Page 26


Austin /F THE SIX indigent health care bills now before the legislature pass without any major amputations, it will mark a small-scale revolution in Texas health care. The war between counties and hospitals over poor people’s medical bills will change into a business relationship. Public teaching hospitals will no longer be a dumping ground for patients not wanted by investor-owned facilities. And more of the desperately underserved indigent population will receive needed care from a system with an equitable method of cost distribution. Never before has a comprehensive attempt been made to allocate the financial burden of medical costs incurred by the poor among the hospitals, be they county, district, non-profit, public, or investor-owned. Until now, the counties alone have been burdened with the statutory requirement that they carry the medical expenses of their residents. Of the six bills, four are structural and two substantive. The first group embodies different components of a system to reapportion health costs. They S.B. 452, the county obligation bill; 789, the hospital obligation bill; Sen. hospital transfer bill; and Oliver’s H.B. 1963, the hospital reporting bill. The principles underlying these interrelated documents are deceptively simple. They grew out of recommendations of the state’s Task Force on Indigent Health Care, created by Governor Mark White in 1983 and chaired by Helen Farabee, whose husband is state Sen. friends in such high places, the bill stands a good change of passage. If the county obligation bill passes, counties without hospitals will pay up to 10 percent of their general revenue fund toward the care of their indigent Yolande Landry is a freelance writer and translator living in Austin. residents, at which point the obligation will cease and the state will pick up 80 percent of any additional costs. In any given year, a county is not liable for the hospital care received by an eligible recipient beyond 30 days of hospitalization or $30,000, whichever occurs first. This provision is essential, as a few catastrophic cases could swallow a county’s entire budget. No hospital will be exempted from paying a minimum share of indigent care. Denial of such responsibility by privately-owned hospitals is an easy route to take when county responsibility is all-encompassing and public hospitals are sitting ducks for patient transfers, as happens in most cities. A timehonored hospital strategy for covering indigent care shifting costs to paying patients is clearly on the decline since If the legislation passes, no hospital will be exempt from paying a minimum share of indigent care. health-care costs have come under the intense scrutiny of insurance companies, consumers, and private hospital shareholders. The hospital obligation bill requires that every facility operating in Texas pay for a minimum of indigent health care. The contribution may be to a fund rather than in the form of service to actual patients, but it must equal three percent of the facility’s operating expenses, minus Medicare, Medicaid, and with credit given for property taxes paid. Hospitals that have performed uncompensated care under the Hill-Burton Act also receive credit. \(Hill-Burton is a federal loan program for hospitals, By law, no Texas hospital may turn down or exact advance payment from patients in need of emergency treatment. In practice, those who cannot pay for but need hospitalization after emergency treatment are routinely moved to the nearest public hospital, often before they are stabilized. A disproportionate burden results, that in time could deplete the resources and reduce the standards in these worthiest of hospitals. They could become indigent hospitals the first large, visible step toward a twotiered health care system that would segregate insured and uninsured, rich and poor. Many administrators of hospitals that pay property taxes feel the transfers are justified, reasoning that their tax money is given to public hospitals so that they will look after the poor and thereby absolve other providers from taking part. The hospital transfer bill prohibits the transfer of patients before their condition is stable and establishes criteria for transfer, including the patient’s consent or that of his or her personal representative and reasonable notice. The hospital reporting bill will enable the state to monitor the amount, type, cost and financing of uncompensated care. Many hospitals report bad debts the difference between their charges and reimbursements paid by some insurers, including Medicaid and Medicare, as uncompensated care \(or charity or free The Texas Hospital Association perpetuates this useful ambiguity, invoking it to argue that its hospital members are doing their fair share for the poor. Statistics prove otherwise; in Texas, seven public teaching hospitals provide 85 percent of the charity care. Many hospitals that are reluctant to give care to the uninsured poor, as well as many physicians, are, nevertheless, often enthusiastic collectors of Medicaid and Medicare payments. They have no problem with this kind of government intervention. In addition to the county and hospital bills, the indigent health care legislative package includes two other bills, designed to create programs to meet the two uppermost health priorities among the poor. These bills are the Maternal and Infant Health Improvement Act bill, and the Texas Department of Health’s Health Services Improvement care bill. Together, they open doors to particularly needy categories of the poor: pregnant women and the newborn and those requiring primary care. Who receives indigent health care? The states do not adhere to federal eligibility standards. They set their own standards of need, primarily to establish the Changing Health-Care Equations By Yolande Landry 6 APRIL 5, 1985