CHAPTER III PUBLIC INDIGENT MEDICAL CARE RESOURCES IN TEXAS Traditionally, in Texas, providing indigent medical care has been the responsibility of local government. It is the last major welfare responsibility left to local government, since all other welfare functions have during the 1930's and 40's become a joint state-federal responsibility. Responsibility, however, is divided among counties, county-wide hospital districts, cities and the State of Texas. COUNTY RESPONSIBILITY There is no general constitutional provision which makes Texas counties responsible for indigent medical care. As a carryover from the Texas Constitution of 1869, the present Texas Constitution written in 1876, in Article 16, Section 8, authorizes the establishment of county poor houses and farms but does not define the extent of county responsibility. Article 2351, Section II, VACS, makes the county responsible for paupers. It states, "Each commissioners court shall provide for the support of pauper... residents of their county, who are unable to support themselves." It should be noted that while no mention is made of medical care, court decisions have held the term "support" to mean: "All that is necessary to bodily health and comfort, and especially does it include proper care, attention and treatment during sickness." COUNTY-WIDE HOSPITAL DISTRICTS (in counties of over 190,000 population, and Galveston County) when formed are responsible for county-wide indigent medical care under Article 9, Section 4 of the Texas Constitution. This provision states, "... such hospital district shall assume full responsibility for providing medical and hospital care for needy inhabitants of the county, and thereafter such county and cities therein shall not levy any other tax for hospital purposes." At present in Texas only Dallas, Bexar, El Paso and Potter counties are operating hospitals under this legal provision. CITY RESPONSIBILITY There are no constitutional or statutory prohibitions against home rule cities providing indigent medical care; therefore, they provide such care under the general authorization which permits them to undertake any program not specifically prohibited by law. However, several statutes permit cities and counties to participate jointly in hospital operations. STATE RESPONSIBILITY The state government first started to provide indigent medical care in many of its state hospitals and institutions. Later, in addition, free care was given to indigents admitted to John Sealy and M. D. Anderson hospitals. Presently at these hospitals a nominal per diem fee is charged the county of residence if a patient cannot afford to pay. Such state medical services are specialized and do not duplicate existing county facilities and programs but tend to supplement local medical care services. The state also participates with the Federal Government in the public assistance program with 55% of the 319,000 recipients having an allowance for medical care budgeted into their assistance grants each month. RESOURCES FOR INDIGENT MEDICAL CARE Each level of Texas government finances local indigent medical care to some degree. No one level of government has assumed full responsibility nor has been required by law or public policy to have the sole responsibility for such care. For this reason, the total amount of such care being given has been left to speculation. The general impression among those concerned has been that local indigent medical care services exist in a few metropolitan areas, while the majority of counties are without such services. Thus, the research staff felt that confirmation or rejection of this hypothesis was important in fitting together the pieces of the total medical care picture. To do this required the analysis of indigent medical care resources in all 254 counties. Data were obtained from all 254 countiesthe first complete county level analysis on this subject ever made. The results shown in the following pages reveal a much greater outlay of tax funds for this function than had been anticipated. TAX SUPPORTED MEDICAL CARE The research staff has identified tax supported medical care ex penditures in Texas amounting to $94.6 million annually.' Functionally it breaks down as follows: Indigent Medical Care Provided by Texas Local Government $21,200,000 Medical Items Paid for by Public Assistance Funds...... 29,100,000 5,300,000 State Hospital and Institution Care (Less Collections) 39,000,000 It should be noted that some of these programs are available to persons other than P. A. recipients; therefore, in the pages that follow costs will be related to such recipients insofar as possible. It should also be emphasized that the preceding figures do not include indigent medical care from non-tax-supported sources. Where such data are available, they are included. MEDICAL CARE TAX SUPPORTED LOCALLY: A complete tabulation of Texas local government tax-supported medical care disclosed much larger expenditures than had been anticipated-$21 million annually. The term "tax-supported" is used rather than "indigent" since not all persons receiving such care are indigent. Tax-supported medical expenditures by type of governmental jurisdiction are as follows: County Government Hospital Districts Total....... $ 4,740,000 annually 7,622,000 8,895,000 $21,257,000 annually At present 223 Texas counties provide $4.7 million in tax-supported medical care services annually. As far as can be ascertained, 31 counties provide no indigent medical care out of tax funds. The total population of these 31 counties is 256,173; therefore, 97.3% of the Texas population live in counties where some level of tax-supported medical care services is available from local government. Tax-supported medical care programs costing more than $100,000 annually per county are provided by Cameron, Crockett, Harris, Hidalgo, McLennan, Nueces, Potter, Tarrant, Wharton and Wichita. 'This figure does not include: V. A. hospital services for Texans; military medical services in Texas; public health expenditures; Hill-Burton Hospital expenditures in Texas (as of Jan. 1, 1959, total Hill-Burton costs have been $213,000,000); public school health services; medical care for persons in state prison system or institutions under the administration of the Texas Youth Council; and cost of health insurance for federal, state and local public employees in Texas. Eleven Texas cities provide $7.6 million in tax-supported medical care services annually. This supplements the medical care provided by the counties in which they are located. Often such care is furnished to non-residents of these counties. Their tax-supported expenditures for medical care are nearly double that of the 223 counties. Of the $7.6 million spent annually by these 11 cities, 98% is spent by five: Austin, Corpus Christi, Galveston, Houston and Wichita Falls. Four county-wide hospital districts supplement the above indigent medical care services. These four hospital districts are located in Bexar, Dallas, El Paso and Potter Counties. The hospital district in Potter County is new and has not operated a full fiscal year as yet, but data on the other three hospital districts disclose they spend $8.9 million each year for tax-supported medical care. Annual per capita expenditures vary widely throughout the state for indigent medical care from a few cents per person in one county to a high of $23.39 per capita each year in Crockett County. Counties in which $5.00 or more per capita per year is spent on tax-supported medical care are: Coke, Crockett, Dallas, Harris, Sterling, Throckmorton and Travis. In the 16 urban counties-those with 100,000 or more people-live 58% of the state's population. These 16 counties and the cities therein account for 94% of all tax-supported medical care at the local level. There are several reasons for this: Availability of facilities and their quality affect the demand for medical care services, indigent as well as non-indigent. ✩ These 16 counties also contain the "regional" medical centers of the state. Counties like Harris, Dallas and Travis frequently admit non-pay or part-pay patients from outside their county. Thus they serve, to some extent, a population greater than that within the county iself. In the mose rural areas of the state more indigent medical care is provided by non-public hospitals, clinics and private practitioners because of the absence of tax-supported services. Such care would therefore not be reflected in the $21.2 million tabulation of tax-supported medical care given annually. HOW MUCH OF THIS LOCAL MEDICAL CARE GOES TO P. A. RECIPIENTS? This is a very difficult question to answer. With the cooperation of one county-wide tax-supported hospital it was possible to analyze the use of the hospital by P. A. recipients over an 11-month period. The county was Travis, with an annual average of 5,203 public assistance recipients. USE OF LOCAL INDIGENT MEDICAL CARE FACILITIES BY If these data were applied against the recipient load in those metropolitan areas where similar facilities are available for indigent care, the breakdown would be as follows: PROJECTED USE OF INDIGENT MEDICAL CARE FACILITIES These metropolitan counties have 23% of the state's public assistance caseload and spend 88% of the funds expended by local government for indigent medical care. To provide a dollar yardstick for measuring the value of the medical services given to public assistance recipients an intensive analysis was made of a sample of P. A. cases treated at on county-wide facility (Travis) for indigent medical care. If these data were projected across the same metropolitan areas the result would be as follows: |