If a needy patient is treated at a state cancer hospital, does the county or hospital district have to pay the bill?

Texas AG Opinion JM-953: Who Pays When a Needy Patient Goes to M.D. Anderson?

Plain-English summary

M.D. Anderson, the University of Texas cancer hospital in Houston, treats patients from all over the state, and many of them cannot afford the bill. The hospital's governing statutes sort patients into two buckets: indigent patients, who have no property and no one legally responsible for their support, and non-indigent patients, who either have some property or have someone legally liable to support them. Indigent patients are cared for at state expense. For non-indigent patients, the state can go after the patient's estate or the person legally responsible for their support, typically a spouse or a parent of a minor.

The University's lawyer had a theory that would shift a lot of these costs onto local government. Texas law makes counties and public hospitals responsible for providing health care to their poor residents, and it makes hospital districts responsible for medical care of their needy inhabitants. If that responsibility counted as being "legally liable for the support" of those people, then those patients would fall into the non-indigent bucket, and M.D. Anderson could bill the county, public hospital, or district instead of eating the cost. The University asked the Attorney General whether that theory works.

The Attorney General said it does not.

The key is the word "support." Being legally responsible for someone's support means a lot more than paying their medical bills. Support means food, clothing, shelter, and medical care, the whole set of necessities. That is the kind of obligation a parent has to a child or a spouse has to a spouse, and that is the kind of obligation article 3196a is talking about when it lets the state seek reimbursement from someone legally liable for a patient's support.

The Indigent Health Care and Treatment Act is narrower than that. It requires counties and public hospitals to provide "health care assistance" to eligible residents, and only as the payor of last resort, when no other public or private source of payment is available. That is a duty to help with health care, not a duty to support a person's whole life. So it does not turn a county or public hospital into someone "legally liable for the support" of its indigent residents. The Attorney General had already reached the same conclusion in a 1987 opinion dealing with the parallel tuberculosis-hospital statute, and applied the same reasoning here. The fact that counties and public hospitals are only payors of last resort actually cuts the other way from the University's theory: it shows the Act was meant to preserve, not eliminate, other public entities' obligations.

The hospital-district piece came out the same way. The Texas Constitution makes a hospital district assume full responsibility for medical and hospital care of its needy inhabitants. But again, providing medical care is not the same as being responsible for a person's support. So needy inhabitants of a hospital district are not "non-indigents" as to M.D. Anderson either. The bottom line: a county, public hospital, or hospital district is not automatically on the hook for a needy patient's care at M.D. Anderson just because the patient lives within its boundaries.

Currency note

This opinion was issued in 1988. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Many of the statutes cited here have since been recodified. The Indigent Health Care and Treatment Act (article 4438f, V.T.C.S.) and article 3196a have been moved into the Health and Safety Code, the Family Code support provision has been renumbered, and the county pauper-support statute (article 2351(6), V.T.C.S.) and the tuberculosis code provisions have likewise changed. The eligibility rules and funding structure for county indigent health care have been amended repeatedly. Anyone deciding who pays for a specific patient's care today should work from the current Health and Safety Code indigent-care provisions and the current statutes governing the treating hospital, not the 1988 versions cited here.

Who this opinion affected (as of 1988)

M.D. Anderson and the University of Texas System: The opinion told them they could not shift indigent patients' costs to counties, public hospitals, or hospital districts on a "legally liable for support" theory.

Counties and public hospitals: The opinion confirmed their duty under the Indigent Health Care and Treatment Act is to provide health care assistance as payor of last resort, not to "support" indigents in the broad sense.

Hospital districts: The opinion confirmed their constitutional duty is to provide medical and hospital care, not general support, so their needy inhabitants are not automatically billable to state hospitals as non-indigents.

Common questions

Does a county have to pay M.D. Anderson for treating one of its indigent residents?
Not automatically. The Attorney General concluded that a county's duty under the Indigent Health Care and Treatment Act is to provide health care assistance as payor of last resort, which does not make the county "legally liable for the support" of the patient, so the patient is not a non-indigent as to M.D. Anderson.

What is the difference between providing health care and being responsible for "support"?
Support means the necessities of life, food, clothing, shelter, and medical attention, the kind of obligation a parent owes a child or a spouse owes a spouse. Providing "health care assistance" is narrower, so it does not amount to legal responsibility for a person's support.

Are hospital districts responsible for their needy inhabitants' care at M.D. Anderson?
No, not on this theory. The constitutional duty of a hospital district is to provide medical and hospital care for its needy inhabitants, which is not the same as being responsible for their support, so those inhabitants are not non-indigents for purposes of the state hospital reimbursement statute.

Who can M.D. Anderson bill for a non-indigent patient?
Under article 3196a, the state may seek reimbursement from a patient with a sufficient estate, and from a spouse, or from a parent when the patient is a minor, where those persons are able to pay.

Background and statutory framework

M.D. Anderson is governed by chapter 73 of the Education Code and is devoted to the diagnosis, teaching, study, prevention, and treatment of neoplastic and allied diseases (Education Code section 73.102); each admission must be accompanied by a physician's statement that the patient has or is suspected of having a neoplasm or allied disease (section 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, applies to M.D. Anderson except where it conflicts with Education Code section 73.101 (Education Code section 73.106). Article 3196a divides patients into indigent patients (those who possess no property of any kind, have no one legally responsible for their support, and are unable to reimburse the state, supported at state expense) and non-indigent patients (those who possess some property out of which the state may be reimbursed, or who have someone legally liable for their support). Section 2 makes a patient with a sufficient estate liable, and makes a spouse liable if able, and a parent liable for a patient under 18 if able.

The University asked whether the Indigent Health Care and Treatment Act (article 4438f, V.T.C.S.), enacted in 1985 to clarify the obligations of counties and public hospitals for indigent health care, makes counties and public hospitals "legally liable for the support" of certain individuals so that they become non-indigents under article 3196a. The Act requires each county to provide health care assistance to each eligible resident who does not reside within a public hospital's or hospital district's service area, and makes the county the payor of last resort (section 2.02); it requires each public hospital to provide health care assistance to eligible residents of its service area (section 10.02) and makes a public hospital the payor of last resort, not liable if any other public or private source of payment is available (section 12.01(e)). Eligibility depends on income and resources (sections 2.03, 10.02(b)). The Attorney General concluded those provisions do not make counties and public hospitals "legally liable for the support" of any individual.

In Attorney General Opinion JM-705 (1987), the Attorney General had addressed a related issue: whether an indigent's county of residence or the University of Texas Health Center at Tyler was liable for the indigent's heart-disease treatment at the Tyler hospital, under a statute (article 4477-11, V.T.C.S., the Texas Tuberculosis Code) that tracks section 1 of article 3196a. That opinion concluded the county was responsible, but only because article 4477-11 applies only to persons with tuberculosis, so a heart-disease patient was not among those supported at state expense; it indicated the state would be responsible had the indigent been treated for tuberculosis. Implicit in that reasoning was that the Indigent Health Care and Treatment Act does not make a county someone "legally responsible for the support" of its indigent residents.

The Attorney General found that implication correct and applicable to article 3196a. The Act requires counties and public hospitals to provide "health care assistance," but "support" ordinarily includes much more than health care assistance: parents are responsible for the support of their children and spouses for each other (Family Code section 4.02), and support in that context includes food, clothing, shelter, and medical attention (Woodruff v. Woodruff, 487 S.W.2d 791, 793 (Tex. Civ. App. - Texarkana 1972, no writ)). Because article 3196a specifically identifies spouses and parents of minors as persons from whom reimbursement may be sought, the word "support" there means someone, such as a parent or spouse, with an obligation to provide the necessities of life. The Act creates a much narrower obligation, so persons for whom counties and public hospitals must provide health care are not non-indigents for purposes of article 3196a. Sections 2.02(b) and 12.01(e), the payor-of-last-resort provisions, bolster that conclusion by showing the Act was not intended to relieve other public entities of their obligations to provide health care. The opinion noted in a footnote the county pauper-support statute (article 2351(6), V.T.C.S.), but reasoned that the specific provisions of article 3196a and chapter 73 of the Education Code would control over that general provision (State v. Jones, 570 S.W.2d 122 (Tex. Civ. App. - Austin 1978, no writ); see also Attorney General Opinion JW-815 (1987)).

On hospital districts, article IX, section 9 of the Texas Constitution allows the legislature to create hospital districts, providing that any district so created assume full responsibility for providing medical and hospital care for its needy inhabitants. Again, a responsibility to provide medical and hospital care is not the equivalent of an obligation to support someone, so article IX, section 9 does not make needy inhabitants of hospital districts non-indigents for purposes of article 3196a. All hospital districts are subject to the statutes under which they are created, and the Attorney General was aware of none that make hospital districts liable for the support of their needy inhabitants.

Citations

Statutory and constitutional authority:

• Chapter 73, Education Code (governing M.D. Anderson; sections 73.101, 73.102, 73.106, 73.108)
• Article 3196a, V.T.C.S. (patient classes and reimbursement for state MHMR hospitals, applied to M.D. Anderson)
• Article 4438f, V.T.C.S. (Indigent Health Care and Treatment Act; sections 2.02, 2.03, 10.02, 12.01)
• Article 4477-11, V.T.C.S. (Texas Tuberculosis Code, section 9)
• Article 2351(6), V.T.C.S. (commissioners court support of paupers)
• Section 4.02, Family Code (spousal and parental support obligation)
• Article IX, section 9, Texas Constitution (hospital districts' responsibility for medical and hospital care of needy inhabitants)

Cases:

• Woodruff v. Woodruff, 487 S.W.2d 791 (Tex. Civ. App. - Texarkana 1972, no writ) (Texas appellate court; "support" includes food, clothing, shelter, and medical attention)
• State v. Jones, 570 S.W.2d 122 (Tex. Civ. App. - Austin 1978, no writ) (Texas appellate court; specific statutory provisions control over general provisions)

Prior Attorney General opinions referenced: JM-705 (1987), JW-815 (1987).

Source

• Landing page: https://www.texasattorneygeneral.gov/opinions/jim-mattox/jm-953
• Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1988/jm0953.pdf

Original opinion text

Best-effort transcription from a scanned PDF. Minor OCR errors may remain; the linked PDF is authoritative.

September 15, 1988

W. O. Shultz II
General Attorney and Associate General Counsel
The University of Texas System
201 West 7th Street
Austin, Texas 78701

Opinion No. JM-953

Re: Circumstances under which a county or public hospital or hospital district 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 section 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 section 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 section 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;

Non-indigent patients;

Indigent 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,] shall be supported at the expense of the State.

Non-indigent patients are those who possess some property out of which the State may be reimbursed, or who have someone legally liable for their support. 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, maintenance, and treatment of such patients.

Sec. 2. Where the patient has sufficient estate of his own, he shall be 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 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." 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 [the] support" of certain individuals so that those individuals can be considered "non-indigents" for purposes of article 3196a.[1]

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 public hospital or hospital district has a legal obligation to serve;

(b) The county is the payor of last resort and shall provide assistance only if other adequate public or private sources of payment are not available.

See also section 2.03 (providing that eligibility depends on income and 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 section 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 those provisions do not make counties and public hospitals "legally liable for [the] support" of any individual.

In Attorney 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, section 9 (Texas Tuberculosis Code). The opinion concluded that the county was responsible for the 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, "support" includes much more than "health care assistance." Parents are responsible for the "support" of their children, and spouses are responsible for the "support" of each other. Fam. Code section 4.02. "Support" 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, no 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 "support" 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 "support." 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]

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 "legally liable for the support" 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 shall assume full responsibility for providing medical and hospital care for its needy inhabitants . . . .

Again, a responsibility to provide medical and hospital care is not the equivalent of an obligation to "support" someone. Therefore, article IX, section 9, of the Texas Constitution does not make needy inhabitants of hospital districts "non-indigents" for purposes of article 3196a.[3]

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 "support" of its needy inhabitants.

SUMMARY

The Indigent Health Care and Treatment Act, article 4438f, 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 "support" 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 "support" 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

[1] The Indigent Health Care and Treatment Act does not affect the obligations of hospital districts. See V.T.C.S. 4438f, sections 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.

[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 extent prescribed by the Indigent Health Care and Treatment Act. See generally 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, 570 S.W.2d 122 (Tex. Civ. App. - Austin 1978, no writ). Article 2351(6) also indicates that medical care is only one aspect of "support."

[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.