counties and 

public hospitals to provide "health care 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 reimbursement may be sought, we think it as clear that 

the word N1supportll in article 3196a means someone such as a 

parent or spouse who has an obligation to provide the 

necessities of life. The Indigent Health Care and Treatment 

Act creates a much narrower obligation, not an obligation to 

*lsupport.ll Therefore, persons for whom counties and public 

hospitals must provide health care under the Indigent Health 

Care and Treatment Act 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 commissioners court 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 

(Footnote Continued) 

p. 4825 
W. 0. Shultz II - Page 6 (JM-953) 

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 

adequate public or private sources of payment are available. 

Those provisions make clear that the Indigent Health Care 

and Treatment Act was not intended to relieve other public 

entities of any obligations to provide health care. 

You also ask whether a hospital district is 

liable for the support" 

"legally 

of its needy inhabitants. Article 

IX, section 9, of the Texas Constitution provides in part: 

The Legislature may by law provide 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 responsibility to provide medical 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" for purposes of article 3196a.3 

(Footnote Continued) 

extent prescribed by the Indigent Health Care 

and Treatment Act. 

See aenerally Attorney General Opinion JW-815 (1987). In 

any case, we think that the specific provisions of article 

3196a and chapter 73 of the Education Code would control 

over the general provision of article 2351(6). See State v. 

Jones, 

l!lri&) . 

570 S.W.2d 122, (Tex. Civ. App. - Austr1978, no 

Article 2351(6) also indicates that medical 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 spending money for medical care for needy inhabitants 

of a hospital district. We point out, though, that article 

IX, section 9, prohibits other municipalities and political 

subdivisions, not the state, from taxing to provide medical 

care. 

p. 4826 
, 

W. 0. Shultz II - Page 7 (JM-953) 

All hospital districts are subject to the provisions of 

the statutes under 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 or public hospitals liable for the 

llsupportl' of indigents. Therefore, article 

4438f does not make indigents for whom 

counties or public hospitals 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 for medical 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 not make needy inhabitants of. 

hospital districts "non-indigents" for 

purposes of article 3196a, V.T.C.S. 

JIM MATTOX 

Attorney General of Texas 

MARY KELLER 

First Assistant Attorney General 

LOU MCCREARY 

Executive Assistant Attorney General 

JUDGE ZOLLIE STEAKLEY 

Special Assistant Attorney General 

RICK GILPIN 

Chairman, opinion Committee 

Prepared by Sarah Woelk 

Assistant Attorney General 

p. 4829