Does a county hospital district pay for a resident's emergency care at an out-of-county hospital?
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Texas AG Opinion JM-540: Hospital District Liability
Plain-English summary
An indigent resident of Nacogdoches County, which has a county hospital district, needed emergency medical treatment and got it at a public hospital in another county that had no hospital district of its own. The question put to the Attorney General was which entity has to pay: does the home hospital district owe the cost of emergency care its resident received across county lines, for care given before September 1, 1986? Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
The AG concluded the home hospital district is liable. A hospital district created under article IX, section 9 of the Texas Constitution "shall assume full responsibility" for the medical and hospital care of its needy inhabitants, and the district's own enabling act (chapter 431 of the 1967 legislature) did not cut back that constitutional duty. The AG pointed to a consistent line of its earlier opinions holding that a hospital district is responsible for the medical bills of its indigent residents even when the treatment happens outside the district, including when the district lacks the facilities to treat the patient itself. So the Nacogdoches County Hospital District was liable for the emergency care its indigent resident received at the out-of-county hospital. Because section 15(a) of the Indigent Health Care and Treatment Act says care furnished before September 1, 1986 is governed by the law then in effect, this result rests on that earlier law. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Currency note
This opinion was issued in 1986. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. The opinion itself addressed only care provided before September 1, 1986, and the Indigent Health Care and Treatment Act (article 4438f) has since been recodified into the Health and Safety Code and amended. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule or citation mentioned here.
Common questions
Does a hospital district pay for a resident's emergency care at a hospital in another county?
Under this opinion, yes. The AG concluded that a hospital district created under article IX, section 9 of the Texas Constitution is liable for emergency health care administered to an indigent resident of the district in a county hospital of another county. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Why does the home district owe the bill instead of the county where care was given?
Because of the district's constitutional duty. The AG explained that a hospital district assumes full responsibility for the medical and hospital care of its needy inhabitants under article IX, section 9, and that duty is not reduced by the district's enabling act. The responsibility follows the resident. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Does it matter that the treating hospital was outside the district?
No. The AG cited its prior opinions holding that a hospital district is liable for its indigent residents' medical bills even when the care is provided outside the district's boundaries, including when the district must send a patient elsewhere because it lacks the facilities to provide the care itself. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Background and statutory framework
The Nacogdoches County Hospital District, covering the entire county, was created by chapter 431 of the 60th Legislature (1967) under article IX, section 9 of the Texas Constitution. That constitutional provision states that a hospital district created under it "shall assume full responsibility for providing medical and hospital care for its needy inhabitants," and section 19 of the district's enabling act uses parallel language; the AG read the enabling act as not reducing the constitutional responsibility. Section 15(a) of the Indigent Health Care and Treatment Act (article 4438f, V.T.C.S.) provides that health care assistance furnished before September 1, 1986 is governed by the law in effect when the assistance was provided, so the AG applied the pre-Act law. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
The AG grounded its conclusion in a line of prior opinions: Attorney General Opinion M-171 (1967) held a hospital district may send an indigent inhabitant to a hospital outside the district and pay those expenses when it lacks sufficient facilities; M-870 (1971) held the district of an indigent prisoner's residence is liable for medical bills even when treatment occurred outside the district; H-703 (1975) reaffirmed that; JM-487 (1981) followed those opinions; and JM-257 (1984) and M-1154 (1972) recognized a district's authority to pay for care of a needy inhabitant at an outside facility. Applying that reasoning, the AG concluded the Nacogdoches County Hospital District was liable for the emergency care its indigent resident received at a public hospital in another county. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Citations and references
The opinion cited the following authorities. Source: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Constitutional and statutory provisions:
- Tex. Const. art. IX, § 9
- Indigent Health Care and Treatment Act, V.T.C.S. art. 4438f, § 15(a)
- Chapter 431, Acts 1967, 60th Leg., § 19 (Nacogdoches County Hospital District)
Attorney General opinions cited:
- Attorney General Opinions M-171 (1967); M-870 (1971); H-703 (1975); M-1154 (1972); JM-257 (1984); JM-487 (1981)
Source
- Landing page: https://www.texasattorneygeneral.gov/opinions/jim-mattox/jm-0540
- Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1986/jm0540.pdf
Original opinion text
Best-effort transcription from a scanned PDF. Minor errors may remain; the linked PDF is authoritative.
September 9, 1986
Honorable Chester V. Hines
County Attorney
Houston County Courthouse
Crockett, Texas 75835
Opinion No. JM-540
Re: Whether a county hospital district is liable for emergency health care administered in a hospital in another county to an indigent resident of the hospital district
Dear Mr. Hines:
You inquire whether a hospital district is liable for emergency health care administered to an indigent resident of the hospital district in a county public hospital of another county prior to September 1, 1986. Section 15(a) of the Indigent Health Care and Treatment Act, codified as article 4438f, V.T.C.S., provides, among other things, that health care assistance provided before September 1, 1986, is governed by the law in effect at the time the assistance was provided.
You advise us that an indigent resident of Nacogdoches County required emergency medical treatment which was supplied by a county public hospital of another county that does not have a hospital district. It is our opinion that the Nacogdoches County Hospital District is liable for such medical treatment.
The Nacogdoches County Hospital District, composed of the entire county, was created by chapter 431, 60th Legislature, 1967, in accordance with the provisions of article IX, section 9 of the Texas Constitution. Article IX, section 9 provides, in part, that a hospital district created thereunder
shall assume full responsibility for providing medical and hospital care for its needy inhabitants. . . .
Chapter 431, section 19 of the 60th Legislature states that the Nacogdoches County Hospital District
shall assume full responsibility for the operation of all hospital facilities for the furnishing of medical and hospital care for its needy inhabitants. . . .
The language of chapter 431, section 19 does not reduce the responsibility of the hospital district for the care of its needy inhabitants that is mandated by article IX, section 9, of the constitution.
Prior opinions of this office have dealt with similar responsibility of hospital districts. Attorney General Opinion M-171 (1967) held that a hospital district, created pursuant to section 9 of article IX of the Texas Constitution, has the full responsibility for providing medical and hospital care for indigent residents of the district and that, when the hospital district cannot adequately discharge its responsibility to an indigent inhabitant because of a lack of sufficient hospital facilities, it may send the indigent to a hospital outside the district and pay for such out-of-district expenses. Attorney General Opinion M-870 (1971) advised that the hospital district of the residence of an indigent prisoner is liable for the medical bills incurred in his treatment, notwithstanding the fact that the treatment was administered in a hospital outside the boundaries of the hospital district. Attorney General Opinion H-703 (1975), citing Attorney General Opinion M-870, reiterated the opinion that where a prisoner is an indigent resident of a hospital district, the hospital district of his residence was constitutionally responsible for his care and was liable therefore. See also Attorney General Opinion JM-487 (1981) (following opinions M-171, M-870, H-703 and concluding that hospital districts of the residence of indigent prisoners are liable for their medical bills regardless of the county in which treatment was received). Cf. Attorney General Opinion JM-257 (1984) (citing prior opinions in noting that in fulfilling its constitutional duty to assume full responsibility for medical and hospital care for its needy inhabitants, a hospital district has authority to pay the medical expense incurred in sending a needy inhabitant to a medical facility outside the district because of lack of facility); Attorney General Opinion M-1154 (1972) (citing prior opinions upholding right of hospital district to pay private hospital for care rendered to needy and indigent persons of the district where it was not practical to treat such persons in the hospital district's own facilities).
Hence, it is our opinion that the Nacogdoches County Hospital District is liable for the emergency health care administered to an indigent resident of that district in a county public hospital of another county.
SUMMARY
A hospital district created under article IX, section 9 of the Texas Constitution, is liable for emergency health care administered prior to September 1, 1986, to an indigent resident of the hospital district in a county hospital of another county.
Very truly yours,
Jim Mattox
Attorney General of Texas
JACK HIGHTOWER
First Assistant Attorney General
MARY KELLER
Executive Assistant Attorney General
RICK GILPIN
Chairman, Opinion Committee
Prepared by Nancy Sutton
Assistant Attorney General
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