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CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($) $ in Millions | 12 Months Ended
--- | ---
Dec. 31, 2024 | Dec. 31, 2023 | Dec. 31, 2022
Cash flows from operating activities: |  |  |
Net income | $ 12.5 | $ 135.3 | $ 87.0
Adjustments to reconcile net income to net cash provided by operating activities: |  |  |
Depreciation and amortization | 152.6 | 118.1 | 114.8
Non-cash lease expense | 38.9 | 35.2 | 34.8
Non-cash interest expense, net | 6.5 | 25.0 | 25.9
Equity-based compensation expense | 33.3 | 17.7 | 18.4
Net loss on disposals, consolidations and deconsolidations | 40.6 | 14.4 | 11.1
Loss on debt extinguishment | 5.1 | 15.5 | 14.9
Deferred income taxes | 131.5 | (1.7) | 21.9
Equity in earnings of unconsolidated affiliates, net of distributions received | (2.0) | (2.2) | (1.8)
Other non-cash income | 0.0 | 0.0 | (7.5)
Changes in operating assets and liabilities, net of acquisitions and divestitures: |  |  |
Accounts receivable | (72.1) | (47.2) | (35.3)
Medicare accelerated payments and deferred governmental grants | 0.0 | (1.2) | (58.4)
Other operating assets and liabilities | (46.8) | (15.1) | (67.0)
Net cash provided by operating activities | 300.1 | 293.8 | 158.8
Cash flows from investing activities: |  |  |
Purchases of property and equipment | (90.4) | (88.8) | (80.6)
Payments for acquisitions, net of cash acquired | (378.8) | (80.0) | (146.4)
Proceeds from disposals of facilities and other assets | 2.6 | 25.8 | 12.9
Purchases of equity investments | (1.7) | (50.3) | (95.1)
Proceeds from sales of equity investments | 4.6 | 1.4 | 12.8
Other investing activities | (24.8) | (33.7) | (11.5)
Net cash used in investing activities | (488.5) | (225.6) | (307.9)
Cash flows from financing activities: |  |  |
Principal payments on long-term debt | (1,279.3) | (807.1) | (862.0)
Borrowings of long-term debt | 1,729.7 | 826.6 | 217.8
Payments of debt issuance costs | (14.9) | (24.3) | 0.0
Payment of premium on debt extinguishment | 0.0 | 0.0 | (11.3)
Proceeds from equity offerings | 0.0 | 0.0 | 882.9
Payments of equity offering costs | 0.0 | 0.0 | (25.2)
Distributions to non-controlling interest holders | (170.5) | (146.1) | (146.8)
Proceeds (payments) related to ownership transactions with non-controlling interest holders | 9.6 | 8.2 | (3.4)
Other financing activities | (12.6) | (12.5) | (9.9)
Net cash provided by (used in) financing activities | 262.0 | (155.2) | 42.1
Net increase (decrease) in cash and cash equivalents | 73.6 | (87.0) | (107.0)
Cash and cash equivalents at beginning of period | 195.9 | 282.9 | 389.9
Cash and cash equivalents at end of period | 269.5 | 195.9 | 282.9
Supplemental cash flow information: |  |  |
Interest paid, net of interest income received | 199.7 | 169.6 | 218.7
Cash paid for income taxes | 1.6 | 1.4 | 1.8
Non-cash purchases of property and equipment | $ 12.9 | $ 18.0 | $ 29.9

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