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Goodwill | 6 Months Ended
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Jun. 30, 2019
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill | Goodwill Changes in goodwill by reportable segment were as follows:
| U.S. dialysis and related lab services |  | Other-ancillary services and strategic initiatives |  | Consolidated total
Balance at December 31, 2017 | $ | 6,144,761 |  |  | $ | 465,518 |  |  | $ | 6,610,279 |
Acquisitions | 130,574 |  |  | 147,774 |  |  | 278,348 |
Divestitures | (331 | ) |  | (15,166 | ) |  | (15,497 | )
Impairment charges | — |  |  | (3,106 | ) |  | (3,106 | )
Foreign currency and other adjustments | — |  |  | (28,064 | ) |  | (28,064 | )
Balance at December 31, 2018 | $ | 6,275,004 |  |  | $ | 566,956 |  |  | $ | 6,841,960 |
Acquisitions | 15,714 |  |  | 50,900 |  |  | 66,614 |
Impairment charges | — |  |  | (41,037 | ) |  | (41,037 | )
Foreign currency and other adjustments | — |  |  | (2,151 | ) |  | (2,151 | )
Balance at June 30, 2019 | $ | 6,290,718 |  |  | $ | 574,668 |  |  | $ | 6,865,386 |
Balance at June 30, 2019: |  |  |  |  |
Goodwill | $ | 6,290,718 |  |  | $ | 643,266 |  |  | $ | 6,933,984 |
Accumulated impairment charges | — |  |  | (68,598 | ) |  | (68,598 | )
| $ | 6,290,718 |  |  | $ | 574,668 |  |  | $ | 6,865,386 |
The Company elected to early adopt ASU No. 2017-04, Intangibles-Goodwill and Other (Topic 350): Simplifying the Test for Goodwill Impairment effective January 1, 2017. The amendments in this ASU simplify the test for goodwill impairment by eliminating the second step in the assessment. All goodwill impairment tests performed since adoption were performed under this new guidance. During the three months ended June 30, 2019, the Company performed annual and other goodwill impairment assessments for various reporting units, including its Brazil kidney care operations. No goodwill impairment was recognized as part of these assessments. During the six months ended June 30, 2019, the Company recognized a $41,037 goodwill impairment charge in its Germany kidney care business. This charge resulted primarily from a change in relevant discount rates, a decline in current and expected patient census in the period and higher than expected current and future costs, primarily due to newly announced legislation that is expected to increase wages in that market. This impairment charge included an $8,865 increase to the goodwill impairment charge, and reduction to deferred tax expense, related to deferred tax assets that the impairment itself generated. The effect was a $41,037 goodwill impairment charge to operating income and an $8,865 credit to tax expense, for a net $32,172 impact on net income. Based on the most recent assessments, the Company determined that changes in expected patient census, increases in operating costs, reductions in reimbursement rates, changes in actual or expected growth rates, or other significant adverse changes in expected future cash flows or valuation assumptions could result in goodwill impairment charges in the future for the following reporting units, which remain at risk of goodwill impairment as of June 30, 2019.
Reporting unit |  | Goodwill balance as of June 30, 2019 |  | Carrying amount coverage(1) |  | Sensitivities
Operating income(2) |  | Discount rate(3)
Brazil Kidney Care |  | $ | 69,887 |  |  | 4.4% |  | (2.8)% |  | (7.0)%
Germany Kidney Care |  | $ | 380,340 |  |  | —% |  | (1.4)% |  | (9.3)%
(1) | Excess of estimated fair value of the reporting unit over its carrying amount as of the latest assessment date.
(2) | Potential impact on estimated fair value of a sustained, long-term reduction of 3% in operating income as of the latest assessment date.
(3) | Potential impact on estimated fair value of an increase in discount rates of 100 basis points as of the latest assessment date.
The Company recognized a $3,106 goodwill impairment charge during the three and six months ended June 30, 2018 at its German other health operations. Except as described above and in Note 11 to the Company's consolidated financial statements included in the 10-K, none of the Company's various other reporting units were considered at risk of significant goodwill impairment as of June 30, 2019. Since the dates of the Company's last annual goodwill impairment assessments there have been certain developments, events, changes in operating performance and other changes in key circumstances that have affected the Company's businesses. However, these changes did not cause management to believe it is more likely than not that the fair values of any of the Company's reporting units would be less than their respective carrying amounts as of June 30, 2019.

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