Was Jackson County responsible for indigent healthcare when a hospital district covered the entire county?

Texas AG Opinion JM-722: Jackson County Hospital District and Indigent Care

Plain-English summary

The Jackson County criminal district attorney asked whether the county had to provide inpatient or outpatient healthcare for indigent residents under the Indigent Health Care and Treatment Act. A hospital district covered all of Jackson County.

The Attorney General concluded that the county was not liable. Article IX, section 9 of the Texas Constitution allowed creation of a hospital district that assumed full responsibility for medical and hospital care for needy residents. Once created, other local governments within the district could not levy taxes or issue obligations for hospital or medical-care purposes.

The Jackson County Hospital District Act followed that constitutional structure. It made patients unable to pay a charge on the district and required the district to operate its hospitals with enough funds, staff, and equipment to serve district residents. Because the district included the entire county, every indigent Jackson County resident lived within the district's service area.

The Indigent Health Care Act did not shift that duty back to the county. Title 2 applied only to eligible county residents outside an area served by a public hospital or hospital district. Title 3 stated that hospital districts provided services and bore liability according to the Texas Constitution and their creating statutes.

Currency note

This opinion was issued in 1987. 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.

Common questions

Did Jackson County have to pay for indigent inpatient care?

No. The opinion concluded that the countywide hospital district, not the county, held responsibility for the required care.

Did the same answer apply to outpatient services?

Yes. The opinion expressly concluded that the county was not liable for either inpatient or outpatient health and medical services.

Why could the county not tax separately for this care?

Article IX, section 9 barred another municipality or political subdivision from levying taxes or issuing bonds for hospital purposes or medical care within the hospital district's boundaries.

How did the Indigent Health Care Act treat a hospital district?

The Act did not classify a hospital district as a governmental entity or its facility as a public hospital for the Act's separate public-hospital provisions. Instead, sections 11.02 and 12.01(b) tied the district's service and liability duties to the Texas Constitution and the statute creating the district.

Background and statutory framework

The Jackson County Hospital District was created under article IX, section 9 of the Texas Constitution and the 1979 Jackson County Hospital District Act. The district included all of Jackson County and assumed full responsibility for needy residents' medical and hospital care.

Title 2 of the Indigent Health Care Act addressed county responsibility only for residents outside a public hospital or hospital district service area. Title 3 preserved a hospital district's obligations under its constitutional and statutory foundation. The opinion therefore found no statutory attempt to impose overlapping county liability.

Citations and references

Statutory authorities:

• Texas Constitution article IX, section 9 (hospital districts)
• Jackson County Hospital District Act, Acts 1979, 66th Legislature, chapter 275, sections 16 and 20
• Article 4438f, V.T.C.S., sections 1.02, 2.01, 2.02, 3.01, 4.01, 10.01, 11.02, and 12.01 (Indigent Health Care and Treatment Act)

Source

• Landing page: https://www.texasattorneygeneral.gov/opinions/jim-mattox/jm-0722
• Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1987/jm0722.pdf

Original opinion text

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

THE ATTORNEY GENERAL
OF TEXAS

June 17, 1987

Honorable Robert E. (Bobby) Bell
Criminal District Attorney
115 W. Main
Edna, Texas 77957

Opinion No. JM-722

Re: Whether Jackson County is required to provide services under the Indigent Health Care Act where the county is encompassed within a hospital district

Dear Mr. Bell:

You ask whether Jackson County is liable under the Indigent Health Care and Treatment Act for health care services for indigent residents of that county. We conclude that the county is not liable for either inpatient or outpatient health and medical services.

The Jackson County Hospital District is created under authority of article IX, section 9, of the Texas Constitution, by chapter 275, 66th Legislature, 1979, which is known as the Jackson County Hospital District Act. See V.T.C.S. art. 4494q. The district includes all of Jackson County. Hence, all indigent residents of the county are residents of the hospital district.

Section 9, of article IX, of the Texas Constitution provides in part that:

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 . . . providing that after its creation no other municipality or political subdivision shall have the power to levy taxes or issue bonds or other obligations for hospital purposes or for providing medical care within the boundaries of the district. . . . (Emphasis added).

The Jackson County Hospital District Act provides in part that:

Sec. 16. Whenever a patient residing within the district is admitted to the facilities of the district, the administrator for the hospital to which the patient is admitted may have an inquiry made as to his or her circumstances and those of the relatives of the patient legally liable for his or her support. . . . If the administrator finds that the patient or his or her relatives are not able to pay either in whole or in part for care and treatment in the hospital, they shall become a charge on the hospital district as to the amount of the inability to pay. . . .

. . . .

Sec. 20. . . . The board shall provide for the administration, maintenance, and operation of both hospitals transferred to the district on its creation so as to furnish adequate hospital and medical care within the district and to ensure that each hospital is provided with sufficient funds, personnel, and equipment to the end that residents of the district have access to quality and competent health facilities; and no other municipality or political subdivision may levy taxes or issue bonds or other obligations for hospital purposes or for providing medical care within the boundaries of the district. The district shall assume full responsibility for providing medical and hospital care for its needy inhabitants. (Emphasis added).

Acts 1979, 66th Leg., ch. 275, at 595-98.

When a hospital district is created for the county pursuant to article IX, section 9, of the Texas Constitution, the county constitutionally does not have the power to levy or use taxes to provide for medical services for indigent residents of the hospital district, as such power and obligation rests exclusively on the hospital district. Attorney General Opinion C-646 (1966). See also Attorney General Opinion Nos. M-870 (1971); C-334 (1964).

The provisions of the Indigent Health Care and Treatment Act, article 4438f, V.T.C.S., are consistent with, and adopt by reference, the provisions of both article IX, section 9, of the Texas Constitution and the Jackson County Hospital District Act. Title 2 of the Indigent Health Care Act specifies the responsibility of a county for health care assistance to the county's eligible residents who do not reside in an area served by a public hospital or hospital district. Secs. 2.01, 2.02(a), 3.01, 4.01. Since all of Jackson County is served by the hospital district, the provisions of Title 2 fixing liability of a county for indigent health care have no application to Jackson County.

Title 3 of the act applies to and determines liability for health care for persons who reside in an area served by a public hospital or hospital district. Sec. 10.01(a). We note that, under the Indigent Health Care Act, a hospital district is not a "governmental entity." Sec. 1.02(6). Hence, a facility of a hospital district is not a "public hospital" within the meaning of that act and the provisions of the act that apply to "public hospitals" are not applicable to hospital districts.

Section 11.02 of Title 3 provides that "[a] hospital district shall provide the health care services required under the Texas Constitution and the statute creating the district." Section 12.01(b) states that "[a] hospital district is liable for health care services as provided by the Texas Constitution and the statute creating the district."

The Indigent Health Care Act does not alter, or attempt to alter, the responsibility of a hospital district for all health care required by article IX, section 9, of the Texas Constitution and the Jackson County Hospital District Act. It is not an attempt by statute to make Jackson County liable for inpatient or outpatient health and medical services for indigent residents of that county.

SUMMARY

In a county in which a hospital district encompasses the entire county, the county is not liable for health care services to indigent residents of the county under any of the provisions of the Indigent Health Care and Treatment Act. Instead, the act specifies that, for indigent persons who reside within a hospital district, the hospital district is liable for health care services as provided by the Texas Constitution and the statute creating the hospital district.

Very truly yours,

JIM MATTOX
Attorney General of Texas

JACK HIGHTOWER
First Assistant Attorney General

MARY KELLER
Executive Assistant Attorney General

JUDGE ZOLLIE STEAKLEY
Special Assistant Attorney General

RICK GILPIN
Chairman, Opinion Committee

Prepared by Nancy Sutton
Assistant Attorney General