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The Tax-Exempt Hospital Sector Hearing Committee THE TAX-EXEMPT HOSPITAL SECTOR HEARING BEFORE THE COMMITTEE ON WAYS AND MEANS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED NINTH CONGRESS FIRST SESSION MAY 26, 2005 Serial No. 109–17 Printed for the use of the Committee on Ways and Means ( U.S. GOVERNMENT PRINTING OFFICE 26–414 WASHINGTON : 2006 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800 Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001 VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00001 Fmt 5011 Sfmt 5011 E:\HR\OC\26414.XXX 26414 COMMITTEE ON WAYS AND MEANS BILL THOMAS, California, Chairman E. CLAY SHAW, JR., Florida CHARLES B. RANGEL, New York NANCY L. JOHNSON, Connecticut FORTNEY PETE STARK, California WALLY HERGER, California SANDER M. LEVIN, Michigan JIM MCCRERY, Louisiana BENJAMIN L. CARDIN, Maryland DAVE CAMP, Michigan JIM MCDERMOTT, Washington JIM RAMSTAD, Minnesota JOHN LEWIS, Georgia JIM NUSSLE, Iowa RICHARD E. NEAL, Massachusetts SAM JOHNSON, Texas MICHAEL R. MCNULTY, New York PHIL ENGLISH, Pennsylvania WILLIAM J. JEFFERSON, Louisiana J.D. HAYWORTH, Arizona JOHN S. TANNER, Tennessee JERRY WELLER, Illinois XAVIER BECERRA, California KENNY C. HULSHOF, Missouri LLOYD DOGGETT, Texas RON LEWIS, Kentucky EARL POMEROY, North Dakota MARK FOLEY, Florida STEPHANIE TUBBS JONES, Ohio KEVIN BRADY, Texas MIKE THOMPSON, California THOMAS M. REYNOLDS, New York JOHN B. LARSON, Connecticut PAUL RYAN, Wisconsin RAHM EMANUEL, Illinois ERIC CANTOR, Virginia JOHN LINDER, Georgia BOB BEAUPREZ, Colorado MELISSA A. HART, Pennsylvania CHRIS CHOCOLA, Indiana DEVIN NUNES, California ALLISON H. GILES, Chief of Staff JANICE MAYS, Minority Chief Counsel Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Ways and Means are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occur- rences are inherent in the current publication process and should diminish as the process is further refined. ii VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00002 Fmt 0486 Sfmt 0486 E:\HR\OC\26414.XXX 26414 C O N T E N T S Page Advisory of May 19, 2005 announcing the hearing .............................................. 2 WITNESSES Internal Revenue Service, Hon. Mark Everson, Commissioner ........................... 8 U.S. Government Accountability Office, Hon. David M. Walker, Comptroller General .................................................................................................................. 19 Centers for Medicare and Medicaid Services, Hon. Mark McClellan, Adminis- trator ..................................................................................................................... 36 University of Illinois College of Law, John Colombo ............................................ 85 Champaign County Board of Review, Stan Jenkins ............................................. 92 Baylor Health Care System, John T. Thomas ....................................................... 98 Sacred Heart Health System, and Catholic Health Association of the United States, Sr. Carol Keehan ..................................................................................... 102 University of Michigan Law School, and National Bureau of Economic Re- search, Jill R. Horwitz ......................................................................................... 110 Harvard School of Public Health, Department of Health Policy and Manage- ment, Nancy M. Kane .......................................................................................... 116 SUBMISSIONS FOR THE RECORD Alliance for Advancing Nonprofit Health Care, statement .................................. 125 American Hospital Association, Mike Rock, statement ........................................ 129 Clarke, Richard L., Healthcare Financial Management Association, letter ....... 132 Forbes, K.B., Consejo de Latinos Unidos, Los Angeles, CA, statement .............. 135 Goodman, Edward, VHA Inc., statement .............................................................. 136 Loftis, Paula, letter .................................................................................................. 140 Schaefer, Philip, Southern Illinois Healthcare, Carbondale, IL, letter ............... 141 Schlesinger, Mark, Yale University, and Bradford H. Gray, Urban Institute, joint statement ..................................................................................................... 142 Wolfson, Jay, Tampa, FL, statement ..................................................................... 155 iii VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00003 Fmt 0486 Sfmt 0486 E:\HR\OC\26414.XXX 26414 VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00004 Fmt 0486 Sfmt 0486 E:\HR\OC\26414.XXX 26414 THE TAX-EXEMPT HOSPITAL SECTOR THURSDAY, MAY 26, 2005 U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON WAYS AND MEANS, Washington, DC. The Committee met, pursuant to notice, at 10:18 a.m., in room 1100, Longworth House Office Building, Hon. Bill Thomas (Chair- man of the Committee) presiding. [The advisory announcing the hearing follows:] (1) VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 E:\HR\OC\26414.XXX 26414 2 ADVISORY FROM THE COMMITTEE ON WAYS AND MEANS FOR IMMEDIATE RELEASE CONTACT: 202–225–1721 May 19, 2005 FC–10 Thomas Announces Hearing on the Tax-Exempt Hospital Sector Congressman Bill Thomas (R–CA), Chairman of the Committee on Ways and Means, today announced that the Committee will hold a hearing titled, ‘‘A Review of the Tax-Exempt Hospital Sector.’’ The hearing will take place on Thursday, May 26, 2005, in the main Committee hearing room, 1100 Longworth House Office Build- ing, beginning at 10:00 a.m. In view of the limited time available to hear witnesses, oral testimony at this hearing will be from invited witnesses only. Invited witnesses will include the Hon- orable David Walker of the U.S. Government Accountability Office, the Honorable Mark McClellan of the Centers for Medicare and Medicaid Services, the Honorable Mark Everson of the Internal Revenue Service (IRS), academic experts and other interested parties. However, any individual or organization not scheduled for an oral appearance may submit a written statement for consideration by the Committee and for inclusion in the printed record of the hearing. BACKGROUND: The Committee on Ways and Means held a hearing on April 20, 2005, to examine the history of the tax-exempt sector, the legal rationale for tax-exemption, and its economic impact. The Committee is continuing its series of hearings to review the tax-exempt sector. These hearings will examine particular components of the tax- exempt sector, such as charitable institutions, cooperatives, and other exempt orga- nizations, to learn more about what they do, how they have evolved over time, if the organizations have become increasingly commercial in their operations, and the current rationale for their tax-exempt status. According to the Joint Committee on Taxation, health-related organizations make up the largest percentage of § 501(c)(3) non-profit organizations, accounting for al- most 60 percent of total revenues of § 501(c)(3)s. Of the health-related organizations, hospitals constitute almost three-quarters of total revenues. In 1956, the IRS first announced a formal position on what is required for a hos- pital to be recognized as exempt under section § 501(c)(3), since the law is silent as to ‘‘health’’ as a criteria for exemption. The ruling had a number of criteria, includ- ing that the facility must be operated to the extent of its financial ability for those not able to pay, and not exclusively for those able and expected to pay. In 1969, the IRS eliminated the requirement that hospitals provide charity care as a condi- tion to receive tax-exempt status. Because this action was taken through an admin- istrative revenue ruling, it was made without public comment. The IRS believed that this change was warranted, in part, by the enactment of the Medicaid and Medicare programs. Moreover, the view was that taxable and tax-exempt hospitals were dissimilar organizations, since taxable hospitals were commonly organized as small physician-owned facilities. Since 1969, hospital tax-exemption has been gov- erned by the ‘‘community-benefit’’ standard. Under this standard, an entity engaged in the promotion of health for the benefit of the community is pursuing a charitable purpose, even though not all members of the community, such as the indigent, di- rectly benefit from the services. The hearing will examine the following issues: • How the standards for hospital tax-exemption evolved over time; VerDate Aug 31 2005 06:54 Apr 28, 2006 Jkt 026414 PO 00000 Frm 00006 Fmt 6633 Sfmt 6621 E:\HR\OC\26414.XXX 26414 3 • What criteria are used to assess if hospitals meet the tax-exempt standard; • If tax-exempt hospitals operate principally as businesses selling their services in a competitive market. In announcing the hearing, Chairman Thomas stated, ‘‘This continues the series of hearings examining the tax-exempt sector. Congress needs a better under- standing of the subsidy for tax-exempt hospitals. Tax-exemption
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