The issue is that, most of the time, "incredibly dense cities" are not the places where this is hitting the hardest. It's the smaller towns where the impact of hospital rollups hits hardest on the property tax rolls.
Problem is, of course, that if we don't get one of the hospitals in, say, Houston, to put a facility in, say, Nacogdoches, on its books; then that facility may go away entirely. In which case you'd have issues in the market with inequity of access for the very populations who may need that access most. (Elderly and poor.) But if you do allow it, well, you have issues with property tax rises.
So local leaders are put in a position of having to weigh the value of having a hospital or clinic be available locally, against any potential decrease in property tax revenues. Now you hope they get that cost-benefit analysis correct, but there's no guarantee.
But churches? Yeah. Not so much.
I agree, the whole ruse that these 501s meaningfully does charitable work for our communities is laughable and their tax exemption should be revoked, at least with regard to land taxes.
And parking is a productive use - they have services once a week, and parking means people can come to the service. That's the definition of productive use. Something does not need to be used 24/7 to be productive.
Every other contemporary development in my area that faces real economic reality is ground floor retail, commercial/residential on top, and optionally underground parking.
There are certainly productive religious charitable efforts using facilities like this: homeless shelters, community low-cost/free clinics, soup kitchens. I think these uses should be tax subsidized, but other mystical efforts should not be whether they generate a profit or not.
I think a good reform to the 501c3 system would be to make non-profits like these churches and hospitals classify their actual charitable activity and separate it from their other activity, just like individuals with a mix of personal/small business income/expenses are required to do.
One thing I might agree with is land tax for non-profits that charge fees for services, as opposed to those who work off of donations. I think that would fix the issue without destroying non-profits.
>Claiming that you have ownership over land on this planet is odd, you didn't create the land and governments change overtime.
The government didn't create the land either.
The exact implementation might be flawed, but if 340b is eliminated it will kill many hospitals in underserved communities.
So any plan to change 340B should really also explain how to fund these critical hospitals.
In the way that surgeries used to be the "money maker" to subsidize other expensive service lines like an ED, pharmacy has filled that gap in recent years.
It is less hospitals getting rich off overcharging insurance for drugs and more hospitals overcharging insurers for drugs since everything else they do is a drain on finances.
For example, Northwestern University (in the middle of downtown Chicago) got itself reclassified as a rural hospital in order to participate in the program.
Moreover, it's grown extremely rapidly over the past ~5 years, and the gravity of the program is starting to create bizarre second-order effects like the one outlined.
My intent with this article is just to highlight some of those effects, not to advocate for eliminating 340B.
Also, not bankrolled by pharma, just a researcher for Turquoise Health (a healthtech startup). I get to dig around in their data and publish occasionally, but editorial control / opinions are my own.
This is also a bit misleading though right? Northwestern was obliged to put 11 other hospitals and something on the order of like 150 to 200 clinic/other locations on its books largely for the purposes of access. So that rural communities across northern Illinois can also have the same access as people in Chicago.
The fact is, they are a rural healthcare system. Because the options that were in those locations previously were unable to make a long term go of it.
AFAIK, the other hospitals/clinics under the Northwestern umbrella don't really factor into whether the downtown Northwestern Memorial campus qualifies for 340B (insofar as they all have their own CCNs and qualify independently). In this case, Northwestern Memorial qualifies because it a) got reclassified as rural b) became an RRC (likely based on its staff specialty mix) c) meets the RRC DSH threshold of >= 8%.
Northwestern Memorial does treat a lot of rural patients, so maybe it does deserve 340B. That said, it seems clear that it's not they type of struggling safety-net/rural hospital 340B was originally intended to subsidize.
There's not really been a real test what a healthcare system with any kind of "natural" market forces at work. The current system is just a mess of tax breaks, middle man companies, hidden pricing, strange federal and local laws, employer choices and so on...
Even when someone talks about single payer, I'm still unsure what they imagine that looks like.
I went to the doctor because of chronic acid reflux. They charged me a copay. They couldn't help so they referred me to a gastro doc. The gastro charged me a copay (more because it was out of network—there's no in network gastro doctors in my city). I was given an upper endoscopy, but insurance only covered 10% of the cost of the procedure. I spent $500 on the medication I was prescribed afterwards.
I have "good" insurance through my employer. If I didn't have insurance, I wouldn't have been able to get treated. The fantasy universe that you're describing is the one we live in: I have almost no choice, nothing is in network, and I spent $10k on healthcare on top of what's already taken out of my pay. Nobody in countries with socialized medicine has any of these problems.
At some point it makes more sense to move every person from their remote hamlet than to create a hundreds different programs and exceptions to deliver broadband, groceries, and healthcare there. Many of these towns are leftover from when farming was 100x more labor intensive or industry had to be located next to a river.
I've consulted with two large health systems that begin with A and they use 340B to subsidize all sorts of treatment.
Unfortunately American healthcare naturally seeks to socialize treatment, but instead of it being direct its in the most round about ways.
https://drive.google.com/file/d/1wzGqzWHDQA4m8DIo174yqx-eYDk...
Also the American healthcare system is such a kludge of laws with mixed motivations and so on. At this point keeping local hospitals operating seems like a good goal considering the pressure on many of them. Rural areas have had hospitals vanishing for a while now, the outcome there is not good.
Call it what it is, a perpetual rent.
There's nothing funnier than a lot of people taking some absurd principles for granted when they make no sense at all, property taxes being one of them. So imagine you grind at least 30 years of your life working extra hours or two jobs to pay for an already inflated asset based on speculated prices rather than the actual cost, only to end up with that asset in a perpetual rent agreement where if you stopped paying it you basically don't own it anymore, a rent that also isn't controlled, so you can get screwed in the future like how a lot of people ended up selling their house because their retirement isn't enough to cover such rent.
Make it make sense, the only real winners here are the banks after they collect all that compound interest throughout all these years, and the government taking all these taxes.
Why should you be allowed to monopolize a piece of finite and scarce resource, land, for free?
Since you think it's a scam, surely you support 100% capital gains taxes on homes? Since old people getting rich off of an unproductive asset, blocking supply to "preserve neighborhood character", and inflating the price of their artificially-scarce goods would be more of a scam?
There's nothing wrong with retirees being forced to sell and downsize. You don't need a family-sized home when you live alone. Property tax is the least unfair tax of them all.
>finite
You think land is finite? You do realize you can fit the entire human race - both the ~8 billion people currently alive and the estimated ~100 to 117 billion people who have ever lived- inside the Grand Canyon? We have enough land that every single person could have an entire farm of their own, not to mention the "land isn't enough" argument makes no sense in a country with giant parking lots, and no exceptions are made for people living in apartment blocks.
The solution is simple for what you mentioned at the end: make houses a depreciated asset, not an investment. Investment by concept must always go up, scale, and grow, making it inevitably unsustainable. Japan did it and fixed the entire housing issue for the next generations to come. I am sure we are smart enough to do the same. Housing and land are made to live in, not to invest in, and keeping them empty to gauge prices up.
Is the deficit a scam too? It does not take enough taxes, you are heavily subsidized and want to be subsidized further.
The argument is simple. Land ownership with no property tax privatizes gains that others must subsidize. Land value comes from government infrastructure for water, electricity, roads, public transportation, which are expensive to maintain. That, and artificial scarcity, is why your house grows in value, which is why people treat it as an investment.
Japan fixed it by having a dying population, which causes other problems.
Totally absurd to think that you should!
>Make it make sense
The cops/judges/prisons/schools/military/etc that maintain a mostly peaceful and ordered society that prevents someone else from walking onto your property and throwing you out costs money, and costs more money every year. The more land you have, the more it costs, since more time, materials, and energy have to be spent moving around all of that surface area you have "own". Surface area is the costliest thing people consume.
Tax on the improvements on the land, as well as earned income tax are the absurd principles.
Universities and hospitals are some of the worst offenders in situations like this, especially in urban cores, likely empowered by their clear transformation into state-sanctioned "non-profit" businesses that provide a good we are compelled to consume if we are a normie who wants a reasonable guarantee of a comfortable, healthy economic existence.
There is some opposite momentum toward the land value tax, which is a good thing, but these are less visible and likely weaker than a tax revolt by landowners.
Eventually, if the current trend continue for property taxes, we will see a disruption in government funding for basic service, and the contraction of the economy through increased taxation of economic activity to compensate for lost revenue from property taxes. It will be a disaster.
This is the endgame of the expansion of land ownership in the post WW2 era. Exemption from property taxes worsen this crisis.
Maybe the government can be fixed, or even "must" be fixed for the sake of the poors that we always pretend we're thinking about (no doubt some are, but most are just using them as a prop for political persuasion), but in the meanwhile contingency plans must be made.
https://www.google.com/maps/@37.8567746,-122.2550107,3a,60y,...
Government provides crucial services that increases land value, offsetting any losses in tax revenue through public utility. Perhaps the same thing can happen with historical buildings.
However, let us note that cities are for living in. It is not a museum.
Ultimately, only the public can determine the balance of concerns to be struck.
