DIRECTOR OF HEALTH MAY SPECIFY CERTAIN GROUPS OF RECIPIENTS UNDER INITIATIVE 178 TO USE COUNTY FACILITIES -- DIRECTOR OF HEALTH IS CHARGED WITH RESPONSIBILITY OF EXPENDITURE OF FUNDS UNDER...

DIRECTOR OF HEALTH MAY SPECIFY CERTAIN GROUPS OF RECIPIENTS UNDER INITIATIVE 178 TO USE COUNTY FACILITIES --DIRECTOR OF HEALTH IS CHARGED WITH RESPONSIBILITY OF EXPENDITURE OF FUNDS UNDER INITIATIVE 178

Under Initiative 178, section 15, the State Board of Health may establish a policy in counties where there are county hospitals requiring that certain specified groups of recipients, such as medically indigent, general assistance, and aid to dependent children, utilize the in-patient [[inpatient]]and out-patient [[outpatient]]facilities and aid to dependent children, utilize the in-patient and out-patient facilities of those hospitals to the fullest extent, provided that the standards of medical care are equivalent in quality to those generally accepted in the community concerned.

Under Initiative 178, section 15 (h), the State Director of Health is charged with the responsibility for the expenditure of funds and is required to do the accounting and approval of vouchers for the State Auditor.

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                                                               December 29, 1950

Honorable J. A. Kahl, M.D.
Acting State Director of Health
Smith Tower
Seattle 4, Washington                                                                                                              Cite as:  AGO 49-51 No. 410

Dear Sir:

            This is to acknowledge receipt of your letter of November 29, 1950, wherein there were two requests for opinions relating to the administration of Initiative 178, section 15.

            The first question was:

            "Can the State Board of Health establish a policy in counties where there are county hospitals requiring that certain specified groups of recipients, such as medically indigent, general assistance, and  [[Orig. Op. Page 2]] aid to dependent children, utilize the in-patient [[inpatient]]and out-patient [[outpatient]]facilities of these hospitals to the fullest extent, provided that the standards of medical care are equivalent in quality to those generally accepted in the community concerned?"

            The second question can be presented by the quotation of the following paragraph:

            "The question that arises is relative to our turning state funds over to the county or group of counties for the auditing and payment of the vendors' fees by the county auditor and county treasurer on county warrants.  Can we legally under the Initiative turn state funds over to the county and accept their audit as correct?  Furthermore, if this is legal, will we need to audit each of the vendor's services rendered?  Or does 178 require that the State Director of Health be held responsible for the expenditure of these funds and be required to do the accounting, approval of vouchers and forwarded to the state auditor?"

            The conclusions reached may be summarized as follows:

            1. Under Initiative 178, section 15, the State Board of Health may establish a policy in counties where there are county hospitals requiring that certain specified groups of recipients, such as medically indigent, general assistance, and aid to dependent children, utilize the in-patient and out-patient facilities of those hospitals to the fullest extent, provided that the standards of medical care are equivalent in quality to those generally accepted in the community concerned.

            2. Under Initiative 178, section 15 (h), the State Director of Health is charged with the responsibility for the expenditure of funds and is required to do the accounting and approval of vouchers for the State Auditor.

                                                                     ANALYSIS

            Section 7 of Initiative Measure No. 178, amending section 15, chapter 6, Laws of 1949 (9998-330 Rem. Supp. 1949), places the responsibility of providing necessary medical, dental and related services to recipients of public assistance in the State Department of Health.

             [[Orig. Op. Page 3]]

            In carrying out the intent of the initiative under the general grant of authority to provide these services, it is directed that the State Department of Health "shall make full use of all existing public and free facilities and services;" that wherever practical the department "shall delegate the administration of the medical service program to local county or district health departments;" that such departments in turn "shall make full use of public, free and voluntary facilities and services in the administration of this program."  (Section 15 (a) (4), 15 (f), 15 (g)).  It is also provided that the individual shall be allowed "as much freedom as practicable in selecting the type of practitioner best able to serve him and if said practitioner has agreed to conform to the rules and regulations prescribed by the State Board of Health."  (Section 15 (a) (6)).

            Under the initiative the State Board of Health has the authority to formulate policies, establish standards and rules and regulations.  (Section 15 (b)).  However, in no instance, may any rule or regulation be passed that would contravene the expressed intent of the initiative that the medical care provided to recipients under the act be equivalent to accepted standards of medical and dental practice in the community where the eligible individual resides.  When the administration of the medical service program is delegated to local county or district health departments, the personnel, facilities, and services must meet the standards established by the State Board of Health.  Whenever it is practicable that an individual is allowed to select a practitioner of his own choice, said practitioner has to conform to the rules and regulations prescribed by the State Board of Health.  Thus, whether the recipient receives his medical services from a practitioner of his own choosing or whether he receives his medical services from a local county or district health department, he receives services of comparable quality, services equivalent to accepted standards of medical practice in the community wherein the recipient lives.

            Inasmuch as it is mandatory that the State Department of Health make full use of all existing public and free facilities and services, and inasmuch as it is mandatory that the Department of Health, whenever practicable, delegate the administration of the medical service program to local county or district health departments, the State Board of Health in formulating its policies and establishing rules and regulations must keep these provisions in mind.  In order to carry out the intent of the Act, the State Board of Health may establish a policy that certain specific groups of recipients, such as the medically indigent, utilize the in-patient (inpatient]]and out-patient [[outpatient]]facilities of county medically indigent, utilize the in-patient and out-patient facilities of county hospitals to the fullest extent.  It lies within the discretion of the Director of Health whether or not it is practical for a recipient to select his own  [[Orig. Op. Page 4]] practitioner or whether or not the local health facilities are to be used.  Therefore, it is not beyond the power of the State Board of Health to determine that certain groups of recipients use the facilities of the county hospital in order that such facilities be fully utilized.

            A Senior Citizen under section 15, chapter 6, Laws of 1949, (Rem. Supp. 1949, § 9998-30), was entitled to receive medical care from a physician of his own choice.  Section 15 (h), of the Initiative 178, which amends the above provision, provides only that the individual be allowed as much freedom as practicable in selecting a practitioner best able to serve him.  That it was intended that a recipient under the new act only choose his own doctor whenever it is deemed practical by the Department of Health cannot be questioned.  A change in legislation purpose must be presumed from a natural change in the wording of a statute.  In re Phillip's Estate, 193 Wash. 194, 74 P. (2d) 1015; State v. Thornburg, 190 Wash. 549, 69 P. (2d) 815.  Therefore, it is discretionary with the Director that a recipient receive care at the hands of his own private physician or through a local or district health department.  And so long as there is no discrimination in the quality of medical service, the State Board of Health may determine that certain groups of recipients use county facilities.

            Initiative 178, section 15 (h), directs that funds shall be appropriated by the legislature to The Department of Health, which is charged with the responsibility of furnishing medical aid to public assistance recipients.  While it is true the language in section 15 (h) reads that money shall be made available to the counties on a quarterly basis, there is no wording in the statute that there is to be a direct appropriation to the counties of funds in order to effectuate the purpose of the act.  Rather, the language indicates only that the Director shall allocate or apportion portions of the funds appropriated to the use for the county.  The appropriation is only to the Department of Health, and, therefore, the auditing and payment of vendor's fees and accounting would not be on a county warrant but on a state warrant.  This provision is to be contrasted with chapter 216, Laws of 1939, Rem. Rev. Stat. Supp. 10007-115 (a), et seq., where in the administration of public assistance laws there is a direct appropriation to the counties for the execution of the  [[Orig. Op. Page 5]] program and where an elaborate procedure is established for county administration. Because the responsibility of providing necessary medical services is placed in the Department of Health and there is an appropriation of funds only to that Department, the Director of Health, as head of the Department, must be held responsible for the expenditure and accounting of the funds for the medical program.

Very truly yours,

SMITH TROY
Attorney General

BARBARA L. OHNICK
Assistant Attorney General