JIM MAlTOX 

Attorney General 

Supreme Court Building 

P. 0. Box 12548 

Austin, TX. 78711. 25u) 

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An Equal Opportunity/ 

Affirmative Action Employer 

The Attorney General of Texas 

October 6, 1986 

Honorable Carl M. Anderson 

Nolan County Attorney 

P. 0. Box 1201 

Sweetwater, Texas 79556 

Opinion No. JM-552 

Ret Whether the city of Sweetwater 

is required to share the expense of 

health care for indigent residents 

of Nolan~County 

Dear Mr. Anderson: 

You inquire whether, under the Indigent Health Care and Treatment 

Act, the city of Sweetwater is required to share the expense of health 

care services for indigents who are residents of Nolan County. We 

conclude that such expense is a joint responsibility of the county and 

the city. We are asked the following specific questions: 

1. Within the provisions of article 4438f. 

V.T.C.S., is an eligible resident,of Nolan County, 

Texas a person who does not reside uithin the area 

that a Iublic hospital or hospital district has a 

legal obligation to serve? 

2. If the answer to the foregoing is in the 

negative then, under the provisions of section 

12.03 of article 4438f, Is the city of Sweetwater, 

Texas, a governmental entity that created or 

authorized the creation of a 'hospital authority' 

as that term is used in section 12.03? 

The only hospital in Nolan County is operated by a joint countycity hospital board created under article 44941-l. V.T.C.S. Such a 

board is a separa'x! entity which acts independently but operates the 

hospital as a joint agent of the county and the city. V.T.C.S. art. 

44941-l. 62. The board may not encumber, sell, lease, or convey real 

or personal property without prior approval of the commissioners court 

and the governing body of the city. Art. 4494i-1, ,65. The board may 

issue revenue bonds, but it may not deliver bonds unless the issuance 

is approved by the comissioners court and the governing body of the 

city. Art. 4494i-1, 506. 8. Section 5 also expressly authorizes the 

county and the city to contract with the board for the care of 

indigent persons with both the county and the city making payments to 

the board pursuant to such a contract from any of their funds or 

resources. 

p. 2450 
Honorable Carl M. Anderson - Page 2 (JM-552) 

Prior to the enactment of the Indigent Health Care and Treatment 

Act, which is codified as article 4438f. V.T.C.S., Attorney General 

Opinion MW-33 (1979) detenained that the commissioners court of each 

county was required by sta:ute to provide necessary medical care for 

its indigents and that a county was liable for expenses of an indigent 

resident incurred at a joint county-city hospital unless the county 

contracted with the city J:CI share such expenses under section 5 of 

article 44941-l. The Indigent Health Care and Treatment Act changes 

the law expressed in that opinion. 

Under the Indigent Health Care Act, each county shall provide 

health care assistance to i.ts eligible residents who do not reside in 

the area that a public hospital or hospital~district has a legal 

obligation to serve. V.T.C.S. art. 4438f, 92.02(a). Each public 

hoapital shall provide health care assistance to the eligible 

residents of the area that the hospital has a legal obligation to 

serve, and each governmentxl entity that owns, operates, or leases a 

public hospital shall provid,e sufficient funding to allow the hospital 

to provide that health ca:re assistance. Art. 4438f, 110.02(a). A 

public hospital is liable for health care services provided by any 

provider, including another public hospital, to an eligible resident 

of the area that the hospital has a legal obligation to serve. Art. 

4438f. 512.01(a). Sectior. 12.03 of the Indigent Health Care Act 

provides that 

[elach governmental entity that ,owns, operates, or 

leases a public hospital shall provide sufficient 

funding to then ho:spital to provide the health care 

assistance require'd by this Act. If a public 

hospital is owned, operated, or leased by a hospital 

authority, the governmental entity that created or 

authorized the creation of the authority shall 

provide sufficient funding to the public hospital or 

hospital authority to provide the health care assistance required by this Act. 

You first ask whether an eligible resident of Nolan County is a 

person who resides within the area that a public hospital or hospital 

district has a legal obligation to serve. Health care assistance to a 

person who does not reside in such an area is provided by the county. 

It is our opinion, however, that an eligible resident of Nolan County 

resides in anarea that a public hospital has a legal obligation to 

serve. 

The hospital in Nolan County operated by the joint county-city 

hospital board is a public hospital as that term is used in the 

Indigent Health Care Act. The act defines a public hospital as "a 

hospital owned. operated, or leased by a governmental entity" and a 

governmental entity includes a county, city, town, hospital authority, 

or other political subdivis,lon of the state, but does not include a 

hospital district. Art. 4438f. 01.02(6)(10). The hospital in 

quest-ion has a legal obligation to serve the area of the county and 

p. 2451 
Honorable Carl M. Anderson '- Page 3 (JM-552) 

the city. Under the Indigent Health Care Act, the public hospital in 

Nolan County provides health care assistance to indigent residents of 

Nolan County. 

Your second question ::I; whether, by creating the joint hospital 

board with the county, the city is a governmental entity that created 

or authorized the creation of a hospital authority as that term is 

used In section 12.03 of th,z Indigent Health Care Act. 

The Indigent Health Cars Act does not define "hospital authority" 

for purposes of the act. .i joint county-city hospital board created 

under article 44941-l and hospital authorities created by a city 

under article 4437e. V.T.C.S., and by a county under article 4494r, 

V.T.C.S.. have both similar and dissimilar characteristics. Neither a 

hospital authority nor a joint county-city hospital board has taxing 

power. Both a hospital authority and a joint county-city hospital 

board are entities separate from the governmental entity that created 

them and may construct, enlarge, furnish, equip, operate, and maintain 

their respective hospitals. V.T.C.S. art. 4437e. 56(a); art. 4494r, 

56(a); art. 44941-l. 54. A hospital authority may Issue revenue bonds 

after an election to approvsz the bonds if ten percent of the qualified 

voters request such an election and without an election if the voters 

do not request it. A jo,Lnt county-city hospital board may issue 

revenue bonds, but all such bonds must be approved by both the county 

and the city that created the joint board. Art.' 44941-l. 58. By 

statute, hospital authorities are a "body politic and corporate" and, 

in the case of a county hos:pital authority, a "political subdivision 

of the State," as distinguished from a joint county-city hospital 

board which constitutes a '"public agency and body politic." Art. 

4437e. 53; art. 4494r. $3; <art. 44941-1, 01. Although a joint countycity hospital board is a separate entity in the performance of the 

functions authorized by article 4494i-1, section 2 of that article 

expressly provides that such a board is a joint agent of the county 

and the city for hospital purposes. 

As a practical matter. whether a joint county-city hospital board 

constitutes a hospital autllority within the meaning of the Indigent 

Health Care Act is immaterial to a determination of the obligation to 

fund the health care assistance required of a hospital operated by a 

joint hospital board. It is our opinion that for purposes of the Indigent Health Care Act, while nominal title is in a joint board, actual 

ownership of a hospital opezated by a joint county-city hospital board 

is in the county and the cj.ty. Such ownership is consistent with the 

statutory agency relationsh:Lp of the joint board to the county and the 

city and with the joint board's authority pertaining to hospital 

property that is subject to prior approval of both the county and 

city. Art. 44941-1. 104, 5. In either capacity, sections 10.02(a) 

and 12.03 of article 4438f provide that the governmental entities that 

own a public hospital or create a hospital authority that owns or 

operates a public hospital shall provide sufficient funding to allow 

the hospital to provide tt.e health care assistance required by the 

Indigent Health Care Act. 'Che act is the legislature's implementation 

p. 2452 
Honorable Carl M. Anderson - Page 4 (JM-552) 

of reconnnendations made b5, the Task Force on Indigent Health Care 

jointly appointed by the governor, lieutenant governor, and speaker of 

the house in September, 1983, and charged with presenting a package of 

findings and recommendaticlns to the Sixty-ninth Legislature. The 

intention of the Task Fore<? recommendations. among other things, was 

to allocate responsibility for the administration and financing of 

indigent care among various levels of government and types of 

providers in an attempt t,o work within the existing system while 

proposing measures to,reduc,e the inequities in that system. See Task 

Force on Indigent Eealth Care. Final Report, December 1984, at 21. 

The provisions of the act ,:hat relate to your questions reflect that 

intention. 

Since the legislature expressly provided in article 4438f. 

sections 10.02(a) and 12.03 that each governmental entity shall 

provide funding to the hospital frhealth care assistance, we 

conclude that the legislature Intends that the share of expense to be 

provided by each entity is a joint responsibility and an internal 

matter to be determined by the county and the city. 

SUMMARY 

Under the Indigent Health Care and Treatment Act, 

an eligible resident of Nolan County is a person who 

resides in an arl?a that a public hospital has a 

legal obligation to serve. A governmental entity 

that either owns, operates, or leases a public 

hospital or that #:reated a hospital authority that 

owns, operates, or leases a public hospital shall 

provide funding fcr health care assistance required 

by the act. Hence, funding for indigent health care 

expense of a hospital operated by a joint countycity hospital board is a joint responsibility of the 

county and the city. 

Attorney General of Texas 

JACK HIGHTOWER 

First Assistant Attorney General 

NARY KELLER 

Executive Assistant Attorney General 

RICK GILPIN 

Chairman, Opinion Committee 

Prepared by Nancy Sutton 

Assistant Attorney General 

p. 2453