Dark v. Prince George's County

Wilner, J. delivered the opinion of the Court. On November 20, 1978, appellant was admitted to the psychiatric ward of Prince George’s General Hospital (appellee) as a voluntary emergency admission. The precise nature of her illness is not reflected in the record; but, aside from the fact that she was an emergency psychiatric admission, there is nothing to suggest that she was legally incompetent. Nor does she claim to have been incompetent, illiterate, or blind.

Appellant remained in the hospital until her discharge on December 15, 1978. Five days later, on December 20, the hospital sent her an itemized bill in the amount of $3,792.63 for the services that it had rendered. Appellant never complained about the quality of the care that she received, or that the charges were unreasonable; indeed, she made no protest at all about the bill. But neither did she pay it or any part of it, or offer to pay it or any part of it.

Eventually, on May 29, 1980, the hospital filed suit against appellant in the Circuit Court for Prince George’s County to collect the overdue debt. Accompanying the Declaration was a motion for summary judgment supported by an affidavit of the manager of delinquent accounts. Attached as a single exhibit to the affidavit, and attested as being true and correct, were: (1) a copy of the itemized bill sent to appellant on December 20, and (2) an "admitting record” purportedly signed by appellant upon her admission. The "admitting record” stated that appellant was employed as a typist for Rapp, Inc. in Washington, D. C., that she had been so employed for two years, and that she earned $200 biweekly.

The form further indicated that appellant was then twenty years old, that she lived with her mother, who was employed as a "clerk supervisor” for the ¹⁸⁵ Library of Congress, and that the family received no income from social services. 1 Just above appellant’s signature was a statement certifying the truth of the information on the form and guaranteeing payment of all charges incurred. Appellant has never denied signing or understanding that form. Appellant’s multiple response to the hospital’s action came on July 22, 1980. The thrust of her defense was that (contrary to the statements on the admission form, which she omitted to mention) she was indigent at the time of her admission and that, by reason of the Federal Hospital Survey and Construction Act of 1946 (hereafter the "Hill-Burton Act”), she was entitled to free or below-cost care.

In furtherance of that defense, appellant: (1) Wrote to the hospital by letter dated July 23, 1980, requesting "uncompensated services” pursuant to CFR 124.502 (one of the many Federal regulations adopted in 1979 to implement the Hill-Burton Act); 2 (2) Purportedly filed a complaint on July 21, 1980, with the Federal Department of Health and Human Services (HHS) claiming that the hospital violated the "uncompensated service requirements” of the Act and its implementing regulations and asking that the Department "find her eligible for free or below-cost care, and.. . order the hospital to provide below-cost care to her.” This letter, addressed to a Dr. H. McDonald Rimple, Assistant Surgeon General, Regional Health Administrator, Department of Health and Human Services, Region III, Philadelphia, was never received by Dr. Rimple (or apparently anyone else at HHS). (3) Answered the Declaration and the motion for ¹⁸⁶ summary judgment and moved for a stay of the judicial proceeding pending the administrative determination by the Department of Health and Human Services. Appellant’s argument, as laid out in her initial pleadings, was that (1) the hospital had received Federal construction loans or grants under the Hill-Burton Act; (2) it was therefore required by that Act to provide free or below-cost care to low income patients and to establish procedures for identifying individuals eligible for such care; (3) the hospital had established such procedures (a copy of which was appended as an exhibit to the motion for stay) but had failed to follow them in processing appellant’s account; and (4) appellant believed herself to be eligible for such care. In effect, appellant was seeking to interpose an alleged violation of the hospital’s obligation under the Hill-Burton Act to provide free or below-cost care to indigent patients as a defense to its collection action against her.

The hospital’s motion for summary judgment and appellant’s motion for stay were heard on October 2, 1980. The court denied the motion for stay on the ground that it had no authority to grant it, and it granted the motion for summary judgment on the theory that if the Federal agency found the hospital to be in violation of the Hill-Burton Act, it would take some action to annul the judgment. The ultimate questions raised by appellant are not easy ones to answer. Reasonable arguments can be made both to support and to deny the right of an allegedly indigent patient to translate a hospital’s obligations under the Hill-Burton Act into an individual right of free or below-cost care, and then to raise that right in defense to a collection action.

It is a matter of first impression in Maryland; we have no precedential authority. Of the few State courts that have so far considered the question, all but one have rejected the position espoused by appellant. See Yale-New Haven Hospital v. Matthews, 343 A.2d 661 (Conn. App. Div. 1974), cert. denied, 423 U.S. 1024 (1975); Falmouth Hospital v. Lopes, 382 N.E.2d 1042 (Mass.

Sup. 1978); Valley Credit Service, Inc. v. Mair, 582 P.2d 47 (Ore. App. 1978); John T. Mather Memorial Hospital, Inc. v. Marco, 413 N.Y.S.2d 88 ¹⁸⁷ (Dist. Ct. 1979); but compare Hospital Center at Orange v. Cook, 426 A.2d 526 (N.J. Super. 1981) permitting such a defense to be raised. We need not answer those ultimate questions in this case.

For the reasons shortly to be explained, we conclude that even if the Federal Act and the regulations promulgated under it permit such a defense, as determined by the New Jersey court, supra, this appellant has no right to raise it in this case. Even to address that limited issue, however, it is necessary for us to consider some of the complex history of Hill-Burton and the regulations adopted under it. For a more detailed chronology, see Note, The Hill-Burton Act, 1946-1980: Asynchrony In The Delivery Of Health Care To The Poor, 39 Md. L. Rev. 316 (1979); also Rose, Federal Regulation Of Services To The Poor Under The Hill-Burton Act: Realities And Pitfalls, 70 Northwestern U.L. Rev. 168 (1975). Hill-Burton was first enacted in 1946 as P.L. 79-725. 3 Its declared purpose (§ 601) was to assist the States in constructing public and other nonprofit hospitals in order to "afford the necessary physical facilities for furnishing adequate hospital, clinic, and similar services to all their people.. . .” (Emphasis supplied.) It proposed to achieve that end by allocating substantial Federal funds to the States, pursuant to State plans approved by the Surgeon General, to be used as grants in aid of approved hospital construction projects.

Congress sought to assure that the Federal largesse would be of service to all the people in three principal ways: (1) by requiring, through regulations to be promulgated by the Surgeon General, that the State plans contain certain assurances in that regard; (2) by requiring the individual project applications to assure compliance with those State plan provisions; and (3) by authorizing the Surgeon General to terminate further grants to a State upon a finding of sub ¹⁸⁸ stantial noncompliance with the obligations in the State plan. The key provision dealing with the State plan was § 622 (f). It directed: "That the State plan shall provide for adequate hospital facilities for the people residing in a State, without discrimination on account of race, creed, or color, and shall provide for adequate hospital facilities for persons unable to pay therefor. Such regulation may require that before approval of any application for a hospital or addition to a hospital is recommended by a State agency, assurance shall be received by the State from the applicant that (1) such hospital or addition to a hospital will be made available to all persons residing in the territorial area of the applicant, without discrimination on account of race, creed, or color, but an exception shall be made in cases where separate hospital facilities are provided for separate population groups, if the plan makes equitable provision on the basis of need for facilities and services of like quality for each such group; and (2) there will be made available in each such hospital or addition to a hospital a reasonable volume of hospital services to persons unable to pay therefor, but an exception shall be made if such a requirement is not feasible from a financial standpoint.” (Emphasis supplied.) As is evident from the aforequoted statutory language, the obligation was a dual one — avoiding both racial-religious and economic discrimination; and, although there is undoubtedly an overlap in the affected populations, the obligations are distinct.

The former, with which we are not concerned here, has been termed the "community service” obligation; the latter, which is at issue, is known as the "uncompensated care” requirement. 4 ¹⁸⁹ Neither the statute nor the initial regulations adopted by the Surgeon General defined with particularity what was meant by the phrase in § 622 (f) (2) — "a reasonable volume of hospital services to persons unable to pay therefor.” The term "reasonable volume of hospital services” was not defined at all; the 1947 regulations defined "persons unable to pay therefor” as "both the legally indigent and persons who are otherwise selfsupporting but are unable to pay the full cost of needed services.” 5 Equally lax was any effective enforcement of the obligation — whatever it was — either by the Federal Government 6 or by the States, who, under their plans, had the primary responsibility for enforcement. Frustrated at the Executive level, advocates for the poor eventually began to seek redress through class action suits in the courts; and in at least three cases, they were successful in establishing an implied right of private action to enforce a hospital’s obligation to provide "uncompensated care.” See Cook v. Ochsner Foundation Hospital, 319 F. Supp. 603 (E.D. La. 1970); Organized Migrants in Community Action, Inc. v. James Archer Smith Hospital, 325 F. Supp. 268 (S.D. Fla. 1971); Euresti v. Stenner, 458 F.2d 1115 (10th Cir. 1972), rev’g 327 F. Supp. 111 (D. Col. 1971). 7 As a result of these decisions, HEW quickly began to develop more particular standards concerning hospital compliance with the "uncompensated care” obligation. These new standards became effective as interim binding regulations in July, 1972, 8 and, with minor changes, were continued as final regulations in June, 1973. 9 The new regulations, which remained in effect until 1979, and thus were operative during appellant’s stay at Prince ¹⁹⁰ George’s General Hospital, made a number of significant changes, in terms of both defining and enforcing the "uncompensated care” obligation. Of particular significance were: (1) 42 CFR § 53.111 (b) (7), which defined the term "reasonable volume of services to persons unable to pay therefor” as "a level of uncompensated services which meets a need for such services in the area served by an applicant and which is within the financial ability of such applicant to provide.” 10 (2) 42 CFR § 53.111 (d), which provided a "presumptive compliance guideline.” A hospital was deemed to be in presumptive compliance with its "uncompensated care” obligation if, in a fiscal year, it either (a) budgeted and, on request, made available uncompensated services at a level not less than the lesser of 3% of operating costs or 10% of the Federal assistance it received under the Act, or (b) certified that it would "not exclude any person from admission on the ground that such person is unable to pay for needed services and that it will make available to each person so admitted services provided by the facility without charge or at a charge below reasonable cost which does not exceed any such person’s ability to pay therefor. .. .” This guideline left the hospital with the choice of setting aside each year a certain amount of money for "charity” care (and actually providing that much care) or adopting what has since become known as an "open door” policy — turning no one away because of inability to pay.

(3) 42 CFR § 53.111 (g), which required the State plan to establish "criteria for identifying persons unable to pay for services, which shall include persons who are otherwise self-supporting but unable to pay the full charge for needed services.” (4) 42 CFR § 53.111 (i), which required the hospital to post a notice "within the facility (admissions, office, emer ¹⁹¹ gency department and business office) for the purpose of informing patients or potential patients that criteria for eligibility and applications are available upon request.” (Emphasis supplied.) The required notice was to contain substantially the following language (in relevant part): "NOTICE OF HILL-BURTON OBLIGATION "This hospital (or other facility) is required by law to give a a [sic] reasonable amount of service at no cost or less than full cost to people who cannot pay. If you think that you are eligible for these services, please contact our business office (give office location) and ask for assistance. If you are not satisfied with the results, you may contact (the State Hill-Burton agency with address).” (5) 42 CFR § 53.111 (j), which required the State plan to provide for evaluation and enforcement of the "uncompensated care” obligation. The State enforcement agency was required to audit compliance at least annually and to establish procedures for investigating complaints.

In addition, the State plan had to provide "adequate methods of enforcement of the assurance, including effective sanctions to be applied against any facility which fails to comply with such assurance. Such sanctions may include, but need not be limited to, license revocation, termination of State assistance, and court action.” The thrust of these new regulations was to place upon the State the direct and primal responsibility for enforcing the "uncompensated care” obligation. Pursuant to these regulations, Maryland adopted a new State plan. The 1974 version of it, which has not been revised, required each hospital subject to the Act to notify the Department of Health and Mental Hygiene (DHMH — the State enforcement agency) of whether it opted for the 3%/10% or the "open door” method of compliance. 11 It also required that: 12 ¹⁹² "Persons who are unable to pay must be identified by institutional procedures for the evaluation of income and resources in relation to the reasonable costs of needed services.

Each case shall be examined individually, considering such factors as health and medical care insurance coverage, personal or family income, the size of the patient’s family, and the financial obligations and resources of the patient or family. The latest revision of the Office of Economic Opportunity (OEO) Poverty Guidelines may be used as a standard of need for low income families.” The next development came from Congress with the enactment of P.L. 93-641 in 1974. Known officially as the National Health Planning and Resources Act of 1974, the law, among other things, enacted a new title XVI to the Public Health Service Act (title 42 U.S.C. §§ 300q — 300t), and, though not repealing the original Hill-Burton Act (title VI), allowed it more or less to die on the vine by terminating all