Condensed Consolidated Statements of Cash Flows - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2019
Cash Flows from Operating Activities:
Net income	$ 645,056	$ 579,533
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation & amortization	376,563	362,736
(Gain) loss on sale of assets and businesses	2,124	(5,982)
Stock-based compensation expense	49,928	52,167
Costs related to extinguishment of debt	1,365
Provision for asset impairment		97,631
Changes in assets & liabilities, net of effects from acquisitions and dispositions:
Accounts receivable	45,435	(37,332)
Accrued interest	(10,526)	(2,962)
Accrued and deferred income taxes	(2,095)	(53,714)
Other working capital accounts	85,944	90,262
Medicare accelerated payments and deferred CARES Act and other grants	878,480
Other assets and deferred charges	1,271	15,237
Other	115,431	(663)
Accrued insurance expense, net of commercial premiums paid	113,571	76,245
Payments made in settlement of self-insurance claims	(84,390)	(68,046)
Net cash provided by operating activities	2,218,157	1,105,112
Cash Flows from Investing Activities:
Property and equipment additions, net of disposals	(546,656)	(480,247)
Proceeds received from sales of assets and businesses	7,851	7,497
Acquisition of businesses and property	(52,009)
Inflows from foreign exchange contracts that hedge our net U.K. investment	22,453	34,484
Costs incurred for purchase and implementation of information technology applications	(5,345)	(18,240)
Investment in, and advances to, joint ventures and other	(997)	(11,949)
Net cash used in investing activities	(574,703)	(468,455)
Cash Flows from Financing Activities:
Reduction of long-term debt	(1,173,590)	(68,175)
Additional borrowings	803,197	15,100
Financing costs	(8,256)
Repurchase of common shares	(200,098)	(587,976)
Dividends paid	(17,344)	(35,556)
Issuance of common stock	9,288	8,248
Profit distributions to noncontrolling interests	(15,175)	(11,887)
Purchase of ownership interests from minority members	(548)
Net cash used in financing activities	(602,526)	(680,246)
Effect of exchange rate changes on cash, cash equivalents and restricted cash	(706)	(1,259)
Increase (decrease) in cash, cash equivalents and restricted cash	1,040,222	(44,848)
Cash, cash equivalents and restricted cash, beginning of period	105,667	199,685
Cash, cash equivalents and restricted cash, end of period	1,145,889	154,837
Supplemental Disclosures of Cash Flow Information:
Interest paid	93,579	122,699
Income taxes paid, net of refunds	208,460	221,298
Noncash purchases of property and equipment	76,402	83,552
Right-of-use assets obtained in exchange for lease obligations	$ 47,679	$ 364,453