Condensed Consolidated Statements of Cash Flows - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Cash Flows from Operating Activities:
Net income	$ 753,721	$ 645,056
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation & amortization	399,850	376,563
(Gain) loss on sale of assets and businesses	(4,803)	2,124
Costs related to extinguishment of debt	16,831	1,365
Stock-based compensation expense	55,548	49,928
Provision for asset impairment	7,195
Changes in assets & liabilities, net of effects from acquisitions and dispositions:
Accounts receivable	(29,079)	45,435
Accrued interest	3,714	(10,526)
Accrued and deferred income taxes	(52,727)	(2,095)
Other working capital accounts	52,616	85,944
Medicare accelerated payments and deferred CARES Act and other grants	(697,393)	878,480
Other assets and deferred charges	(34,038)	1,271
Other	9,607	115,431
Accrued insurance expense, net of commercial premiums paid	140,702	113,571
Payments made in settlement of self-insurance claims	(60,069)	(84,390)
Net cash provided by operating activities	561,675	2,218,157
Cash Flows from Investing Activities:
Property and equipment additions	(666,025)	(546,656)
Proceeds received from sales of assets and businesses	21,143	7,851
Acquisition of businesses and property	(39,391)	(52,009)
Inflows from foreign exchange contracts that hedge our net U.K. investment	4,261	22,453
Decrease in capital reserves of commercial insurance subsidiary	100
Costs incurred for purchase of information technology applications, net of refunds	20,202	(5,345)
Investment in, and advances to, joint ventures and other		(997)
Net cash used in investing activities	(659,710)	(574,703)
Cash Flows from Financing Activities:
Repayments of long-term debt	(3,026,888)	(1,173,590)
Additional borrowings	2,912,374	803,197
Financing costs	(17,967)	(8,256)
Repurchase of common shares	(770,665)	(200,098)
Dividends paid	(50,284)	(17,344)
Issuance of common stock	10,108	9,288
Profit distributions to noncontrolling interests	(5,744)	(15,175)
Purchase of ownership interests by (from) minority members	13,046	(548)
Net cash used in financing activities	(936,020)	(602,526)
Effect of exchange rate changes on cash, cash equivalents and restricted cash	(682)	(706)
(Decrease) increase in cash, cash equivalents and restricted cash	(1,034,737)	1,040,222
Cash, cash equivalents and restricted cash, beginning of period	1,279,154	105,667
Cash, cash equivalents and restricted cash, end of period	244,417	1,145,889
Supplemental Disclosures of Cash Flow Information:
Interest paid	58,719	93,579
Income taxes paid, net of refunds	286,376	208,460
Noncash purchases of property and equipment	$ 73,428	$ 76,402