Income Taxes (Details 2)	12 Months Ended
	Dec. 31, 2015	Dec. 31, 2014	Dec. 31, 2013
Effective tax rate reconciliation
Statutory U.S. federal tax rate	35.00%	35.00%	35.00%
Increase (decrease) in rate resulting from:
Effect of qualified domestic production deduction	(0.00%)	(1.40%)	(0.40%)
Effect of Patient Protection and Affordable Care Act		0.00%	0.90%
Effect of noncontrolling interest	5.30%	(2.50%)	(1.30%)
State and local income taxes, net of related federal taxes	1.40%	2.70%	2.00%
Income taxes on foreign earnings	9.40%	(0.40%)	0.10%
Change in pre-acquisition tax liability	3.50%	0.00%	0.40%
Tax associated with accrued and unpaid dividends	(13.60%)
Goodwill impairment	(35.60%)
Nondeductible compensation	(5.00%)	0.20%	0.10%
Other, net	1.70%	(0.20%)	(0.80%)
Effective tax rate	2.10%	33.40%	36.00%