Court Opinion

ID: 9851335
Source: CourtListenerOpinion
Date Created: 2023-09-24 05:10:52.905653+00
Date Added: 2024-06-11T09:20:53.743298
License: Public Domain

STEWART, Justice
(dissenting):
I. INTRODUCTION
A majority of the Court holds that Utah Valley Hospital and American Fork Hospital are not entitled to ad valorem property tax exemptions as charitable institutions under Article XIII, Section 2 of the Utah Constitution and that U.C.A., 1953, § 59-2-30, which defines charitable institutions, is unconstitutional. In holding the hospitals to be noncharitable, the majority opinion ignores the donation of literally tens of millions of dollars worth of private and public funds for the erection of hospital buildings and the purchase of equipment dedicated to the welfare of the public at large. Also ignored by the majority is the hospitals’ expenditure of hundreds of thousands of dollars for the care of indigents and several millions of dollars for direct subsidization of hospital care to low income groups. The hospital facilities are made available to all persons, irrespective of race, religion, national origin, or ability to pay.1
The Court’s holding is without precedent either in Utah or elsewhere in the United States. The majority seeks to dismiss the solid array of law from other jurisdictions with the assertion that the “decisions from other jurisdictions ... incorporate unexamined assumptions about the fundamental nature of hospital-based medical care_” That assertion is erroneous.
The majority asserts that its opinion is based only on the “facts of this case.” But this case is much more than an anomalous, one-time departure from controlling legal principles. It enunciates principles that are intended to define what constitutes a gift that will, I submit, result in the taxation of virtually all nonprofit hospitals, both primary and tertiary care, in the state. The basic rationale of the majority opinion is that no essential difference exists between for-profit and nonprofit hospitals and that the hospitals in this case did not show that they make any gift to the public or relieve any government burden and are essentially the equivalent of for-profit hospitals. In reaching these conclusions, the Court’s reasoning sweeps in every nonprofit hospital *280that receives substantial revenues from patients or third-party payors.
The effect of the majority opinion will likely be far-reaching. According to the chairman of Intermountain Health Care, Inc. (IHC), the taxation of tertiary care hospitals, which provide the most sophisticated and technologically advanced medical care, will jeopardize their existence. The immediate result of the majority’s holding is that the already high cost of hospital care will be increased. If patients treated at Utah Valley Hospital and American Fork Hospital were required to pay ad valorem property taxes at only the 1980 level, they would pay $371,274.07 and $26,-177.58, respectively, in addition to the cost of hospital services. In the case of Utah Valley Hospital, that amounts to an additional overhead cost of approximately $1,000 per day or approximately $1,000 per bed per year.
II. THE FACTS
Intermountain Health Care, Inc., is a nonprofit eorpoi’ation which owns Utah Valley Hospital, a nonprofit corporation, and operates American Fork Hospital, also a nonprofit organization, which American Fork City leased to IHC. IHC owns and manages a total of twenty-one hospitals, fifteen of which, including Utah Valley Hospital, were founded and formerly owned and operated by the Church of Jesus Christ of Latter-Day Saints.2 They were transferred to Health Services Inc., a church-controlled nonprofit corporation, and then transferred to IHC in 1974. The Tax Commission found that (1) IHC hospitals provide medical services without regard for a patient’s ability to pay; (2) IHC revenues are derived primarily from “gifts (wills, endowments and contributions),” as well as from patient charges and third-party payors such as Blue Cross, Medicare, and Medicaid; (3) IHC has no capital stock and pays no dividends or profits to the incorporators or the governing trustees of IHC, who serve without remuneration of any kind; and (4) “[n]o part of any proceeds will inure to the benefit of any private person” upon dissolution of the corporation. The following facts are undisputed, although not part of the Commission’s findings. The Boards of Trustees of IHC and of Utah Valley are lay boards whose members volunteer their time. Both hospitals are tax exempt under Section 501(c)(3) of the Internal Revenue Code. Utah Valley Hospital is an acute care hospital that as of 1980 employed 1,700 persons and had 385 beds. American Fork Hospital, which was built by the City of American Fork, is a primary care hospital that employs approximately 240 people and has 82 beds. IHC took over its operation from the City and, since this case was initiated, has constructed new physical facilities. Both hospitals accept all patients regardless of race, religion, national origin, or ability to pay.
III. DEFINITION OF CHARITY
Two centuries ago, the Lord Chancellor of England declared that charity is “[a] gift to a general public use, which extends to the poor as well as to the rich,” Jones v. Williams, 2 Amb. 651 (cited in Matanuska-Susitna Borough v. King’s Lake Camp, Alaska, 439 P.2d 441, 446 (1968)). Justice Crockett, in a concurring opinion in Benevolent & Protective Order of Elks No. 85 v. Tax Commission, Utah, 536 P.2d 1214, 1219-20 (1975), overruled on other grounds, Loyal Order of Moose No. 259 v. County Board of Equalization, Utah, 657 P.2d 257 (1982), stated:
The term charity ... is broad in compass, having a number of related meanings. While it includes giving to the poor and needy, it is not restricted to that narrow concept.... Safeguarding and promoting the general welfare of citizens is one of the responsibilities of government.
*281Accord. Youth Tennis Foundation v. Tax Commission, Utah, 554 P.2d 220 (1976). Indeed, courts have long recognized that for an institution to qualify as a charitable institution, its beneficiaries need not be indigent or needy. Matanuska-Susitna Borough v. King’s Lake Camp, supra; Dingwell v. Seymour, 91 Cal.App. 483, 267 P. 827, 333 (1928).3 In proposing Article XIII, Section 2, the framers of our Constitution acted on the premise that individual group action in furthering charitable community objectives should be encouraged. “By exempting property used for charitable purposes, the constitutional convention sought to encourage individual or group sacrifice for the welfare of the community.” Salt Lake County v. Tax Commission ex rel. Greater Salt Lake Recreational Facilities, Utah, 596 P.2d 641, 643 (1979).
The majority’s ruling represents a sharp and singular break with traditional legal principles. It is black letter law that nonprofit hospitals which are operated for the benefit of the public at large, and not for the benefit of any individual or group of individuals, and whose revenues are used for the charitable purposes of the organization are charitable institutions. The following passage in 15 Am.Jur.2d Charities § 183 at 220-21 (1976) summarizes the settled, well-established law:
The word “hospital” in its popular usage denotes a charitable institution; it is only where income may be used for the profit of the owners that a hospital corporation ceases to be a charity. A corporation the object of which is to provide a general hospital for sick persons, having no capital stock or provision for making dividends or profits, deriving its funds mainly from public and private charity and holding them in trust for the object of sustaining the hospital, and conducting its affairs for the purpose of administering to the comfort and healing of the sick, without expectation or right on the part of those immediately interested in the corporation to receive compensation for their own benefit, is a public charitable institution. Moreover, the [fact] that a corporation established for the maintenance of a public hospital, by its rules requires of its patients payment for their board according to their circumstances and the accommodation they receive, ... [does] not render it the less a public charity. [Footnotes omitted.]
See also Restatement (Second) of Trusts § 372 (1959). The Supreme Court of Nebraska in Evangelical Lutheran Good Samaritan Society v. Gage County, 181 Neb. 831, 151 N.W.2d 446, 449 (1967), stated that hospitals operated as nonprofit institutions “are universally classed as charitable institutions.” The cases which support that proposition are legion. Many are referred to in Justice Howe’s dissent and need not be repeated here.
This Court affirmed that basic proposition in William Budge Memorial Hospital v. Maughan, 79 Utah 516, 3 P.2d 258 (1931). In holding that a for-profit hospital organized as a business corporation was not a charitable organization within the meaning of Article XIII, Section 2, this Court held that “[t]he test which determines whether a hospital is charitable or otherwise is its purpose, that is, whether it is maintained for gain, profit, advantage, or not.” 79 Utah at 523, 3 P.2d at 261.
The rule stated in Budge was applied and elaborated on by the Supreme Court of Virginia in 1960 in City of Richmond v. *282Richmond Memorial Hospital, 202 Va. 86, 116 S.E.2d 79, 82 (1960), which construed a Virginia constitutional provision similar to Article XIII, Section 2 of the Utah Constitution. The Virginia Supreme Court stated:
Whether these hospitals are “conducted not for profit, but exclusively as charities,” within the meaning of the constitutional provision, depends not upon the number of patients who are treated free of charge, but the nature of the institutions, and the purpose of their operations. The nature of these institutions, the purpose and use to which they are put, all combine to show that they are operated “exclusively as charities.”
... Patients who are able to pay do pay, and those who cannot pay do not pay. The citizens who contributed to the hospitals can never get a return in money from their contributions. The charters of the corporations do not permit it, and the donors do not expect it.
There is ho wording in Section 183(3) requiring free care or free service. The phrase “exclusively as charities,” describes the institutions entitled to exemption. It does not designate whether the service rendered by them shall be free to the recipients. If the framers of the Constitution had so intended it would have been easy and natural to have specified the rendering of free service as the basis for the exemption.
The framers of the (1902) Constitution presumably knew that such charitable organizations as YMCA’s, asylums, and hospitals customarily charge for services. Thus while some or all of the charities specified in Section 183(e) may render more or less free service, the language of the Constitution contains no such requirement.
The charging of fees for services rendered, and even the receipt of revenues in excess of expenses, does not make a nonprofit hospital noncharitable if the surplus is used for the charitable purposes of the organization. E.g., Scripps Memorial Hospital v. California Employment Commission, 24 Cal.2d 669, 151 P.2d 109 (1944); Hungerford Convalescent Hospital Ass’n v. Osborn, Fla., 150 So.2d 230 (1963); Elder v. Henrietta Egleston Hospital, 205 Ga. 489, 53 S.E.2d 751 (1949); Gundry v. R.B. Smith Memorial Hospital Ass’n, 293 Mich. 36, 291 N.W. 213 (1940); Community Memorial Hospital v. Moberly, Mo., 422 S.W.2d 290 (1967); Intercity Hospital Ass’n v. Squire, 56 F.Supp. 472 (W.D.Wash.1944). See generally Eastern Kentucky Welfare Rights Organization v. Simon, 506 F.2d 1278, 1288-89 (D.C.Cir.1974), vacated on other grounds, Simon v. Eastern Kentucky Welfare Rights Organization, 426 U.S. 26, 96 S.Ct. 1917, 48 L.Ed.2d 450 (1976); 84 C.J.S. Taxation § 282(b) (1954).
The legal concept of charity does not require, as the majority apparently requires, that a hospital incur a deficit to qualify as a charitable institution. Charitable hospitals need not be self-liquidating. In City of Richmond v. Richmond Memorial Hospital, supra, the court held that the extent or amount of free service rendered is not controlling as long as the hospital is willing to render free service. The actual extent of free service is not critical. The Virginia Supreme Court stated in language directly relevant here:
The legal interpretation of the phrase “not for profit, but exclusively as charities”, is not controlled by free service to the indigent or poor. Nonprofit hospitals which are devoted to the care of the sick, which aid in maintaining public health, and contribute to the advancement of medical science, are and should be regarded as charities.
116 S.E.2d at 84. Accord Gundry v. R.B. Smith Memorial Hospital Ass’n, supra.
One court has noted: “The image of a voluntary institution as a charitable organization, financing its care of patients to a substantial degree through philanthropy ... is largely anachronistic. Philanthropy, though increasing, has not been able to match the redoubled demands for health care.” Eastern Kentucky Welfare Rights Organization v. Simon, 506 F.2d at 1288 n. 20 (quoting Professor William Thomas, *283Hearings on Conditions and Problems of the Nation’s Nursing Homes, Subcommittee on Longterm Care, Spec. Committee on Aging, U.S. Senate, 89th Cong. 1st Sess., Pt. 2 (Feb. 15, 1965), p. 55). The California Supreme Court has declared that the percentage of free services rendered is immaterial. Scripps Memorial, 24 Cal.2d at 678, 151 P.2d at 114. And in a statement of the law that is directly on point, Vick v. Cleveland Memorial Medical Foundation, 2 Ohio St.2d 30, 206 N.E.2d 2 (1965), declared:
Where a corporation not for profit is operating a hospital for the primary purpose of providing services for those in need, without regard to race, creed, color or ability to pay, the facts that the hospital charges patients who are able to pay for its services and that a surplus has been created in the hospital fund (no part of which has been diverted to a private profit) do not change its essentially charitable nature. Goldman v. Friars Club (1952), 158 Ohio St. 185, 107 N.E.2d 518; Taylor v. Protestant Hospital Ass’n (1911), 85 Ohio St. 90, 96 N.E. 1089, 39 L.R.A., N.S., 427. The fifth paragraph of the syllabus in O’Brien, Treas., v. Physicians’ Hospital Ass’n (1917) 96 Ohio St. 1, 116 N.E. 975, L.R.A. 1917F, 741, states the law applicable in this case, as follows:
“A public charitable hospital may receive pay from patients who are able to pay for the hospital accommodations they receive, but the money received from such source becomes a part of the trust fund, and must be devoted to the same trust purposes and cannot be diverted to private profit. (Taylor, Admr., v. The Protestant Hospital Assn., 85 Ohio St. 90 [96 N.E. 1089], approved and followed.)”
206 N.E.2d at 4.
It is also permissible for charitable nonprofit hospitals to fix their rates to cover the cost of replacing capital assets, as well as to meet the costs of current operations. In West Allegheny Hospital v. Board of Property Assessment, 500 Pa. 236, 455 A.2d 1170 (1982), the Pennsylvania Supreme Court held that a hospital maintained in part by public and private charity was exempt from real estate taxes, even though the hospital passed on approximately 70 percent of the cost of capital acquisitions to paying patients..
It is true that the hospitals in this case receive substantial revenues from third-party payors and patients, but there is not a shred of evidence in this record, much less a finding by the Tax Commission, that one cent of the revenues is used for any purpose other than furthering the charitable purposes of providing hospital services to the sick and infirm. On the contrary, the Tax Commission’s findings affirmatively establish that no person has profited from the revenues produced at either Utah Valley or American Fork Hospitals other than patients. Under time-honored legal principles, both hospitals qualify as charitable institutions.
IV. UTAH VALLEY HOSPITAL’S AND AMERICAN FORK HOSPITAL’S GIFTS TO THE COMMUNITY
The majority states Utah law4 to be as follows:
An entity may be granted a charitable tax exemption for its property under the Utah Constitution only if it meets the definition of a “charity” or if its property is used exclusively for “charitable” purposes. Essential to this definition is the element of gift to the community. “Charity is the contribution or dedication of something of value ... to the common good_ By exempting property used for charitable purposes, the *284constitutional convention sought to encourage individual or group sacrifice for the welfare of the community. An essential element of charity is an act of giving.” Salt Lake County v. Tax Commission ex rel. Greater Salt Lake Recreational Facilities, Utah, 596 P.2d 641, 643 (1979) (emphasis added). A gift to the community can be identified either by a substantial imbalance in the exchange between the charity and the recipient of its services or in the lessening of a government burden through the charity’s operation. Laborers Local No. 295, 658 P.2d at 1198 (Oaks, J., concurring).
The Court contends that neither of the hospitals here at issue has demonstrated “any substantial imbalance between the value of the services it provides and the payments it receives” because “the vast majority of the services provided ... are paid for by government programs, private insurance companies, or the individuals receiving care.” The majority cites no authority in support of the assertion that a nonprofit hospital loses its charitable status if its patient receipts cover current operating costs. The law, as stated above, is otherwise. More importantly, there is in fact a very substantial imbalance between the total cost of the hospital care given and the revenues of the hospital in this case, which is so apparent from the record as to be undeniable.
A. Direct Patient Subsidies
The basic facts are not disputed. Both hospitals render wholly free patient services in substantial amounts. In addition, they subsidize the cost of hospital services to the poor, the elderly, and workers whose hospital bills are paid only in part by worker’s compensation. During the years 1978-80, Utah Valley Hospital rendered wholly free services to indigents in the amount of $200,000, and in each of those years the amount increased substantially over the preceding year. During the same period, the hospital subsidized services rendered to Medicare, Medicaid, and worker’s compensation patients in the amount of $3,174,024. The corresponding figures for American Fork Hospital were $39,906 in indigent care and $421,306 for subsidization of Medicare, Medicaid, and worker’s compensation benefits.
However, the value of the charity extended to indigents is in fact greater than the amounts stated. The cost of the charity extended to patients who are first identified as charity patients after admission rather than at admission is charged to the “bad debts” account, along with traditional uncollectible accounts or bad debts, instead of being charged to charity. The reason for this accounting procedure is that some patients do not, or cannot (as in the case of emergency admissions), report their indi-gency status when they are first admitted to the hospital. After services have been rendered, the hospitals stop collection efforts once it is determined that a patient qualifies for charity. In such cases, the hospital accounting system shows the patient as a noncharity account. This accounting procedure is not unique to IHC hospitals. See, e.g., Jackson County v. State Tax Commission, Mo., 521 S.W.2d 378 (1975); West Allegheny Hospital v. Board of Property Assessment, 63 Pa. Commw. 555, 439 A.2d 1293, 1295 n. 4 (1981), reversed, 500 Pa. 236, 455 A.2d 1170 (1982).
In sum, the direct cost of patient charity given away by Utah Valley Hospital for the period in question is in excess of $3,374,-024, but less than $4,942,779 (which includes bad debts). The direct cost of the charity given away by American Fork Hospital is in excess of $461,212, but less than $639,024 (which includes bad debts).
The majority argues that for-profit hospitals also have bad debts. That is, of course, true, but it completely evades the central point.. Unlike for-profit hospitals, Utah Valley and American Fork have a policy against turning away indigent patients. Therefore, that portion of the hospitals’ bad debts which is attributable to indigency is bona fide charity since the charges would have been initially made to *285the charity account had the patient’s indi-gency been discovered at admission. Those charges are not just ordinary business bad debts experienced by all commercial enterprises, as the majority would have it.
More importantly, the majority opinion ignores the total dollar amount of charity provided by each hospital by dismissing the hospitals’ subsidization of Medicare, Medicaid, and worker’s compensation patients with the assertion that for-profit hospitals do the same. Even if that be true, it does not dimmish the value of the benefits of a tertiary care hospital available to them (in the case of Utah Valley Hospital) which they would not have at a for-profit hospital.
B. Capital Subsidies and Gifts
The most glaring lapse in the majority opinion, in my view, is its flat-out refusal to recognize that there would be no Utah Valley Hospital — at all — if it had not been given lock, stock, and barrel to IHC by the Church of Jesus Christ of Latter-Day Saints, which initially built the hospital. American Fork Hospital apparently was initially erected by taxpayers’ money. At the City’s request, IHC took over the operation of the hospital as a lessee of American Fork City to relieve the City of a governmental burden. It follows that all patients at both hospitals, whether indigent, part-paying, or fully paying patients, are direct beneficiaries of large monetary investments in land, buildings, and medical equipment. In the case of Utah Valley Hospital, the total value of the plant and equipment approximates $24,769,220. In the case of American Fork Hospital, the amount approximates $1,963,515.5
In addition to the “gift to the community” of the actual physical facilities, each and every patient benefits from the fact that IHC is a nonprofit corporation whose hospitals make no profit on the value of the assets dedicated to hospital care. The majority’s effort to portray IHC hospitals as if they were operated as for-profit entities has no substance in the record whatsoever. A for-profit hospital, unlike a nonprofit hospital, must necessarily price its services to make a profit on its investment if it is to stay in business. The surplus that Utah Valley and American Fork budget for is not by any means the equivalent of profit, as the majority wrongly suggests.6
In short, all patients at American Fork and Utah Valley Hospitals, whether indigent, partially subsidized, or those who pay the full amount charged, are benefited by the initial gift of the capital assets and by all subsequent donations to capital. In addition, they benefit directly by the nonprofit structure of the hospitals, which means that the hospital rates charged include nothing for profit or a return of capital invested by investors. Moreover, the direct contributions to patient care referred to above are understated by the amortized value of the capital assets donated and the amount of profit that would be charged patients had those hospitals been for-profit hospitals.
The majority’s dismissal of the $4,000,-000 donated to Utah Valley Hospital for the construction of additional physical facilities in 1978 demonstrates the scope of the Court’s disregard of the facts. The majority simply sets that gift at naught with the comment that there “was no demonstration of the impact of that donation on the current support, maintenance, and operation of that hospital in the tax year in question.” (Emphasis added.) Apparently the majority holds that the $4,000,000 should be ignored because it was not *286shown to have been expended, at least in part, on current expenses. It is clear that that sum did not go into current operating expenses, but rather into physical assets.7 In all events, the amount was substantial by any measure: some twenty percent of the whole project.
I know of no epistomology that requires that a perfectly obvious fact must be measured before its existence can be admitted. A flyer who ignores a mountain in plain view because it has not been measured courts disaster. A court of law that ignores obvious, relevant facts can hardly avoid substantial error.
Furthermore, the majority inaccurately asserts that Utah Valley charges rates comparable to other similar entities. The evidence is to the contrary. Utah Valley Hospital, with its 385 beds and expensive, sophisticated acute care equipment, charges rates comparable to the rates charged by Payson Hospital, a small for-profit hospital that renders inexpensive types of services. That comparison indicates that Utah Valley’s rates are low. Certainly the cost of operating the 80-bed, primary care Payson hospital ought to be lower than Utah Valley’s costs. Furthermore, the majority flatly ignores the uncon-tradicted testimony of the chairman of IHC that “we charge significantly less for the same admission” and “[w]e charge lower prices to our patients for the same level of complexity than would a for-profit hospital.”
In a similar vein, the majority asserts that there is no evidence that the gifts and donations to the hospital resulted in patient charges below “prevailing market rates,” that is, rates established by for-profit hospitals. The above facts show otherwise. In addition, there are no “prevailing market rates” for tertiary care hospitals, if by that term the majority means prevailing rates of competitive for-profit hospitals. There is no for-profit tertiary care hospital in the entire state of Utah; all tertiary care hospitals are non-profit institutions. In fact, there is no other tertiary care hospital, whether nonprofit or for-profit, in the immense, sparsely populated area served by the Utah Valley Hospital, which extends from Utah County to the Nevada-Arizona border. Indeed, the facts strongly suggest that a for-profit tertiary care hospital could not survive in the geographical market area served by Utah Valley.
In summary, Utah Valley Hospital made substantial gifts to all patients who use its facilities and even greater gifts to needy and indigent patients for the period 1978-80 to the following extent:
(1) Needy and indigent patients received in excess of $3,374,224 for direct patient care;
(2) All patients had access to a tertiary care hospital valued in excess of $24,769,-220, dedicated to serving all persons regardless of ability to pay, race, religion, or national origin and a hospital that would not exist but for the gift of that facility to the community by the Church of Jesus Christ of Latter-Day Saints;
(3) All patients received the value of having hospital services performed free of any charge for profit or cost of capital; and
(4) Some $4,000,000 was given by the community for capital improvements.
American Fork Hospital conferred the following financial gifts for the same period:
(1) In excess of $461,212 for direct patient care;
(2) Access to a local primary care community hospital dedicated to serving all persons regardless of ability to pay, race, religion, or national origin — and a hospital that would not exist but for the taxpayers of American Fork City, having a value in plant and equipment in excess of $1,963,515; and
(3) The value of having hospital services performed free of any charge for profit or cost of capital.
*287In short, all patients at both hospitals receive substantial benefits from tens of millions of dollars that have been invested to promote the health of citizens in Utah County and in the entire central and southern parts of the state. Common sense dictates that the above realities be recognized, yet the majority refuses to recognize any value whatsoever in the gift of the capital assets or the value of having those assets free of any charge for a return on interest.
In Salt Lake County v. Tax Commission ex rel. Greater Salt Lake Recreational Facilities, Utah, 596 P.2d 641, 643 (1979), we declared that “charity is the contribution or dedication of something of value ... to the common good_” In my view, the above facts and the Commission’s findings speak so loudly and eloquently for themselves as to determine the outcome.8 The majority wholly dismisses or ignores these facts and focuses on the assertion that “current operating expenses for both hospitals are covered almost entirely by revenue from patient charges” (emphasis added) and that “neither of the hospitals in this case demonstrated any substantial imbalance between the value of the services it provides and the payments it receives apart from any gifts, donations, or endowments.”
Presumably, only if the hospitals ran deficits, i.e., if the direct expenses of patient care exceeded patient income, would a hospital qualify in the majority’s view as a charitable institution. Of course, the deficits would have to be made up by donations, or the hospital would shortly lapse into bankruptcy. As the cases cited above recognize, modern hospitals can hardly be run on the basis that donations must subsidize current expenses. Moreover, the majority concludes that because governmental programs, private insurance companies, and individuals pay for the vast majority of the services provided, “collection of such remuneration does not constitute giving, but is a mere reciprocal exchange of services for money.” That conclusion is wrong because it ignores the fact that the hospitals’ charges do not cover the full costs, both overhead and direct, of operating a hospital. In the private sector of the economy, services are rarely given at cost or less than cost, let alone for free. If on rare occasions that does occur, it is usually only as a sales promotion to stimulate further profits. In contrast, the exchange in this case is not reciprocal because rates charged by these hospitals do not cover all costs.
Of course hospital charges are made; of course those who can pay do pay, whether it be through their insurance companies, through government programs, or personally; of course expenses are generally covered by revenues. As far as I know, every single court that has considered these factors has held that they do not make a nonprofit hospital noncharitable for tax purposes. See cases cited in Part VII, infra. The majority’s suggestion that a nonprofit hospital must have a deficit in its current accounts to qualify for charitable status is both anachronistic and a prescription for lesser quality hospital care, if not bankruptcy. The majority is quite explicit. “None of the defendants in this case made any effort to demonstrate that they would suffer any operating losses or have to discontinue any services if they are ineligible for exemption from property taxes.”9
*288V. TAX EXEMPT STATUS OF NONPROFIT HOSPITALS UNDER THE MAJORITY OPINION
The majority opinion, in effect, precludes all IHC nonprofit primary care hospitals from qualifying for a charitable exemption. IHC tertiary care hospitals may, however, qualify as a charity if tertiary care services are given away or shown to relieve a government burden. In footnote 14, the majority opinion sets forth the test that a hospital must meet:
Because of the unique character of [tertiary] medical care, it may well be possible to identify a substantial imbalance in the exchange between Utah Valley Hospital and the recipients of its tertiary care, or a lessening of a government burden through the offering of such care. In light of our statement in Loyal Order of Moose, 657 P.2d at 264, that “any separate part of the building occupied and used exclusively for charitable purposes ... qualifies for exemption,” it may be possible that the provision of tertiary care services could qualify as a charity if the requisite gift to the community were to be demonstrated. In this case, no effort was made to demonstrate for the record whether certain types of care were actually being “given away” by either institution or whether they could not in fact be provided without the offsetting factor of a tax exemption, at least to the extent of the value of the facilities needed to provide such care. We do not rule on the availability of tax exemptions under such circumstances in the context of this undeveloped record.
The majority’s suggestion that certain “separate part[s] of the building occupied and used” by a tertiary care hospital can qualify for an exemption is impracticable. Charity patients cannot realistically be isolated in one area of the hospital. An indigent, expectant mother must be treated like all other expectant mothers, and an indigent heart patient must be treated in the same facilities and with the same equipment as other heart patients. The particular nature of a patient’s medical problems has little to do with the financial resources of the patient. Nor is there a valid basis to say that a CAT scanner may be exempt because of the manner in which its use is priced. Obviously, the price of its use could be set either at cost or below cost. If the latter, the hospital could recoup the loss by charging higher prices for obstetrical care, for example. The point is that it is the hospital as a unit that is either a charity or not; it cannot be validly divided into areas or services. The majority’s slight opening of the door for tertiary care hospitals to qualify a part of their operations as charitable is so impractical and unrealistic as to be really no opening at all in my view.
The record also demonstrates that the primary care hospital and the tertiary care hospital involved in this case relieve a significant governmental burden, one of the two alternative tests for determining whether a nonprofit hospital qualifies to be treated as a charitable institution. If the two hospitals in this case do not relieve governmental burdens, as the majority holds, I do not know what more needs to be shown to prove the point. In the wide-open spaces of the West, where small communities are widely separated, the profit motive has not been sufficient to provide the needed impetus for the building of community hospitals (except in rare instances). Nor has it resulted in the construction of tertiary care hospitals on the more populous parts of the state.
*289The majority’s argument is that no government burden is relieved by providing hospital service to those who can pay for it on a for-profit basis. The argument misses the mark for two reasons. First, the alternatives are not for-profit or nonprofit hospitals. The alternatives are nonprofit hospital care or no hospital care at all, at least within the relevant geographical markets. Second, the charitable status of a hospital does not turn on whether it provides care for patients who can pay. The basic policy is not to tax the sick and infirm irrespective of ability to pay. A county provides many services to rich and poor alike without charging the rich for those services. Parks and playgrounds are but examples. Providing medical services may not be mandatory for counties or cities, but if they do, they most certainly promote the public health, safety, morals, and welfare in a most fundamental way. Surely cities and counties would, as a practical matter, be compelled to provide hospital services if the nonprofit hospitals in this state did not exist. Nor does the majority offer a valid reason for distinguishing between tertiary care and primary care hospitals with respect to relieving a governmental burden.
The majority’s central concern seems to be to establish competitive equality between for-profit and nonprofit primary care hospitals. The essence of competitive enterprise is profit. It is ironic indeed that the majority construes Article XIII, Section 2 to protect for-profit entities from the competition of nonprofit entities. The constitutional provision simply was not designed to deal with competitive equality. Nonprofit charitable corporations, such as Utah Valley Hospital and American Fork Hospital, are created for the sole purpose of conferring a public benefit, providing hospital care at the lowest possible rate. If, indeed, a nonprofit hospital has a competitive advantage over a for-profit hospital, that is of no concern in the application of Article XIII, Section 2. The majority misconstrues the basic premises of that provision by suggesting that nonprofit hospitals, which serve the sick and infirm for a purely altruistic purpose, are not essentially different for legal purposes from for-profit hospitals.
Furthermore, there are indeed numerous charities that have some commercial competition, such as the YWCA, the Red Cross, and many others. Certainly the majority’s wholly unsupported and entirely novel assertion that tax exemptions for nonprofit hospitals raise a serious constitutional question is, I submit, utterly meritless.
VI. DIFFERENCES BETWEEN FOR-PROFIT AND NONPROFIT HOSPITALS
A fundamental proposition which pervades the majority opinion is that there is no essential difference between for-profit and nonprofit hospital corporations. The majority declares that “the significant difference between for-profit and nonprofit hospital corporations is, in effect, the method of distribution of assets upon dissolution of the corporation, which is itself a rare occurrence.” The majority further asserts, without any record support, that “a large portion of the profits of most for-profit entities is used for capital improvement and new, updated equipment, and the defendant hospitals here similarly spend their revenues in excess of operational expenses.” 10
Two fundamental differences between for-profit and nonprofit corporations are ignored by the majority. First, it is axiomatic that a for-profit hospital must conduct its business to make a profit if it is to remain in business. Second, a for-profit hospital’s investment decisions as to what markets or communities to enter and what kinds of equipment to invest in are made from a basically different motive than a nonprofit hospital’s. The decisions of a for-profit hospital corporation must be based upon careful calculations as to the rate of return that may be expected on *290invested capital. If the rate of return is not sufficient, the investment is not made. Whether the surplus is reinvested in part or paid out to investors in dividends in whole or in part, the investor receives personal monetary benefit either in the increased value of his stock or in dividends.
The record indicates that for-profit hospitals in Utah have invested to a limited extent in high-volume, low-cost services such as pediatric, psychiatric, and obstetrical-gynecological services, but not in higher-cost, lower-volume kinds of services. It may well be that competition from a for-profit hospital is beneficial to the hospital industry generally, but there is no indication in this record that for-profit hospitals have acted in any fashion other than a for-profit corporation would normally act.
Nonprofit hospitals must, of course, be concerned with generating sufficient revenue to maintain themselves, but they are not concerned with earning a return on their investment for the benefit of stockholders. Their purposes are altruistic. Any surplus must be used in a manner that aggrandizes no one, such as for the lowering of rates, the acquisition of new equipment, or the improvement of facilities. This fundamental difference was explained by Mr. William N. Jones, a trustee and chairman of the Board of Trustees of Inter-mountain Health Care. He testified:
A nonprofit hospital system or hospital has a different approach to hospital care or health care, if you will, than someone who might be involved in it as a business, a business where they desire to have a fine product, and they do. I’m talking now about' profit-oriented business systems or hospitals, [they] must do well as a business. We must as a nonprofit system do well in our mission which is to provide health care. So consequently] when we try to provide health care, we do not try to provide just the health care that’s easy and remunerative such as obstetrics and pediatrics which are relatively not too complex, and you receive a fairly high level of income from them. On the other hand, examples of health care which are not — you are not able to really receive enough to cover them would be trauma, burns, open-heart, that kind of high level care.
Moreover, there is credible evidence that nonprofit hospitals in general are more efficient and charge less than for-profit hospitals. One study indicates that for-profit hospitals charge 17 percent more per admission to patients with health insurance and that administrative and general service costs were 13 percent higher than nonprofit hospitals. Paul Starr, The Social Transformations of American Medicine, 434 (1982). “National data also indicate that, for every bed-size category, for-profit hospitals have higher costs than the overall coverage for community hospitals.” Id. Mr. Jones also testified that IHC’s Board of Trustees considers itself a trustee of the health care facilities for the public. “[W]e see ourselves as owned by the community since the corporation owns itself and in effect the church gave the hospitals to the communities, and we’re entrusted with the running of the hospitals. We see them as in effect owned by the communities. We have fund raising drives and strive to have the communities feel that [they are] involved.”
In short, the majority’s argument that the only significant difference between for-profit and nonprofit hospitals is the distribution of assets on dissolution simply ignores reality. The majority’s wholly unsupported assertion that “the historical distinction between for-profit and nonprofit hospitals has eroded” is without any factual foundation in this record. The Court states:
Because the vast majority of their services are paid for, the nonprofit hospitals in this case accumulate capital, as do their profit-seeking counterparts. The record indicates that this accumulated capital is used for the construction of additional hospitals and other facilities throughout the IHC system and the provision of expanded services. The record before us is undeveloped on this point, but there is nothing therein to indicate that the capi*291tal accumulated by either of the defendant hospitals is even earmarked in any way for use in their facilities or even in Utah County.
Again, the Court’s position is contrary to the facts. Utah Valley Hospital budgets for the projected cost of services plus an additional five to seven percent reserve for contingencies and for replacement of building and equipment and for future expansion. Nothing is budgeted for IHC expansion. Even if the five to seven percent reserve were considered the equivalent of profit, which it is not, that would not begin to compare with the amount that would be required by most commercial institutions to make a reasonable return on investment. The administrator of Utah Valley Hospital, Mr. Davis, testified that the budget at that hospital
consists of those actual costs plus a contingency or reserve, and that includes, of course, monies or funds for either future expansion, replacement of equipment, replacement of buildings and so on. You see, we are in many ways, we are at the mercy of doctors and public and economy. For example, how do you budget the number of patients that are going to come to your hospital in a year or in advance? We find many times that we miss that sometimes regionally, sometimes nationally. Wherein we would budget for a given number of patients or income and the bottom falls out for three or four months. In that case, there is no reserve. There is no originality. We fight and scramble to make ends meet for the year, and those are the things that we are vulnerable to.... I think it is safe to say in order to remain viable, in order to keep from — what’s the word I want — self-liquidating ourselves, we must have something in the range of probability five or seven percent in order to stay alive. Now, that’s what we shoot for. That’s not what we always get. Without that, you see, we would be self-liquidating.
Utah Valley Hospital has recently acquired expensive, high technology equipment not found in any other hospital in its market area, whether for-profit or nonprofit. That technology includes a 22-bed neonatal unit, a linear accelerator to treat cancer, and a heart catheterization laboratory. It also has a number of well-recognized specialists on its staff and has recently applied to do open heart surgery because of the facilities it has been able to acquire. Whether those facilities were acquired from surplus revenues or from donations is of no consequence in my judgment.
VII. OTHER COURTS HAVE RECOGNIZED THE REALITIES OF MODERN HOSPITAL CONDITIONS
The majority declares that the “economic environment in which modern hospitals function is critical to our analysis in this case because it is an analysis which is generally not present in any of the cases relied upon by the dissenting opinions.” The majority tenders not one single item of proof in support of that sweeping and plainly inaccurate statement. For the majority to assert that all other courts have failed to perceive patently obvious changes in the business operations of hospitals over the past 60 years is just plainly wrong. The Court assumes a lack of perspicacity on the part of sister courts that is unwarranted.
For example, in Harvard Community Health Plan, Inc. v. Board of Assessors of Cambridge, 384 Mass. 536, 427 N.E.2d 1159, 1163 (1981), the Massachusetts Supreme Judicial Court stated:
However, we recognize too that major changes in the area of health care, especially in modes of operation and financing, have necessitated changes as well in definitional predicates. The term “charitable,” as applied to health care facilities, has been broadened since earlier times, when it was limited mainly to almshouses for the poor. As a result, the promotion of health, whether through the provision of health care or through medical education and research, is today generally seen as a charitable purpose. A. Scott, supra at §§ 368, 372; G.T. Bogert, *292Trusts & Trustees § 374 (rev. 2d ed. 1977). Such a purpose is separate and distinct from the relief of poverty, and no health organization need engage in “almsgiving” in order to qualify for exemption. See Barrett v. Brooks Hosp., Inc., 338 Mass. 754, 759, 157 N.E.2d 638 (1959); A. Scott, supra at 2895-2896. See also Eastern Ky. Welfare Rights Organization v. Simon, 506 F.2d 1278, 1287-1289 (D.C.Cir.1974), vacated on other grounds, 426 U.S. 26, 46, 96 S.Ct. 1917, 1928, 48 L.Ed.2d 450 (1976); Sound Health Ass’n v. Commissioner, 71 T.C. 158, 177-179 (1978). [Footnote omitted.]
In Evangelical Lutheran Good Samaritan Society v. Gage County, 181 Neb. 831, 151 N.W.2d 446 (1967) (quoting in part Young Men’s Christian Ass’n v. Lancaster County, 106 Neb. 105, 182 N.W. 593 (1921)), the Nebraska Supreme Court stated:
Formerly all institutions furnishing [care to sick or convalescing patients], including both hospitals and nursing homes, were providing care for many patients without compensation and extended charity in the sense of alms-giving or free services to the poor. With the advent of present day social security and welfare programs, this type of charity is not often found because assistance is available to the poor under these programs. Yet, “ * * * the courts have defined ‘charity’ to be something more than mere alms-giving or the relief of poverty and distress, and have given it a significance broad enough to include practical enterprises for the good of humanity operated at a moderate cost to those who receive the benefits.”
Eastern Kentucky Welfare Rights Organization v. Simon, 506 F.2d 1278, 1288 (D.C.Cir.1974), vacated on other grounds, Simon v. Eastern Kentucky Welfare Rights Organization, 426 U.S. 26, 96 S.Ct. 1917, 48 L.Ed.2d 450 (1976), discussed the development of hospitals from “almshouses supported by philanthropy and serving almost exclusively the sick poor” to “primary community health facility for both rich and poor.” The court recognized that prívate philanthropy had been in part displaced by Medicare, Medicaid, and local nonemergen-cy care for the poor. The court concluded: “[I]t appears that the rationale upon which the limited definition of ‘charitable’ was predicated has largely disappeared. To continue to base the ‘charitable’ status of a hospital strictly on the relief it provides for the poor fails to account for these major changes in the area of health care.” Id. at 1288-89.
Numerous opinions have discussed the manner in which modern nonprofit hospitals are operated, including particular practices which the majority asserts have changed hospitals to garden-variety commercial ventures. For example, it has long been recognized that patients in nonprofit hospitals who are financially able to pay are expected to pay. Eg., Harvard Community Health Plan, Inc. v. Board of Assessors, 384 Mass. 536, 427 N.E.2d 1159, 1163 n.10 (1981); Mayo Foundation v. Commissioner, 306 Minn. 25, 236 N.W.2d 767, 773 (1975); Jackson County v. State Tax Commission, Mo., 521 S.W.2d 378 (1975); Community Memorial Hospital v. Moberly, Mo., 422 S.W.2d 290, 295 (1967); Vick v. Cleveland Memorial Medical Foundation, 2 Ohio St.2d 30, 206 N.E.2d 2, 4 (1965); West Allegheny Hospital v. Board of Property Assessment, 500 Pa. 236, 455 A.2d 1170 (1982); City of Richmond v. Richmond Memorial Hospital, 202 Va. 86, 116 S.E.2d 79, 83 (1960). The importance of third-party payors and government welfare assistance programs in financing most patient care has been recognized. Intercity Hospital v. Squire, 56 F.Supp. 472 (W.D.Wash.1944); People v. Southern Illinois Hospital Corp., 404 Ill. 66, 88 N.E.2d 20, 23 (1949); Jackson County v. State Tax Commission, Mo., 521 S.W.2d 378, 384 (1975); Community Memorial Hospital v. Moberly, Mo., 422 S.W.2d 290, 293 (1967); Evangelical Lutheran Good Samaritan Society v. Gage County, 181 Neb. 831, 151 N.W.2d 446, 448 (1967); West Allegheny Hospital v. Board of Property Assessment, 500 Pa. 236, 455 A.2d 1170, 1172 (1982). The payment of *293reasonable salaries to hospital personnel and the realization of a surplus and the reinvestment of the surplus in maintaining or replacing plant and equipment or other charitable activities have been expressly approved. Scripps Memorial Hospital, Inc. v. California Employment Commission, 24 Cal.2d 669, 151 P.2d 109, 115 (1944); Harvard Community Health Plan, Inc. v. Board of Assessors, 384 Mass. 536, 427 N.E.2d 1159 (1981); Mayo Foundation v. Commissioner, 306 Minn. 25, 236 N.W.2d 767, 769, 774 (1975); Jackson County v. State Tax Commission, Mo., 521 S.W.2d 378 (1975); Community Memorial Hospital v. Moberly, Mo., 422 S.W.2d 290, 293 (1967); Evangelical Lutheran Good Samaritan Society v. Gage County, 181 Neb. 831, 151 N.W.2d 446, 448 (1967); West Allegheny Hospital v. Board of Property Assessment, 500 Pa. 236, 455 A.2d 1170, 1172 (1982); City of Richmond v. Richmond Memorial Hospital, 202 Va. 86, 116 S.E.2d 79, 80 (1960).
Numerous nonprofit hospitals have used credit counselors and debt collection agencies to collect from patients who are able to pay. E.g., Mayo Foundation v. Commissioner, 306 Minn. 25, 236 N.W.2d 767, 770 (1975); West Allegheny Hospital v. Board of Property Assessment, 500 Pa. 236, 455 A.2d 1170, 1172 (1982). The courts have also emphasized the critical difference between the profit and nonprofit corporate structure of hospitals and sustained the charitable status of nonprofit hospitals because their “business” nature is merely an incident to the primary mission of providing health care to the general population. Cf. Barnes Hospital v. Leggett, Mo., 589 S.W.2d 241 (1979) (en banc).
The majority’s assertion that “traditional assumptions bear little relationship to the economics of the medical-industrial complex of the 1980’s” is based on the majority’s refusal to acknowledge the development of case law that has occurred over at least the past 40 years.
Of course, a nonprofit corporate structure is not itself enough to provide tax immunity for a hospital. If a nonprofit hospital is operated to provide monetary benefits to its sponsors, it is not charitable. See Georgia Osteopathic Hospital, Inc. v. Alford, 217 Ga. 663, 124 S.E.2d 402 (1962); Aransas Hospital, Inc. v. Aransas Pass Independent School District, Tex.Civ.App., 521 S.W.2d 685 (1975). Utah law is to the same effect. Salt Lake County v. Tax Commission, Utah, 596 P.2d 641 (1979) (“where a profit motive underlies the activity,” there is no exemption even though a nonprofit corporation “is interposed between an entrepreneur and his customers”). In the instant case, however, the sponsors of the hospitals in question are not persons whose private, pecuniary interests are furthered by their control of the hospitals.
VIII. BURDEN OF PROOF
Finally, it should be noted that the majority does not dispute the fact that the hospitals meet the standards established by § 59-2-30.11 Nor does the majority dispute the fact that the standards there set out are supported by general principles of law widely accepted in other states. Nevertheless, the majority holds that provision unconstitutional, at least as applied, without saying specifically why.
Procedurally, the Court treats that statute as if it does not exist in holding that the hospitals have the burden of proving their entitlement to the tax exemption. In fact, the hospitals did prove that they complied with the standards set out in section 59-2-30. At that point, Utah County, not the hospitals, had the burden to prove that the statute was unconstitutional. The principle that one who attacks the constitutionality of a statute must assume the burden of proof is so well established as to require no citation. In constantly placing the burden on the hospitals, the Court, in my view, fails to apply the proper rule. In any event, the record is sufficient to sustain the tax exemptions of both hospitals, irrespective of burden of proof.
*294IX. CONCLUSION
In sum, I submit that the majority misapplies Article XIII, Section 2 of the Constitution and makes a radical departure from sound legal principles that are universally recognized. In part, the majority comes to the result it does because it refuses to recognize facts that are patently evident, in part because it assumes propositions of fact about this case that are unproved, and in part because it believes that nonprofit hospitals should stand on the same footing as for-profit hospitals to assure competitive equality because of changes in the nature of the hospital.
Because I fundamentally disagree with the majority, I dissent. I also concur in Justice Howe’s dissent to the extent that it addresses the substantive issues.

. The majority’s intimation that these facilities are not available to those who cannot pay is directly contrary to the'explicit findings of the Tax Commission and to the record. See infra.

. Religious organizations have played a major role in sponsoring nonprofit hospitals in the United States generally. It has been estimated, for example, that Catholic hospitals account for 25 percent of the hospital beds in the United States at present. Clark, Does the Nonprofit Form Fit the Hospital Industry? 93 Harv.L.Rev. 1416, 1458 (1980).

. In Dingwell, the court stated:
Any person, the rich as well as the poor, may fall sick or be injured or wounded and become a fit subject for charity. St. Luke, chapter 10, verses 30-37. A trust may be and often is charitable in its nature, uses, and purposes without giving alms to the poor. It is true that poverty is a condition which, even when brought about by indolence and waste of life’s opportunities, arrests the attention and commands the consideration of charity. Yet perhaps more worthy and deserving members of society than the ne’er-do-well poor may under certain conditions be proper objects of charity. A gift to establish and maintain a public institution where the misery and unhappiness of any person of high or low degree, rich or poor, may be considered and sanely dealt with would come within the purview of the definition of a public charity.
267 P. at 333.

. Without any stated justification, the Court also imports into Utah law a test formulated by the Minnesota Supreme Court under Minnesota law in North Star Research Institute v. Hennepin County, 306 Minn. 1, 236 N.W.2d 754 (1975). This Court modifies the standards enunciated there in one major respect. It requires that gifts and donations be shown to have a specific quantifiable effect on rates charged patients. The majority does not explain why it adds that requirement. There is no constitutional reason for that requirement.

. These figures are computed from the assessments appearing on the property tax notices and are probably low. It is significant that Utah Valley added a $21,000,000 addition to its building in 1978. No government funds were used for that addition.

. The majority argues that the "rapid growth" of IHC hospitals indicates that the earnings of Utah Valley and American Fork Hospitals are the equivalent of a for-profit hospital’s profit. Again, the record does not support the majority’s claim. IHC has taken over community hospitals such as one at Delta, Utah, because the municipal authorities asked IHC to do so, as one means of growth.

. Even if the amount were translated into its effect on the overhead part of patient charges or rates, the majority gives no indication of any standards that would determine whether the gift was sufficient to qualify as a gift.

. There is no question in this case that any of the funds generated by the hospitals are used for other than charitable purposes and that no individual benefits as a result of being a sponsor or incorporation of the hospitals.

. In addition, the majority states: "Justice Stewart’s assertion that the taxes levied by the county would have to be passed on to patients in the form of higher charges is without any foundation in the evidence. The far more logical assumption is that the growth of the IHC system would possibly be slowed, but there is no indication of a likelihood that current and future levels of care would be jeopardized.” The majority errs with that flight into fantasy. The chairman of IHC testified that tertiary hospital care would be jeopardized by the loss of a charitable tax exemption. Furthermore, the record does not indicate that either Utah Valley Hospital or American Fork Hospital has contributed financially to the growth of the IHC system. Indeed, at least part of IHC's growth has occurred from its taking over operation of municipal community hospitals, such as in *288American Fork and Delta, Utah. The short of it is that patients at American Fork and Utah Valley Hospitals will indeed pay the property taxes, as will the patients in all other nonprofit hospitals in Utah, because patient revenues are the only source from which such funds could be obtained.
If, however, it were demonstrated that patients of these hospitals paid hospital fees used in part to build or operate hospitals in other states, I might question the effect of that on the hospitals’ charitable status. I doubt that Utah County taxpayers should be required to subsidize IHC’s building of hospitals in Idaho or Wyoming.

. If a nonprofit hospital has been organized for the private gain of the sponsors of the hospital, which may occur for a variety of reasons, the courts have held those hospitals to be nonchari-table. E.g., Georgia Osteopathic Hospital, Inc. v. Alford, 217 Ga. 663, 124 S.E.2d 402 (1962).

. The text of that provision is set out in footnote 1 of the majority opinion.