         Honorable Dudley Harrison            Opinion NO.   (JR-858)
         Chairman
         Agriculture and Livestock            Re:   Responsibility of a
            Committee                         hospital district to pro-
         Texas House of Representatives       vide medical     care for
         P. 0. Box 2910                       the needy   inhabitants of
         Austin, Texas 78769                  the district   and related
                                              questions (RQ-1199)

         Dear Representative   Harrison:

              You have asked several questions      regarding  the
         responsibility of a hospital district to provide medical
         care for the needy inhabitants of the district.  You pose
         three questions  regarding the Presidio  County Hospital
     -
         District, which we restate as follows:

                   1. What are the definitions of 'needy'
                and 'inhabitant of the district' as those
                terms are used in the constitutional  and
                statutory provisions    applicable to the
                Presidio County Hospital District?

                   2. Who sets the standards to        determine
                whether someone is 'needy'?

                   3. May the Presidio County       Hospital
                District fund capital expenditures     for a
                hospital located outside the district?

              The Presidio County Hospital District is a countywide
         hospital district created under authority of article IX,
         section 9, of the Texas Constitution.     Acts 1965, 59th
         Leg., ch. 643, at 1455. See V.T.C.S. art. 4494q. 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 . . . with
                power to issue bonds for the purchase,
                construction, acquisition, repair or renova-
                tion of buildings    and improvements    and
                equipping same, for hospital purposes . . .



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       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. . . .

     The statute creating    the Presidio   County   Hospital
District provides in part:

          Sec. 3.    The District authorized to be
       created by this Act is charged with the
       responsibility of establishing a hospital or
       a hospital system within its boundaries    to
       furnish hospital   and medical care to the
       residents    of   the   District. . . . This
       District    shall   provide   all   necessary
       hospital and medical    care for the needy
       inhabitants of the District.

Acts 1965, 59th Leg., ch. 643, at 1455.

     Other relevant constitutional  and statutory provi-
sions are found in article IX, section 9A, of the Texas
Constitution and the Indigent Health Care and Treatment
Act (article 4438f, V.T.C.S.).

     The Indigent Health Care and Treatment   Act (the act)
provides for the medical care and treatment of indigents.
Definitions of residency     and procedures  for resolving
residency disputes are governed by sections   1.03 and 1.04
of the act.    Section    1.05(b) of the act prohibits    a
hospital  district   from    denying or reducing    medical
assistance to an eligible     resident due to the person's
inability or refusal to contribute to the cost of the
assistance rendered.

     According  to the act, a hospital       district   must
provide the health care services required under the Texas
Constitution and the statute creating the district, and a
hospital district. is liable for such services as may be
required by the constitution   and its enabling    statute.
Sets. 11.01 and 12.01(b). A hospital district may arrange
to provide health care services through another       health
care provider.  Sec. 11.03(a). A hospital district       may
also affiliate  with other public hospitals or hospital
districts   or with a governmental    entity    to provide



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regional  administration  and     delivery   of   health   care
services.  Sec. 11.03(b).

     The Texas Constitution was amended by adding article
IX, section 9A, in 1985 to permit the legislature      to
determine the health care services a hospital    district
must provide, the requirements a resident of the district
must satisfy to qualify      for service, and any other
provisions necessary to regulate health care to hospital
residents.   However,  no legislation has been adopted
pursuant to this constitutional amendment.

    Your first question concerns the meaning     of the terms
"needy" and "inhabitant of the district" as those terms
are used in the pertinent     constitutional and statutory
provisions.    This office addressed     this    question   in
Attorney  General Opinion H-703      (1975).    That opinion
equated a "needy inhabitant" with an "indigent resident."
Indigency, the opinion noted, cannot be translated        into
precise income levels without resolving factual matters.
Such a determination is not appropriate       to the opinion
process.   Since the enactment of the Indigent Health Care
Act, hospital districts have been provided with necessary
guidelines to determine    residency within the hospital
district.   V.T.C.S. art. 4438f, §§1.03, 1.04.

     The answer to your second question was also addressed
in Attorney  General Opinion H-703.    The opinion  stated
that the initial determination of indigency is to be made
by the hospital district.    Section 14 of the district's
enabling statute provides:

          Sec. 14. A person who resides within the
       District is entitled to receive necessary
       medical and hospital care whether he has the
       ability to pay for the care or not.       The
       Board shall by rule or    regulation adopt a
       procedure for determining   the ability of a
       patient to pay for his medical and hospital
       care and for determining the amount each
       patient shall be required to pay.

Acts 1965, 59th Leg., ch. 643, at 1460.         Additional
guidance for   the district  in determining a resident's
indigent status is offered by       section  1.06 of the
Indigent Health Care Act.    While this provision is not
applicable to a hospital district, it may be useful to the
district in establishing its own eligibility standards.

     Finally, you   inquire about the        authority   of the
Presidio  County    Hospital District        to make     capital



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expenditures  for a hospital     located  outside    of the
district's boundaries.   As we understand it, no hospital
facilities have been established within     the boundaries      -
of the Presidio Hospital     District  since its creation
,,pr;;mately  twenty years ago. We note that the creation
          district   triggered   the   constitutional   and
statutory prohibition against a municipality or political
subdivision within the district   levying a tax or issuing
bonds for the purpose of providing    medical care services
within  the district's   boundaries. See Tex. Const. art.
IX, 59; Acts 1965, 59th Leg., ch. 643, 53, at 1455.

     Presidio County Hospital    District has an absolute
obligation to provide medical services, but the district
has failed to      establish  the facilities    within  its
boundaries to accomplish this duty. Rather,    residents of
Presidio County travel to a hospital that is operated by
another hospital district in an adjacent county to receive
medical treatment.   The district is liable for the medical
expenses of its indigents. Attorney General Opinion Nos.
JM-540 (1986); JM-487, JM-257 (1984); H-703   (1975); M-171
(1967).

     The Presidio County Hospital District     is now being     -.
asked by the other hospital district to assist in funding
construction and repairs of its facility. Standing alone,
the Presidio County Hospital District's    enabling legisla-
tion appears to limit the use of taxes collected       by the
district to the purposes enumerated in sections 3 and 9 of
the enabling    statute.    Providing  funding for capital
improvements for a hospital located outside the district
would not appear to come within     the prescribed uses   for
the district's   taxes. However,    the district's   enabling
legislation must be read and harmonized,        if possible,
with the later adoption of the Indigent Health Care and
Treatment Act. In accordance with section 11.03 of the
Indigent Health Care and Treatment        Act,    a hospital
district "may affiliate with other public hospitals        or
hospital   districts   or with a governmental      entity to
provide regional    administration  and delivery   of health
care services."    Identical authorization for affiliation
by counties is provided by section 3.02(b) of the act.

     TO "affiliate" means to associate     as a member.
Webster's Ninth New Collecriate Dictionary    61,   (1985).
Thus, the legislature, in enacting a comprehensive scheme
for the delivery of medical care to the state's indigent
residents,   recognized  the   disparities in     available
facilities throughout the state. To assist the affected
governmental   entities which are required     to provide



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        indigent health care, the legislature   authorized regional
        service among the affected entities.

              In our opinion, this authority to affiliate contem-
        plates a broad range of possible agreements between    the
        entities involved. We cannot say that an affiliation that
        results in one hospital district funding capital expendi-
        tures for a second hospital district in exchange   for the
        provision of health care services is beyond the scope of
        arrangements intended by the legislature.  In our opinion,
        therefore, section 11.03 of the Indigent Health   Care and
        Treatment Act authorizes   the Presidio County Hospital
        District to affiliate with a neighboring hospital district
        in a manner that allows Presidio District to fund con-
        struction and repairs for the second district's     agree-
        ment to provide medical  care to the needy inhabitants of
        Presidio County.

                               SUMMARY

                    The terms "needy" and "inhabitant" found
               in Texas Constitution article IX, section  9,
               and in the enabling legislation       for the
    -          Presidio County Hospital District are eguiva-
               lent to the terms "indigent" and "resident."

                    Absent legislative  action pursuant   to
               article IX, section 9A, of the Texas Consti-
               tution establishing eligibility requirements,
               the Presidio County Hospital   District must
               determine  whether a    county resident     is
               indigent.

                    Presidio County Hospital   District may
               affiliate with another hospital district   to
               provide medical care to the needy inhabitants
               of Presidio County. The agreement     between
               the affiliating   entities may provide    for
               Presidio County Hospital   District to fund
               capital expenditures for the other hospital
               district.

                                           Very truly yours,



                                           JIM     MATTOX
                                           Attorney General of Texas

        MARY KELLER
        First Assistant Attorney General


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LOU MCCREARY
Executive Assistant Attorney General

JUDGE ZOLLIE STEAKLEY
Special Assistant Attorney General

RICK GIl.,PIN
Chairman, Opinion Committee

Prepared by Karen C. Gladney
Assistant Attorney General




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