Should the Texas Indigent Health Care and Treatment Act be Amended?

By Ronald L. Scott

In 1997, Texas Speaker James E. "Pete" Laney issued an interim charge to the House Committees on Public Health and County Affairs to review the Indigent Health Care and Treatment Act of 1985 (Act) for possible amendment. A legislative working group formed under the auspices of the Subcommittee on County Indigent Health Care (Working Group) issued a draft interim report on October 8, 1998, available at

The Act requires that counties not fully served by a hospital district or public hospital must operate a County Indigent Health Care Program (CIHCP) to provide health care to eligible indigent residents. Of the 254 counties in Texas, 136 are currently required to administer such a program. CIHCPs provided care for approximately 17,000 patients in fiscal year 1997. The Act provides that CIHCPs are payors of last resort, i.e., they only provide assistance when other adequate public or private sources of payment (such as Medicaid) are not available. The Act further establishes stringent eligibility standards; and only requires counties to provide coverage to clients with incomes at or below 11% of the federal poverty level guidelines, although counties are free to adopt more generous standards. Under the Act, counties are required to provide certain "mandatory" services to eligible residents, and counties receive partial state reimbursement for the cost of providing such services. Mandated services include medically necessary inpatient and outpatient hospital care, physician services, skilled nursing facility care and three prescription drugs a month. A county must first spend 10% of its general revenue tax levy on mandatory care before receiving state assistance. Only eleven counties qualified to receive state assistance in 1997, and $4.8 million of the state-appropriated $12 million for the county assistance fund for the 1996-97 biennium went unclaimed.

The Working Group recommended several policy options, including adding an "optional" list of services that counties could choose to provide that would be eligible for state reimbursement. The Working Group also recommended that the Act be modified to reflect the shift of focus of health care delivery from acute care to primary and preventive care. Currently, because of a variety of factors, counties lack an incentive to provide primary and preventive health care services under the Act. This results in the deterioration of patientsí medical conditions until more expensive acute and emergency care is needed. By providing primary and preventive services, the Working Group determined Texas would be able to prevent or limit the effects of disease and disability among indigent Texans, offer more cost-effective care, and save money on acute care among patients whose conditions are controlled by preventive care. To that end, the Working Group recommended adding to the list of "mandatory" services in the Act specific primary and preventive health care services, and providing "optional services" which would count toward eligibility for state assistance, if deemed cost effective. This emphasis on primary and preventive health care services presents a good opportunity to extend cost-effective health care to the indigent population.