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Consolidated Statements of Cash Flows - USD ($) $ in Thousands | 12 Months Ended
--- | ---
Dec. 31, 2023 | Dec. 31, 2022 | Dec. 31, 2021
Cash Flows from Operating Activities: |  |  |
Net income | $ 719,307 | $ 656,982 | $ 987,632
Adjustments to reconcile net income to net cash provided by operating activities: |  |  |
Depreciation & amortization | 568,041 | 581,861 | 533,213
(Gain) loss on sales of assets and businesses | (6,250) | 584 | (5,170)
Stock-based compensation expense | 87,720 | 85,378 | 73,686
Costs related to extinguishment of debt | 0 | 0 | 16,831
Provision for asset impairment | 0 | 57,550 | 14,391
Changes in assets & liabilities, net of effects from acquisitions and dispositions: |  |  |
Accounts receivable | (182,444) | (258,338) | (8,873)
Accrued interest | 1,193 | 1,835 | 4,950
Accrued and deferred income taxes | (43,450) | (29,510) | (54,030)
Other working capital accounts | (32,321) | (146,692) | 46,526
Medicare accelerated payments and deferred CARES Act and other grants | 2,978 | 2,391 | (698,762)
Other assets and deferred charges | 48,517 | 19,918 | (39,337)
Other | 39,133 | (8,676) | (82,075)
Accrued insurance expense, net of commercial premiums paid | 183,462 | 174,723 | 186,215
Payments made in settlement of self-insurance claims | (118,089) | (141,983) | (91,502)
Net cash provided by operating activities | 1,267,797 | 996,023 | 883,695
Cash Flows from Investing Activities: |  |  |
Property and equipment additions | (743,055) | (734,001) | (855,659)
Acquisition of businesses and property | (3,728) | (20,309) | (105,415)
(Outflows) inflows from foreign exchange contracts that hedge our net U.K. investment | (40,695) | 94,913 | 1,357
Proceeds received from sales of assets and businesses | 24,187 | 12,001 | 25,425
Costs incurred for purchase and implementation of information technology applications | 0 | 0 | 19,726
Decrease (increase) in capital reserves of commercial insurance subsidiary | 16 | 100 | 100
Net cash used in investing activities | (763,275) | (647,296) | (914,466)
Cash Flows from Financing Activities: |  |  |
Repayments of long-term debt | (85,480) | (89,367) | (3,037,868)
Additional borrowings | 185,100 | 705,321 | 3,254,974
Financing costs | (308) | (3,164) | (18,770)
Repurchase of common shares | (547,363) | (832,918) | (1,220,875)
Dividends paid | (55,480) | (58,449) | (65,896)
Issuance of common stock | 13,654 | 14,068 | 13,372
Profit distributions to noncontrolling interests | (6,830) | (5,391) | (7,080)
Purchase (sale) of ownership interests by (from) minority member | 2,762 | (48,500) | 13,193
Net cash used in financing activities | (493,945) | (318,400) | (1,068,950)
Effect of exchange rate changes on cash and cash equivalents | 3,056 | (8,424) | (499)
Increase decrease in cash, cash equivalents and restricted cash | 13,633 | 21,903 | (1,100,220)
Cash, cash equivalents and restricted cash, beginning of period | 200,837 | 178,934 | 1,279,154
Cash, cash equivalents and restricted cash, end of period | 214,470 | 200,837 | 178,934
Supplemental Disclosures of Cash Flow Information: |  |  |
Interest paid | 200,446 | 120,136 | 75,607
Income taxes paid, net of refunds | 257,896 | 250,759 | 362,978
Noncash purchases of property and equipment | $ 66,899 | $ 72,064 | $ 167,234

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