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CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($) $ in Millions | 12 Months Ended
--- | ---
Dec. 31, 2023 | Dec. 31, 2022 | Dec. 31, 2021
Cash flows from operating activities: |  |  |
Net income | $ 135.3 | $ 87.0 | $ 70.7
Adjustments to reconcile net income to net cash provided by operating activities: |  |  |
Depreciation and amortization | 118.1 | 114.8 | 98.8
Non-cash lease expense | 35.2 | 34.8 | 39.1
Non-cash interest expense, net | 25.0 | 25.9 | 22.0
Equity-based compensation expense | 17.7 | 18.4 | 17.4
Net loss on disposals, consolidations and deconsolidations | 14.4 | 11.1 | 2.2
Loss on debt extinguishment | 15.5 | 14.9 | 9.1
Deferred income taxes | (1.7) | 21.9 | 8.9
Equity in earnings of unconsolidated affiliates, net of distributions received | (2.2) | (1.8) | 0.2
Other non-cash income | 0.0 | (7.5) | 0.0
Changes in operating assets and liabilities, net of acquisitions and divestitures: |  |  |
Accounts receivable | (47.2) | (35.3) | (32.1)
Medicare accelerated payments and deferred governmental grants | (1.2) | (58.4) | (73.6)
DOJ settlement payments | 0.0 | 0.0 | (32.2)
Other operating assets and liabilities | (15.1) | (67.0) | (43.4)
Net cash provided by operating activities | 293.8 | 158.8 | 87.1
Cash flows from investing activities: |  |  |
Purchases of property and equipment | (88.8) | (80.6) | (57.6)
Payments for acquisitions, net of cash acquired | (80.0) | (146.4) | (285.8)
Proceeds from disposals of facilities and other assets | 25.8 | 12.9 | 6.0
Purchases of equity investments | (50.3) | (95.1) | 0.0
Proceeds from sales of equity investments | 1.4 | 12.8 | 5.4
Other investing activities | (33.7) | (11.5) | 0.3
Net cash used in investing activities | (225.6) | (307.9) | (331.7)
Cash flows from financing activities: |  |  |
Principal payments on long-term debt | (807.1) | (862.0) | (343.2)
Borrowings of long-term debt | 826.6 | 217.8 | 299.4
Payments of debt issuance costs | (24.3) | 0.0 | (11.7)
Payment of premium on debt extinguishment | 0.0 | (11.3) | 0.0
Proceeds from equity offerings | 0.0 | 882.9 | 581.8
Payments of equity offering costs | 0.0 | (25.2) | (27.6)
Distributions to non-controlling interest holders | (146.1) | (146.8) | (131.0)
Proceeds (payments) related to ownership transactions with non-controlling interest holders | 8.2 | (3.4) | (28.4)
Payments of preferred dividends | 0.0 | 0.0 | (5.1)
Other financing activities | (12.5) | (9.9) | (17.9)
Net cash (used in) provided by financing activities | (155.2) | 42.1 | 316.3
Net (decrease) increase in cash and cash equivalents | (87.0) | (107.0) | 71.7
Cash and cash equivalents at beginning of period | 282.9 | 389.9 | 318.2
Cash and cash equivalents at end of period | 195.9 | 282.9 | 389.9
Supplemental cash flow information: |  |  |
Interest paid, net of interest income received | 169.6 | 218.7 | 194.3
Cash paid for income taxes | 1.4 | 1.8 | 1.5
Non-cash purchases of property and equipment | $ 18.0 | $ 29.9 | $ 22.3

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