Condensed Consolidated Statements of Cash Flows - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2023	Sep. 30, 2022
Cash Flows from Operating Activities:
Net income	$ 499,685	$ 486,613
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation & amortization	422,560	433,508
(Gain) loss on sale of assets and businesses	(6,250)	584
Stock-based compensation expense	65,702	62,741
Changes in assets & liabilities, net of effects from acquisitions and dispositions:
Accounts receivable	(193,108)	(155,142)
Accrued interest	60	529
Accrued and deferred income taxes	(33,240)	(4,900)
Other working capital accounts	(65,062)	(173,903)
Medicare accelerated payments and deferred CARES Act and other grants	1,764	2,921
Other assets and deferred charges	48,985	22,219
Other	13,717	(23,358)
Accrued insurance expense, net of commercial premiums paid	141,414	134,908
Payments made in settlement of self-insurance claims	(80,861)	(88,001)
Net cash provided by operating activities	815,366	698,719
Cash Flows from Investing Activities:
Property and equipment additions	(536,665)	(569,555)
Proceeds received from sales of assets and businesses	23,688	12,001
Acquisition of businesses and property	(3,728)	(18,666)
(Outflows) inflows from foreign exchange contracts that hedge our net U.K. investment	(7,723)	177,214
Decrease in capital reserves of commercial insurance subsidiary	0	100
Net cash used in investing activities	(524,428)	(398,906)
Cash Flows from Financing Activities:
Repayments of long-term debt	(54,009)	(194,115)
Additional borrowings, net	165,000	705,321
Financing costs	(308)	(2,541)
Repurchase of common shares	(385,339)	(723,384)
Dividends paid	(41,964)	(44,192)
Issuance of common stock	9,841	10,399
Profit distributions to noncontrolling interests	(5,258)	(5,426)
Purchase (sale) of ownership interests by (from) minority members	408	(49,089)
Net cash used in financing activities	(311,629)	(303,027)
Effect of exchange rate changes on cash, cash equivalents and restricted cash	493	(10,339)
(Decrease) increase in cash, cash equivalents and restricted cash	(20,198)	(13,553)
Cash, cash equivalents and restricted cash, beginning of period	200,837	178,934
Cash, cash equivalents and restricted cash, end of period	180,639	165,381
Supplemental Disclosures of Cash Flow Information:
Interest paid	149,247	78,992
Income taxes paid, net of refunds	191,189	182,091
Noncash purchases of property and equipment	$ 108,412	$ 97,264