Scholars and public officials concerned with social justice consider redistribution of land values to be an especially important objective of urban policy in Latin American countries, where great differences in access to scarce urban infrastructure and services result in an unfair distribution of land values. However, value capture policies and instruments used in principle to “redistribute the valorization gain” or “promote redistribution of land value increments” are rejected by some progressive sectors because they believe that, in spite of the redistributive connotation, those instruments are not really aimed at redistribution in practice.1 This article explores a number of questions that must be addressed to achieve a better understanding of the value capture concept and its potential to play a truly redistributive role in Latin America.
The Distributive Principle and the Redistributive Goal
The basic principle of value capture 2 is to return to the community the land value increments resulting from community action. The most usual way to define those increments is to focus on particular increases in land value that result from specific and dated public actions. The corresponding value capture instruments could, therefore, be thought of as devices to recover for the public the increase in land value associated with public actions that otherwise would be captured by private entities. The aim of this distributive policy is to restore a previous state of distribution that, in essence, is taken as a proper or given one.
An alternative interpretation is based on the principle stated by Henry George that all land value, irrespective of its origin, is the product of community effort. In this view, only when all of the land value is taken into consideration and the goal of altering the current state of land value distribution is introduced can the value capture idea acquire a truly redistributive perspective.
Redistributing land values is but one of the possible goals of urban land policy. Other goals are raising public revenues to finance urban services, regulating and managing urban land uses, and controlling undesirable outcomes of the functioning of urban land markets. That is, redistribution may be a guide to more progressive distributive policies, but it is not necessarily the basic principle of value capture.
Thus, we can distinguish between the distributive principle of value capture policies-to restore a certain state of distribution-and a redistributive goal of urban land policies-to alter a certain state of distribution. This distinction allows us to address the confusion about distribution and redistribution applied to land values and to the value capture idea.
The Practice of Value Capture in Latin America
In its generic sense, the value capture idea applies to any levy or planning tool intended to distribute land value increments. Almost all Latin American countries have experience with the property tax, and many have other planning tools such as the compulsory donation of land for public purposes in land parceling or subdivision projects. Historically, the development of the value capture idea has been associated with a specific instrument known as Contribución de Valorización/Mejoras. This special assessment or valorization charge, incorporated into the legislation of most Latin American countries, aims at capturing a portion of special benefits (land valorization) that arise from public investments in infrastructure and services, to finance such investments.
Even with this narrow definition, the implementation of value capture has been limited and controversial. Both the political influence of landowners and the technical (but also often legal) shortcomings of adequately assessing land values have been identified as restraints to its use in many countries. Colombia is perhaps the only country with an established tradition of using the instrument, but even there its implementation is subject to serious limitations. Some observers acknowledge its incapacity for redistribution and others claim it frequently loses the link with the distributive principle and becomes simply a practical way to pay the community for the costs of a public action that generates benefits for only some individuals.
A closer look at concrete Latin America experiences with the implementation of value capture instruments leads to a disturbing conclusion. Rather than evolving from the ethical principle of fairness, whereby the increment of land value resulting from community action returns to the community, the value capture idea seems to have been adopted in Latin America as a pragmatic cost-recovery mechanism to overcome the chronic shortage of public revenues to finance urban infrastructure. The major goal of such value capture instruments has been ultimately to raise public revenues, whether based on a distributive principle or not.
Linking Value Capture and Redistribution
Even when the distributive principle is secured, the goal of raising public revenues can differ from or even contradict other goals of urban land policy, including the important redistributive goal. For instance, when a public investment in urban infrastructure generates land value increments in a highly valued area, and then associated income from the use of a value capture instrument is reinvested in the same area, the result is not redistributive and can even be regressive.
To understand the contradictions that arise between the traditional use of value capture instruments to raise general revenues and the necessity of incorporating the redistribution goal into those policies, we need to consider value capture as a more comprehensive concept. Even when limited to its usual definition centered on specific land value increments, at least three non-autonomous public actions or decisions must be associated with the distributive principle of value capture:
1. an original public action (regulation, investment, etc.) that results in land value increments;
2. a second action to capture (some of) this value; and
3. a third action related to the destination or use of collected resources.
While the second action implies the use of a general or specific value capture instrument, the first and third actions, though related to specific decisions, cannot be separated from two basic questions concerning public decisions as a whole: How are public works allocated in space, and how is the general revenue distributed?
Allocation of public works
When raising revenues and promoting redistribution are concurrent goals, the second does not necessarily follow the first. In Latin America these goals are often contradictory. Under conditions of highly uneven distribution of wealth and scarce funds to finance public works, it is usually easier to guarantee the raising of revenues through the allocation of public works (original action) in areas where more absolute revenues can be collected. Even with the use of a value capture instrument, when the subsequent decision (destination of resources) maintains the same state of wealth distribution, the whole public action becomes regressive.
On the other hand, rejection of value capture instruments does not prevent the misallocation of public works. In fact, it just contributes to the status quo. For example, the facelift of Copacabana in Rio de Janeiro, which replaced old trees and modernized sidewalks, was financed by the general revenue, not by a specific value capture device. However, many of the poor areas of the city have neither sidewalks nor a single tree on their streets. Recognizing this irony reinforces the need for a new framework for value capture policies that can allocate public works more equitably.
Distribution of general revenue
Latin America presents extreme relative and absolute differences in public infrastructure provision, calling for equity criteria to evaluate distributive policies. Yet, equity criteria are subjective and there are distinct visions on what is fair. Given the disparities in wealth and in access to serviced land, it is important to consider not only relative differences but also the absolute differences between highest and lowest levels.
To illustrate this point we can apply the classic redistributive argument to the distribution of land values in a society with 10 units of wealth (i.e., land value) distributed between two groups: the higher group has 8 units or 80 percent of the wealth and the lower group has 2 units (see Table 1). This example can represent the typical differences between serviced areas occupied by the rich and unserviced areas occupied by the poor in Latin American cities. An increase of 50 percent in this wealth (5 total units), if distributed in the same ratio, does not change relative differences, but the absolute difference between the two groups is increased by 50 percent, from 6 to 9 units.
TABLE 1: Distributive Value Capture Policies Total Wealth Lower Group Higher Group Relative Differences Absolute Difference original: 10 units 2 units 8 units 1:4 6 units increased: 15 units 3 units (2+1) 12 units (8+4) 1:4 9 units
Another important consideration is the level of the group in the lowest position. Value capture instruments are justified as distributive tools to return to the community special benefits resulting from a public action that only some individuals receive. But that justification in turn raises the need to clearly separate special benefits from basic needs. If we consider access to urban infrastructure as a basic need, the society must decide on the minimum level of access for the lower group. Priority should be given to actions that achieve those minimum levels before other benefits accrue to the higher group. If this society decides that the minimum level of wealth should be 6 units for the lower group, then an increment of 5 units of land value would be distributed in such a way as to decrease both relative differences and absolute differences (see Table 2).
TABLE 2: Linking Value Capture and Redistribution Total Wealth Lower Group Higher Group Relative Differences Absolute Differences original: 10 units 2 units 8 units 1:4 6 units increased: 15 units 6 units (2+4) 9 units (8+1) 2:3 3 units
Value Capture and Socio-spatial Equity
Urban planning decisions, such as the norms and regulations on land use and development rights, also affect the distribution of urban land values and must be integrated into value capture policies. In Latin America, where the differences in access to public infrastructure and urban services are marked by severe social segregation and exclusion, this integration implies the inclusion of a socio-spatial dimension that can deal with the disparities between serviced rich center cities (for the few) and unserviced poor peripheries (for the majority). Therefore, land value redistribution policies acquire a particular political context in which the generation of land value increments and the destination of corresponding funds are fixed in distinct socio-economic areas of the city.
However, even when this socio-spatial dimension is incorporated, most redistributive value capture instruments provide necessary but not sufficient conditions for a better distribution of land values. While redistribution from rich areas to all areas involves altering the distribution of general revenue to achieve its equity objective, redistribution from all areas to poor areas involves altering the allocation of public works and/or development rights on land to arrive at a better distribution of land values.
Since these approaches involve greater institutional changes, a third option seeks to stimulate the generation of land value increments in rich areas in order to raise revenues that can be redistributed to poor areas. These so-called “Robin Hood” policies are being considered to deal with urgent needs in poor areas, combined with specific opportunities and demands in rich areas. One example is the “linkage operation” recently popularized in many large Brazilian cities, where the negotiation of legal exceptions for development generates payments earmarked for social housing. However, a careful examination of this transfer tool shows that stimulation of land value increments in rich areas actually increases intra-urban differentiation and as a result may exacerbate the gap between rich and poor areas.
This and other largely unanticipated perverse outcomes show that the development of value capture policies and instruments for Latin American countries cannot be considered independently from an urban land policy oriented to the reduction of socio-spatial inequalities. The latter can be attained only by direct actions geared to altering the current distribution pattern of land values. This means that redistribution, although not necessarily implied in the value capture idea, must be incorporated deliberately into the development of distributive value capture policies.
Guidelines for Implementing Value Capture Policies
This discussion reinforces the argument that value capture policies in Latin America must be preceded by changes in the process of distributing land values in the broadest sense, especially where redistribution is pursued as a major goal of urban policy. This perspective would help to consider in an integrated manner, in each public decision concerning a specific way of distributing urban land values, several other ways in which the public sector contributes to this distribution, including:
The potential and limits of specific value capture instruments are conditioned by those distributional public actions and decisions. When specific value capture instruments are used independently from this consideration, the whole process may be undermined. Collection of land taxes is usually neglected; public investments tend to be allocated unjustly; political impediments to the use of value capture instruments abound; revenues are not distributed in a socially equitable manner; development rights are incorporated in ownership rights, etc. As a consequence, redistribution cannot be attained and the distributive principle is imperiled.
The challenge in Latin America, then, is to work out the preconditions for improved use of the value capture idea, rather than simply to focus on overcoming procedural difficulties in applying existing instruments or to reject those instruments in favor of replacement tools usually subject to similar shortcomings. To have a chance of being truly redistributive, these distributional decisions should account for all components of land value, including accumulated, potential and specific increments, not only land value increments in the strictest sense. Efforts in this direction may contribute to a redistributive perspective on value capture policies.
How much value capture is “enough” will vary among countries, but the balance of policies should include these basic guidelines:
These guidelines are strongly associated with urban land value increments in the broadest sense, and they can be used to reduce absolute and relative socio-spatial differences. If they continue to be neglected, and value capture policies are confined to specific land value increments, attempts at redistribution in Latin American countries are bound to fail. Furthermore, the implementation of value capture instruments will continue to serve as an anti-social mechanism that only exacerbates the already great differences between rich and poor.
Fernanda Furtado is a fellow of the Lincoln Institute. She received a dissertation fellowship from the Institute to help complete her Ph.D. thesis on “Urban Land Value Recapture in Latin America” at the Faculty of Architecture and Urbanism at the University of São Paulo, Brazil.
See the Latin American Program and Land Lines sections of this website for additional articles and reports on this topic in both English and Spanish.
Notes
1 See Donald Shoup, “Is under-investment in public infrastructure an anomly?” in Gareth A. Jones and Peter Ward, eds. 1994. Methodology for Land and Housing Market Analysis. Cambridge, MA: Lincoln Institute of Land Policy. Shoup’s piece includes the debate held during the 1991 Fitzwilliam Workshop on Land Values and Land Valorization in Developing Countries at the University of Cambridge on whether value capture instruments are intended to redistribute the valorization gain or are just a device to strengthen government finance.
2 It would be more precise to speak of value recapture, because besides better representing public interventions in order to return to the community the unearned land value captured by private entities, the term alludes to redistribution as a specific way of developing such policies. However, the more generic term value capture is used in this article.
Government-owned property is exempt from local taxes almost everywhere in the United States, but this situation is based less on logic than on now-outdated historical considerations. Remarkably, there are no comprehensive estimates of the value of these exemptions. For comparison, the value of property tax exemptions for nonprofit institutions (excluding houses of worship) was about $900 billion in 1997, and charitable properties (including hospitals and universities) accounted for about $500 billion of this figure (Cordes, Gantz and Pollak 2002, 89). Even without comprehensive data, it is clear that the amount of government-owned land is vastly greater than nonprofit holdings. However, the exempt status of government land barely provokes complaint (except in the western states where federal landholdings are enormous) whereas exemptions for nonprofit organizations are frequently challenged.
Historical Background and Federalism Today
Government-owned property traditionally has been exempt from taxation in order to avoid an empty ritual whereby the sovereign taxed itself. The implicit assumption of a single sovereign was quite reasonable in Elizabethan England, where the property tax first took root, but not so in the U.S. today. The myriad school districts and special districts that now compete with counties and municipalities for property tax revenues were virtually nonexistent in the nineteenth century. Today there is no economic reason to exclude all government property from the tax base.
Exemptions for private, nonprofit entities grew out of the government exemption. In the seventeenth century, private parties did not always wait for the Crown to repair their bridges, causeways, seawalls or highways. They assumed this responsibility whenever self-interest required and the purse permitted. The capital-intensive nature of such activities that relieved government of a burden made a property tax exemption a logical tool for encouraging private initiative. Thus the first charitable exemptions were a type of quasi-government exemption, subsidizing private parties who discharged public responsibilities.
Charitable exemptions for the alleviation of poverty began as a separate category, because reducing poverty was not originally considered a government responsibility. The change in this attitude over time had the effect of diminishing the distinction between alleviating poverty and relieving government of a burden, but these remain two separate bases for the charitable exemption. Before the New Deal of the 1930s, U.S. counties had the primary governmental responsibility for poor relief, through maintaining almshouses and work farms. The principal public expenditure required for them was for land and construction, since the residents did the day-to-day work of running these facilities. In this situation, a property tax exemption made sense. If a charitable organization did not build such a facility, the responsibility would fall to county government and would be funded through property taxes. It was easy to see a clear and convincing connection between the alleviation of poverty, relief of a government burden and a property tax exemption.
Modern U.S. federalism has undermined these connections. There is no single sovereign now, but rather 87,000 units of government, including 19,000 municipalities, 16,600 townships and towns, 3,000 counties, 13,700 school districts and 34,700 special districts, which often overlap in complex ways. The property tax is virtually the sole source of internally generated revenues for school districts and special districts. A government exemption can be administered so that no unit of government need pay taxes to itself, while taxpayers outside the taxing jurisdiction who benefit from the property would pay the tax.
Valuation of unique government property and infrastructure is a problem, but it is not insurmountable. A new addition to generally accepted accounting principles requires local governments to carry on their balance sheets the depreciated value of their physical assets, including infrastructure, which can be a starting point for valuing such property. Already local government property is taxable in 11 states, provided it lies outside the owner’s boundary. For example, a reservoir owned by a water district can be taxed by the town or county where the reservoir is located, and the tax can be collected through increased water rates charged to the utility’s customers.
The strong consensus in favor of exempting government property is due to inertia, power and precaution. The federal government has vast landholdings, collects no property taxes, and therefore would oppose any tax on government property. Besides, the Constitution shields it. State governments also have extensive holdings and do not benefit from property taxes to any significant degree, so they too would oppose taxing government property. Local governments, special districts and school districts would be the net beneficiaries if government property were taxed, since their own property holdings are small in comparison to federal and state governments, yet the property tax provides almost 40 percent of their revenue (U.S. Census Bureau 1998).
Charitable Exemptions as Sovereign Exemptions
As long as government property is exempt, the case for charities is strengthened. Evelyn Brody (1998; 2002) argues that the states, by conferring benefits of sovereignty on nonprofit institutions, are acknowledging the underlying independent, self-governing nature of those institutions. “Tax exemption carries with it a sense of leaving the nonprofit sector inviolate, and the very concept of sovereignty embodies the independent power to govern” (Brody 1998, 588). Under federal tax law, neither charitable institutions nor local governments are taxed on net income, contributions or interest income from bonds, but both are taxed for payments made for services rendered. Considering charitable nonprofit institutions as quasi-sovereign allows us to make sense of “the rules in the tax scheme that operate to curtail rather than enhance the economic strength of the charitable sector. After all, rival sovereigns rarely feel comfortable letting the other grow too powerful” (Brody 1998, 586).
The U.S. Supreme Court, in Walz v Tax Commissioners, 397 U.S. 664 (1969), supports the position taken by Brody: “[Exemption] restricts the fiscal relationship between church and state, and tends to complement and reinforce the desired separation insulating each from the other (emphasis added).” Churches, and by extension other nonprofit institutions, are sovereigns in their own domain, which is circumscribed by a higher sovereign—state government.
Conversely, arguments used to attack certain charitable exemptions can also be applied to the governmental exemption. Critics of nonprofit tax exemption focus on large, property-rich and financially strong organizations, calling them commercial enterprises (Balk 1971; Hyman 1990; Gaul and Borowski 1993). This category includes colleges, universities, hospitals and nursing homes. No state prohibits charities from engaging in commercial activities, but 8 states out of 43 responding to the survey described below prohibit charities from earning a profit, even for institutional purposes. All states prohibit the charitable owner of exempt property from distributing profit to private parties. “It is a well-established principle of law that a charitable institution does not lose its charitable character and its consequent exemption from taxation merely because recipients of its benefits who are able to pay are required to do so, as long as funds derived in this manner are devoted to the charitable purposes of the institution” (American Jurisprudence 1944).
Commercial enterprises of local government are generally tax exempt, including air and marine ports, electric power generating facilities, water treatment and distribution plants, golf courses, package liquor stores and parking garages, to name a few. If commercial activity is to be the test for taxation, this should be applied evenhandedly and extend to government property as well.
A Survey of State Charitable Exemptions
Every state exempts charitable property, but the meaning of “charitable” varies quite a lot because its legal antecedents are traceable to the English Statute of Charitable Uses of 1601. Policy makers have shown considerable ingenuity in adapting an ancient law to modern needs, and ingenuity breeds variety. A Lincoln Institute-sponsored survey explored the laws in each of the 50 states to clarify the definition and application of “charitable” property tax exemptions.
As befitting a sovereign, private nonprofit institutions enjoy a constitutionally protected tax exemption in almost as many states as do local governments. The constitutions of 38 states make reference to exemption of local government or private institutions, or both. States have probably been reluctant to define charity statutorily because the judicial branch is the final arbiter of constitutional matters. Four states authorize legislatures to grant exemptions without giving specific direction; only 9 (including all 6 New England states) are silent. Specific exemptions are mandated in 27 states, and are discretionary in 16. Arizona, Missouri, Nebraska, North Carolina and Virginia are in both categories because they mandate some exemptions (usually governmental) but give their legislatures discretion with respect to other classes of institutional property.
Only 10 states have statutory definitions, and they show very little similarity (see Figure 1). Four of them define charity in terms of a public benefit, two in terms of relieving government of a burden, and one (Florida) could be placed in either category. Other individual states define charity in terms of relief of poverty or deriving income in the form of donations, or simply by listing exemption-eligible activities, with a slight overlap with relief of poverty. Five state definitions (Florida, Nebraska, New Hampshire, North Carolina and Pennsylvania) are extremely broad, which essentially punts the issue to the judicial branch.
The lack of a discernable pattern in judicial opinions arouses suspicion that courts must work backwards from a desired result to develop standards and tests. The situation today parallels the first half of the twentieth century, when bureaucrats and judges were gatekeepers to the nonprofit sector, approving or denying a petition for a nonprofit corporate charter, and they “used their control to promote the causes they believed in” (Silber 2001, 6). Awarding a nonprofit charter is now a ministerial act, but property tax exemption for charitable purposes remains subject to a variety of state laws with idiosyncratic judicial interpretations in every state. Confusion in the public debate over the charitable property tax exemption is the sure result. In devising tests, courts sometimes conflate public benefit with relief of poverty, and the result is unenforceable. Either one or the other must take precedence. Unless statutes are clear, courts are free to choose and to switch back and forth.
The case of hospitals is illustrative. Although one will find exempt hospitals in every state, the law is ambivalent. Hospitals have constitutional protection in only 3 states, while in 17 they are exempt only because the court regards them as “institutions of purely public charity.” The famous 1985 decisions in the supreme courts of Utah and Pennsylvania that undermined hospital tax exemption were health care cases. The courts concluded that the hospital (Utah) and the consortium of hospitals (Pennsylvania) were not in fact charities. Without putting too fine a point on it, the judicial remedies were based on the principle of relieving poverty.
Much angst and legal conflict could be averted if relief of poverty could be treated as separate and distinct from public benefit and relieving government of a burden, and fortunately it can be quantified. If a legislature wants a particular type of institution (e.g., hospitals) to relieve poverty, then the state should tax the hospitals, but award each property owner in the group a tax credit equal to the amount of service they give away up to their tax liability. This proposal raises the thorny question of how to measure the value of services priced below market, but the problems are surmountable (see Bowman [1999] for a method for hospital services). Solutions to these complexities are not likely to introduce the element of arbitrariness that pervades judicial decisions today.
H. Woods Bowman is associate professor in the Public Services Program at DePaul University in Chicago, Illinois. He was a visiting fellow at the Lincoln Institute in 2001 and he contributed to the Urban Institute book, Property Tax Exemption for Charities, edited by Evelyn Brody (2002).
References
American Jurisprudence. 1944. Taxation 51 § 602.
Balk, Alfred. 1971. The Free List: Property Without Taxes. New York: The Russell Sage Foundation.
Bowman, Woods. 1999. Buying charity care with property tax exemptions. Journal of Policy Analysis and Management vol. 18, no. 1 (winter): 120–125.
Brody, Evelyn. 1998. Of sovereignty and subsidy: Conceptualizing the charity tax exemption. Journal of Corporation Law vol. 23, no. 4 (summer): 585–629.
_____. 2002. Legal theories of tax exemption, quasi and real. In The Property Tax Exemption: Mapping the Battlefield, Evelyn Brody, ed., 145–172. Washington, DC: Urban Institute.
Cordes, Joseph J., Marie Gantz, and Thomas Pollak. 2002. What is the property-tax exemption worth? In The Property Tax Exemption: Mapping the Battlefield, Evelyn Brody, ed., 81–112. Washington, DC: Urban Institute.
Gaul, Gilbert and Neill A. Borowski. 1993. Free Ride: The Tax-Exempt Economy. Kansas City: Andrews McMeel.
Hyman, David A. 1990. The conundrum of charitability: Reassessing tax exemption for hospitals. American Journal of Law and Medicine vol. 6, no. 3: 327–380.
Silber, Norman I. 2001. A corporate form of freedom: The emergence of the nonprofit sector. Boulder, CO: Westview Press.
U.S. Census Bureau, U.S. Department of Commerce. 1998. Statistical Abstract of the United States 1998, table 500 (reporting 1995 data).
Figure 1: Statutory Criteria for Charitable Organizations
Arizona requires “qualifying charitable organizations” to spend at least 50 percent of their budgets on services to state residents who receive “temporary assistance to needy families benefits or low income residents…and their households” [A.R.S. § 43-1088 G(2)].
In Florida, “Charitable purpose means a function or service which, if discontinued, could legally result in the allocation of public funds for the continuance of the function or service. It is not necessary that public funds [actually] be allocated, but only that such allocation is legal” [F.S. §196.012]. Houses of worship are exempt under a separate statute.
Hawaii defines charitable purposes as “community, character building, social service, or educational nature, including museums, libraries, art academies, and senior citizens housing facilities qualifying for a loan under the laws of the United States” [H.C.A. § 246-32(c)(2)].
In Montana charities must accomplish their activities “through absolute gratuity or grants” [M.C.A. § 15-6-201(2)(a)(i)].
In Nebraska charities must operate “exclusively for the purposes of the mental, social, or physical benefit of the public or an indefinite number of persons” [R.S.N.A. § 77-202(1)(d)].
A New Hampshire charity is one that performs “some service of public good or welfare advancing the spiritual, physical, intellectual, social or economic well-being of the general public or a substantial and indefinite segment of the general public that includes residents of the state of New Hampshire…” [R.A. § 72:23-1].
In North Carolina, “A charitable purpose is one that has humane and philanthropic objectives; it is an activity that benefits humanity or a significant rather than a limited segment of the community without the expectation of pecuniary profit or reward. The humane treatment of animals is also a charitable purpose” [N.C. Gen. Stat. § 105-278.3(d)(2)].
Pennsylvania requires: (1) relief of poverty; (2) advancement and provision of education, including secondary education; (3) advancement of religion; (4) prevention of treatment of disease or injury, including mental retardation and mental disorders; (5) government or municipal purposes; or (6) accomplishment of a purpose that is recognized as important and beneficial to the public and that advances social, moral, or physical objectives” [10 Penn. Stats. § 372].
A South Dakota public charity “must receive a majority of its revenue from donations, public funds, membership fees, or program fees generated solely to cover operating expenses; it must lessen a government burden by providing its services to people who would otherwise use government services; it must offer its services to people regardless of their ability to pay for such services…” [S.D.C.L. § 10-4-9.1].
Texas defines charity by reference to the type of activity such an organization undertakes. T.T.C. § 11(d) lists 19 activities, including: (d)(1) “providing medical care without regard to the beneficiaries’ ability to pay…”