Condensed Consolidated Statements of Cash Flows - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2024	Sep. 30, 2023
Cash Flows from Operating Activities:
Net income	$ 826,062	$ 499,685
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation & amortization	438,050	422,560
Gain on sale of assets and businesses	(5,124)	(6,250)
Costs related to extinguishment of debt	3,158	0
Stock-based compensation expense	72,727	65,702
Changes in assets & liabilities, net of effects from acquisitions and dispositions:
Accounts receivable	11,703	(193,108)
Accrued interest	(1,762)	60
Accrued and deferred income taxes	(10,949)	(33,240)
Other working capital accounts	1,329	(65,062)
Medicare accelerated payments and deferred CARES Act and other grants	0	1,764
Other assets and deferred charges	(5,621)	48,985
Other	25,732	13,717
Accrued insurance expense, net of commercial premiums paid	175,104	141,414
Payments made in settlement of self-insurance claims	(121,745)	(80,861)
Net cash provided by operating activities	1,408,664	815,366
Cash Flows from Investing Activities:
Property and equipment additions	(697,865)	(536,665)
Proceeds received from sales of assets and businesses	30,219	23,688
Acquisition of businesses and property	0	(3,728)
Outflows from foreign exchange contracts that hedge our net U.K. investment	(35,667)	(7,723)
Decrease in capital reserves of commercial insurance subsidiary	197	0
Net cash used in investing activities	(703,116)	(524,428)
Cash Flows from Financing Activities:
Repayments of long-term debt	(2,471,515)	(54,009)
Additional borrowings, net	2,210,248	165,000
Financing costs	(9,992)	(308)
Repurchase of common shares	(420,588)	(385,339)
Dividends paid	(40,302)	(41,964)
Issuance of common stock	10,864	9,841
Profit distributions to noncontrolling interests	(5,791)	(5,258)
Sale of ownership interests to minority members	8,959	408
Net cash used in financing activities	(718,117)	(311,629)
Effect of exchange rate changes on cash, cash equivalents and restricted cash	2,696	493
Decrease in cash, cash equivalents and restricted cash	(9,873)	(20,198)
Cash, cash equivalents and restricted cash, beginning of period	214,470	200,837
Cash, cash equivalents and restricted cash, end of period	204,597	180,639
Supplemental Disclosures of Cash Flow Information:
Interest paid	144,378	149,247
Income taxes paid, net of refunds	236,975	191,189
Noncash purchases of property and equipment	$ 87,333	$ 108,412