                                The Attorney        General of Texas

JIM MAlTOX                                     October 6, 1986
Attorney General


Supreme Court Building                                                         JM-552
                               Honorable Carl M. Anderson        Opinion No.
P. 0. Box 12548
Austin, TX. 78711. 25u)
                               Nolan County Attorney
5121475.2501                   P. 0. Box 1201                    Ret Whether the city of Sweetwater
T~I~X 9iofa74.l387             Sweetwater, Texas 79556           is required to share the expense of
Telecopier   512i47502Sa                                         health care for indigent residents
                                                                 of Nolan~County
714 Jackson, Suite 700
Dallas, TX. 752024506          Dear Mr. Anderson:
214/742-a944
                                    You inquire whether, under the Indigent Health Care and Treatment
                               Act, the city of Sweetwater is required to share the expense of health
4824 Alberta Ave.. Suite la0
El Paso, TX. 79905.2793        care services for indigents who are residents of Nolan County. We
9151533.3484                   conclude that such expense is a joint responsibility of the county and
                               the city. We are asked the following specific questions:
1001 Texas. Suite 700
                                           1. Within the provisions of article 4438f.
Houston. TX. 77002.3111
                                        V.T.C.S., is an eligible resident,of Nolan County,
713x223-5886
                                        Texas a person who does not reside uithin the area
                                        that a Iublic hospital or hospital district has a
808 Broadway. Suite 312                 legal obligation to serve?
Lubbock. TX. 79401-3479
8081747.5238
                                           2. If the answer to the foregoing is in the
                                        negative then, under the provisions of section
4309 N. Tenth, Suite B                  12.03 of article 4438f, Is the city of Sweetwater,
McAllen, TX. 78501-1685                 Texas, a governmental entity that created or
5121682.4547
                                        authorized the creation of a 'hospital authority'
                                        as that term is used in section 12.03?
200 Main Plaza, Suite 400
San Antonio, TX. 782052797          The only hospital in Nolan County is operated by a joint county-
512/2254191                    city 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
An Equal Opportunity/
                               hospital as a joint agent of the county and the city. V.T.C.S. art.
Affirmative Action Employer    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:CIshare 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.tseligible 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,esufficient 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 thenho: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 assis-
         tance 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,lonof the state, but does not include a
hospital district.    Art. 4438f. 01.02(6)(10). The hospital in
quest-ionhas 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,zIndigent 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 approvszthe 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:pitalauthority, 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 county-
city 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 autlloritywithin 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 Indi-
gent 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:Lpof 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. 'Cheact is the legislature's implementation



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




of reconnnendationsmade 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,ethe inequities in that system.   See Task
Force on Indigent Eealth Care. Final Report, December 1984, at 21.
The provisions of the act ,:hatrelate 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 #:reateda 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 county-
         city 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
