Understanding the Indigent Health Care and Treatment Act in Texas

The Indigent Health Care and Treatment Act (part of the Texas Health and Safety Code, Chapter 61), enacted by the Sixty-ninth Texas Legislature in 1985, mandates that counties subsidize the cost of basic health care services for their indigent residents—low-income individuals who lack health insurance and do not qualify for other forms of public assistance. The act enables these residents to receive a defined set of medical services through local hospital districts or, where no such infrastructure exists, through newly-established County Indigent Health Care Programs (CIHCPs). It also outlines eligibility criteria, specifies how much counties must budget for these programs, and enables counties to request reimbursement from the state once they exceed the budget. The act's primary goal is to ensure that indigent residents across Texas can obtain basic medical care through a more structured system in which counties are held accountable to the state for meeting minimum service and funding requirements.

Before the passage of the legislation, Texas delegated the administration of indigent health care to counties through a century-old statute that permitted them to "provide for the support of paupers, residents of their county, who are unable to support themselves." However, the vague language of this provision meant that, in practice, the delivery of care to indigent residents was left up to county discretion. While some urban counties had well-developed public health systems funded by stable tax bases, many rural counties lacked the infrastructure and resources to deliver consistent care to their indigent residents. County programs varied in their eligibility criteria and available funding, meaning that the county where indigent residents lived often determined their access to care.

One of the most vocal advocates for reform was Valley Interfaith, a grassroots coalition formed in 1982 by clergy and community leaders in the historically underserved communities of the Rio Grande Valley. Valley Interfaith transformed a loose network of regional leaders into a coordinated political coalition and, along with its allies, helped elevate indigent health care to the top of Texas legislative priorities. In response to growing concerns about county health care disparities, Governor Mark White and Lieutenant Governor Bill Hobby convened the Task Force on Indigent Health Care in 1983 and appointed Helen Farabee of Wichita Falls as chair. The task force was charged with evaluating the state of indigent care in Texas and developing legislative recommendations to address disparities in access, funding, and service availability.

Acting on the task force's recommendations, Governor White called a special session of the Sixty-ninth Texas Legislature in 1985. The resulting legislation designated counties’ public hospital districts and newly-created County Indigent Health Care Programs (CIHCPs) as payors of “last resort,” responsible for covering care for indigent residents when other sources—such as Medicaid, private insurance, or other public assistance—are unavailable or exhausted. In counties with public hospital districts, the district is responsible for subsidizing care it delivers to indigent patients; in counties without such districts, CIHCPs reimburse local providers for the cost of care rendered to eligible residents. To qualify, residents must meet income thresholds established by the Texas Department of State Health Services, set at or below 21 percent of the federal poverty level. Eligible residents are entitled to a codified list of basic health services, including immunizations, medical screenings, annual physical exams, inpatient and outpatient hospital care, rural health clinics, laboratory and x-ray services, family planning, limited prescription drug coverage, and skilled nursing facility care. Each fiscal year, counties must provide up to $30,000 of services per eligible resident or thirty days of inpatient care, whichever comes first.

The act also established a funding mechanism that divided fiscal responsibility for indigent health care between counties and the state. Each year, counties are required to spend a minimum percentage of their General Revenue Tax Levy (GRTL) on indigent care—originally set at 10 percent. Amendments passed by the Seventy-sixth legislature in 1999 lowered this threshold to 8 percent. Once a county surpasses this threshold, it becomes eligible to seek reimbursement for additional expenses from the state’s Indigent Health Care Assistance Fund, covering 90 percent of costs beyond the local requirement. A further change came during the Eighty-sixth Texas Legislature, when the repeal of Rider 120 removed the cap on the amount counties could initially request from the fund, allowing for more flexible and responsive access to state support.

Over time, the scope of services available under CIHCPs has also evolved. The 1999 amendment to the Indigent Health Care and Treatment Act enabled counties to offer a range of optional services beyond those initially listed. These include care given by advanced practice providers and licensed mental health professionals, dental and vision services, diabetic care and supplies, durable medical equipment, emergency medical services, and physical and occupational therapy. A key 2008 revision expanded this flexibility, allowing counties to count "any other appropriate health care service…determined to be cost-effective" toward their 8 percent GRTL threshold and state reimbursement eligibility. This incentivized counties to expand the number of services available to indigent residents and offer quality care above the minimum standard outlined by the original act.

Despite efforts to standardize and strengthen indigent care across Texas, the question of whether undocumented immigrants were eligible for assistance under the Indigent Health Care and Treatment Act became a highly disputed legal and political question. The statute includes a framework for covering lawfully admitted noncitizens but does not explicitly address the eligibility of undocumented residents. This ambiguity became more urgent following the 2001 opinion by Texas Attorney General John Cornyn, who argued that federal welfare reform laws passed in 1996 prohibited undocumented immigrants from accessing publicly funded non-emergency medical services unless authorized by state legislation. However, Harris County Attorney Michael Stafford issued a counter-opinion, asserting that a 1999 Texas constitutional amendment reaffirmed the responsibility of counties to provide care to "needy inhabitants," regardless of immigration status. The legal uncertainty was resolved in 2003 by the passage of House Bill 2292, which permitted CIHCPs and hospital districts to offer services to undocumented immigrants. While hospitals are required to ask patients about their immigration status under Governor Greg Abbott’s Executive Order GA-46, signed in 2024, patients can decline to answer. Their answers cannot impact the care they receive, and hospitals are prohibited from sharing personally identifiable information with the state without patient consent.

Another debated feature of the law is its provision allowing counties and public hospitals to make CIHCP benefits contingent on participation in employment services programs. A series of amendments passed in the 2010s permitted local entities to require applicants to “register for work with the Texas Workforce Commission.” While not universally adopted, such provisions raised concerns about whether access to basic medical care should be conditioned on job-seeking behavior or workforce participation, particularly for residents facing obstacles such as lack of transportation or caregiving responsibilities that make employment difficult to obtain or sustain. Proponents argue that these measures reduce long-term dependency on public programs, but critics contend they risk excluding the most vulnerable individuals from needed care, especially in a system designed to serve as a last-resort safety net.

Nearly four decades after its passage, the Indigent Health Care and Treatment Act remains a significant part of Texas's health care safety net. As of 2024, roughly 700,000 Texans fell into the Medicaid coverage gap—nearly half of the 1.6 million uninsured adults living in the United States who are excluded from Medicaid eligibility in states that declined the option under the federal Affordable Care Act to broaden Medicaid coverage based on income and the federal poverty line to low-income adults. Without broader coverage options, this population often turns to CIHCPs for basic medical services. Texas currently operates 137 County Indigent Health Care Programs alongside a network of public hospital districts that deliver essential health care to low-income residents without access to other forms of assistance.