HCA HEALTHCARE, INC., 10-K filed on 2/18/2022
Annual Report
v3.22.0.1
Cover Page - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Jan. 31, 2022
Jun. 30, 2021
Cover [Abstract]      
Document Type 10-K    
Amendment Flag false    
Document Period End Date Dec. 31, 2021    
Document Fiscal Year Focus 2021    
Document Fiscal Period Focus FY    
Trading Symbol HCA    
Entity Registrant Name HCA Healthcare, Inc.    
Entity Central Index Key 0000860730    
Current Fiscal Year End Date --12-31    
Entity Current Reporting Status Yes    
Entity Filer Category Large Accelerated Filer    
Entity Shell Company false    
Entity Small Business false    
Entity Emerging Growth Company false    
Entity Common Stock, Shares Outstanding   303,600,000  
Entity Interactive Data Current Yes    
Entity File Number 1-11239    
Entity Incorporation, State or Country Code DE    
Entity Tax Identification Number 27-3865930    
Entity Address, Address Line One One Park Plaza    
Entity Address, City or Town Nashville    
Entity Address, State or Province TN    
Entity Address, Postal Zip Code 37203    
City Area Code 615    
Local Phone Number 344-9551    
Document Annual Report true    
Document Transition Report false    
Title of 12(b) Security Common Stock, $0.01 Par Value    
Security Exchange Name NYSE    
Entity Voluntary Filers No    
Entity Well-known Seasoned Issuer No    
Entity Public Float     $ 51,895
ICFR Auditor Attestation Flag true    
Auditor Firm ID 42    
Auditor Name Ernst & Young LLP    
Auditor Location Nashville, Tennessee, United States of America    
v3.22.0.1
Consolidated Income Statements - USD ($)
shares in Thousands, $ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Income Statement [Abstract]      
Revenues $ 58,752 $ 51,533 $ 51,336
Salaries and benefits 26,779 23,874 23,560
Supplies 9,481 8,369 8,481
Other operating expenses 9,961 9,307 9,481
Equity in earnings of affiliates (113) (54) (43)
Depreciation and amortization 2,853 2,721 2,596
Interest expense 1,566 1,584 1,824
Losses (gains) on sales of facilities (1,620) 7 (18)
Losses on retirement of debt 12 295 211
Total expenses including equity in earnings of affiliates 48,919 46,103 46,092
Income before income taxes 9,833 5,430 5,244
Provision for income taxes 2,112 1,043 1,099
Net income 7,721 4,387 4,145
Net income attributable to noncontrolling interests 765 633 640
Net income attributable to HCA Healthcare, Inc. $ 6,956 $ 3,754 $ 3,505
Per share data:      
Basic earnings per share $ 21.52 $ 11.10 $ 10.27
Diluted earnings per share $ 21.16 $ 10.93 $ 10.07
Shares used in earnings per share calculations (in millions):      
Basic 323,315 338,274 341,210
Diluted 328,752 343,605 348,226
v3.22.0.1
Consolidated Comprehensive Income Statements - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Statement of Comprehensive Income [Abstract]      
Net income $ 7,721 $ 4,387 $ 4,145
Other comprehensive income (loss) before taxes:      
Foreign currency translation (9) 18 5
Unrealized (losses) gains on available-for-sale securities (16) 14 15
Defined benefit plans 87 (71) (63)
Pension costs included in salaries and benefits 28 28 13
Total defined benefit plans 115 (43) (50)
Change in fair value of derivative financial instruments 1 (66) (50)
Interest costs (benefits) included in interest expense 37 24 (17)
Total change in fair value of derivative financial instruments 38 (42) (67)
Other comprehensive income (loss) before taxes 128 (53) (97)
Income taxes (benefits) related to other comprehensive income items 30 (11) (18)
Other comprehensive income (loss) 98 (42) (79)
Comprehensive income 7,819 4,345 4,066
Comprehensive income attributable to noncontrolling interests 765 633 640
Comprehensive income attributable to HCA Healthcare, Inc. $ 7,054 $ 3,712 $ 3,426
v3.22.0.1
Consolidated Balance Sheets - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Current assets:    
Cash and cash equivalents $ 1,451 $ 1,793
Accounts receivable 8,095 7,051
Inventories 1,986 2,025
Other 2,010 1,464
Total current assets 13,542 12,333
Property and equipment, at cost:    
Land 2,496 2,269
Buildings 19,211 18,471
Equipment 28,256 27,082
Construction in progress 1,387 1,495
Property and equipment, at cost 51,350 49,317
Accumulated depreciation (27,287) (26,118)
Property and equipment, net 24,063 23,199
Investments of insurance subsidiaries 438 388
Investments in and advances to affiliates 448 422
Goodwill and other intangible assets 9,540 8,578
Right-of-use operating lease assets 2,113 2,024
Other 598 546
Total assets 50,742 47,490
Current liabilities:    
Accounts payable 4,111 3,535
Accrued salaries 1,912 1,720
Other accrued expenses 3,322 3,240
Long-term debt due within one year 237 209
Total current liabilities 9,582 8,704
Long-term debt, less debt issuance costs and discounts of $248 and $236 34,342 30,795
Professional liability risks 1,514 1,486
Right-of-use operating lease obligations 1,755 1,673
Income taxes and other liabilities 2,060 1,940
Stockholders' equity:    
Common stock $0.01 par; authorized 1,800,000,000 shares; outstanding 305,476,800 shares — 2021 and 339,425,600 shares — 2020 3 3
Capital in excess of par value 0 294
Accumulated other comprehensive loss (404) (502)
Retained earnings (deficit) (532) 777
Stockholders' equity (deficit) attributable to HCA Healthcare, Inc. (933) 572
Noncontrolling interests 2,422 2,320
Total stockholders' equity (deficit) 1,489 2,892
Total liabilities and stockholders' equity (deficit) $ 50,742 $ 47,490
v3.22.0.1
Consolidated Balance Sheets (Parenthetical) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Statement of Financial Position [Abstract]    
Debt issuance costs $ 248 $ 236
Common stock, par value $ 0.01 $ 0.01
Common stock, shares authorized 1,800,000,000 1,800,000,000
Common stock, shares outstanding 305,476,800 339,425,600
v3.22.0.1
Consolidated Statements of Stockholders' Equity (Deficit) - USD ($)
$ in Millions
Total
Common Stock [Member]
Capital in Excess of Par Value [Member]
Accumulated Other Comprehensive Loss [Member]
Retained Earnings (Deficit) [Member]
Equity Attributable to Noncontrolling Interests [Member]
Balances at Dec. 31, 2018 $ (2,918) $ 3   $ (381) $ (4,572) $ 2,032
Balance, shares at Dec. 31, 2018   342,895,000        
Comprehensive income (loss) 4,066     (79) 3,505 640
Repurchase of common stock $ (1,031)   $ (302)   (729)  
Repurchase of common stock, shares (7,949,000) (7,949,000)        
Share-based benefit plans $ 313   313      
Share-based benefit plans, shares   3,500,000        
Cash dividends declared (555)       (555)  
Distributions (542)         (542)
Other 102   (11)     113
Balance at Dec. 31, 2019 (565) $ 3   (460) (2,351) 2,243
Balance, shares at Dec. 31, 2019   338,446,000        
Comprehensive income (loss) 4,345     (42) 3,754 633
Repurchase of common stock $ (441)       (441)  
Repurchase of common stock, shares (3,287,000) (3,287,000)        
Share-based benefit plans $ 265   300   (35)  
Share-based benefit plans, shares   4,267,000        
Cash dividends declared (150)       (150)  
Distributions (626)         (626)
Other 64   (6)     70
Balance at Dec. 31, 2020 2,892 $ 3 294 (502) 777 2,320
Balance, shares at Dec. 31, 2020   339,426,000        
Comprehensive income (loss) 7,819     98 6,956 765
Repurchase of common stock $ (8,215)   (578)   (7,637)  
Repurchase of common stock, shares (37,812,000) (37,812,000)        
Share-based benefit plans $ 280   280      
Share-based benefit plans, shares   3,863,000        
Cash dividends declared (628)       (628)  
Distributions (749)         (749)
Other 90   4     86
Balance at Dec. 31, 2021 $ 1,489 $ 3 $ 0 $ (404) $ (532) $ 2,422
Balance, shares at Dec. 31, 2021   305,477,000        
v3.22.0.1
Consolidated Statements of Stockholders' Equity (Deficit) (Parenthetical) - $ / shares
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Statement of Stockholders' Equity [Abstract]      
Cash dividends declared, per share $ 1.92 $ 0.43 $ 1.60
v3.22.0.1
Consolidated Statements of Cash Flows - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Cash flows from operating activities:      
Net income $ 7,721 $ 4,387 $ 4,145
Increase (decrease) in cash from operating assets and liabilities:      
Accounts receivable (962) 327 (326)
Inventories and other assets (540) (304) (158)
Accounts payable and accrued expenses 999 1,255 396
Depreciation and amortization 2,853 2,721 2,596
Income taxes (70) 41 250
Losses (gains) on sales of facilities (1,620) 7 (18)
Losses on retirement of debt 12 295 211
Amortization of debt issuance costs 27 30 30
Share-based compensation 440 362 347
Other 99 111 129
Net cash provided by operating activities 8,959 9,232 7,602
Cash flows from investing activities:      
Purchase of property and equipment (3,577) (2,835) (4,158)
Acquisition of hospitals and health care entities (1,105) (568) (1,682)
Sales of hospitals and health care entities 2,160 68 61
Change in investments (117) (20) 25
Other (4) (38) 34
Net cash used in investing activities (2,643) (3,393) (5,720)
Cash flows from financing activities:      
Issuances of long-term debt 4,344 2,700 6,451
Net change in revolving credit facilities 2,780 (2,480) (560)
Repayment of long-term debt (3,869) (3,437) (5,324)
Distributions to noncontrolling interests (749) (626) (542)
Payment of debt issuance costs (38) (35) (73)
Payment of dividends (624) (153) (550)
Repurchase of common stock (8,215) (441) (1,031)
Other (284) (205) (142)
Net cash used in financing activities (6,655) (4,677) (1,771)
Effect of exchange rate changes on cash and cash equivalents (3) 10 8
Change in cash and cash equivalents (342) 1,172 119
Cash and cash equivalents at beginning of period 1,793 621 502
Cash and cash equivalents at end of period 1,451 1,793 621
Interest payments 1,502 1,607 1,914
Income tax payments, net $ 2,182 $ 1,002 $ 849
v3.22.0.1
Accounting Policies
 12 Months Ended
Dec. 31, 2021
Accounting Policies [Abstract]  
Accounting Policies
NOTE 1 — ACCOUNTING POLICIES
Reporting Entity
HCA Healthcare, Inc. is a holding company whose affiliates own and operate hospitals and related health care entities. The term “affiliates” includes direct and indirect subsidiaries of HCA Healthcare, Inc. and partnerships and joint ventures in which such subsidiaries are partners. At December 31, 2021 these affiliates owned and operated 182 hospitals, 125 freestanding surgery centers, 21 freestanding endoscopy centers and provided extensive outpatient and ancillary services. HCA Healthcare, Inc.’s facilities are located in 20 states and England. The terms “Company,” “HCA,” “we,” “our” or “us,” as used herein and unless otherwise stated or indicated by context, refer to HCA Healthcare, Inc. and its affiliates. The terms “facilities” or “hospitals” refer to entities owned and operated by affiliates of HCA and the term “employees” refers to employees of affiliates of HCA.
Basis of Presentation
The preparation of financial statements in conformity with generally accepted accounting principles requires management to make estimates and assumptions that affect the amounts reported in the consolidated financial statements and accompanying notes. Actual results could differ from those estimates.
The consolidated financial statements include all subsidiaries and entities controlled by HCA. We generally define “control” as ownership of a majority of the voting interest of an entity. The consolidated financial statements include entities in which we absorb a majority of the entity’s expected losses, receive a majority of the entity’s expected residual returns, or both, as a result of ownership, contractual or other financial interests in the entity. The accounts of acquired entities are included in our consolidated financial statements for periods subsequent to our acquisition of controlling interests. Significant intercompany transactions have been eliminated. Investments in entities we do not control, but in which we have a substantial ownership interest and can exercise significant influence, are accounted for using the equity method.
The majority of our expenses are “cost of revenue” items. Costs that could be classified as general and administrative include our corporate office costs, which were $400 million, $416 million and $370 million for the years ended December 31, 2021, 2020 and 2019, respectively.
COVID-19
Pandemic
On March 11, 2020, the World Health Organization designated
COVID-19
as a global pandemic. Patient volumes and the related revenues for most of our services were significantly impacted during the latter portion of the first quarter and the first half of the second quarter of 2020 and have continued to be impacted as various policies were implemented by federal, state and local governments in response to the
COVID-19
pandemic. During the second quarter of 2021, our patient volumes improved as the effects of the pandemic moderated and certain pandemic-related restrictions and policies were eased. For the remainder of 2021, our patient volumes exhibited consistent growth over the prior year, with the exception of inpatient surgeries, and included a resurgence of
COVID-19
admissions and the
re-imposition
of pandemic-related restrictions in certain markets. We believe the extent of the
COVID-19
pandemic’s impact on our operating results and financial condition has been and will continue to be driven by many factors, most of which are beyond our control and ability to forecast. Because of these uncertainties, we cannot estimate how long or to what extent the pandemic will impact our operations.
 
Revenues
Our revenues generally relate to contracts with patients in which our performance obligations are to provide health care services to the patients. Revenues are recorded during the period our obligations to provide health care services are satisfied. Our performance obligations for inpatient services are generally satisfied over periods that average approximately five days, and revenues are recognized based on charges incurred in relation to total expected charges. Our performance obligations for outpatient services are generally satisfied over a period of less than one day. The contractual relationships with patients, in most cases, also involve a third-party payer (Medicare, Medicaid, managed care health plans and commercial insurance companies, including plans offered through the health insurance exchanges) and the transaction prices for the services provided are dependent upon the terms provided by (Medicare and Medicaid) or negotiated with (managed care health plans and commercial insurance companies) the third-party payers. The payment arrangements with third-party payers for the services we provide to the related patients typically specify payments at amounts less than our standard charges. Medicare generally pays for inpatient and outpatient services at prospectively determined rates based on clinical, diagnostic and other factors. Services provided to patients having Medicaid coverage are generally paid at prospectively determined rates per discharge, per identified service or per covered member. Agreements with commercial insurance carriers, managed care and preferred provider organizations generally provide for payments based upon predetermined rates per diagnosis, per diem rates or discounted
fee-for-service
rates. Management continually reviews the contractual estimation process to consider and incorporate updates to laws and regulations and the frequent changes in managed care contractual terms resulting from contract renegotiations and renewals.
Our revenues are based upon the estimated amounts we expect to be entitled to receive from patients and third-party payers. Estimates of contractual adjustments under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured discounts and contractual discounts). We also record estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record these revenues at the estimated amounts we expect to collect. Our revenues by primary third-party payer classification and other (including uninsured patients) for the years ended December 31, are summarized in the following table (dollars in millions):
 
   
Years Ended December 31,
  
   
2021
    
Ratio
    
2020
    
Ratio
    
2019
    
Ratio
  
Medicare
  
$
10,447
 
  
 
17.8
% 
   $ 10,420       20.2 %    $ 10,798       21.0 % 
Managed Medicare
  
 
8,424
 
  
 
14.3
 
     6,997       13.6       6,452       12.6  
Medicaid
  
 
2,290
 
  
 
3.9
 
     1,965       3.8       1,572       3.1  
Managed Medicaid
  
 
3,124
 
  
 
5.3
 
     2,621       5.1       2,450       4.8  
Managed care and other insurers
  
 
30,295
 
  
 
51.6
 
     26,535       51.5       26,544       51.6  
International (managed care and other insurers)
  
 
1,336
 
  
 
2.3
 
     1,120       2.2       1,162       2.3  
Other
  
 
2,836
 
  
 
4.8
 
     1,875       3.6       2,358       4.6  
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Revenues
  
$
58,752
 
  
 
100.0
% 
   $ 51,533       100.0 %    $ 51,336       100.0 % 
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Laws and regulations governing the Medicare and Medicaid programs are complex and subject to interpretation. Estimated reimbursement amounts are adjusted in subsequent periods as cost reports are prepared and filed and as final settlements are determined (in relation to certain government programs, primarily
 
Medicare, this is generally referred to as the “cost report” filing and settlement process). The adjustments to estimated Medicare and Medicaid reimbursement amounts and disproportionate-share funds related primarily to cost reports filed during the respective year resulted in net increases to revenues of $53 million, $70 million and $51 million in 2021, 2020 and 2019, respectively. The adjustments to estimated reimbursement amounts related primarily to cost reports filed during previous years resulted in a net increase to revenues of $19 million in 2021, a net reduction to revenues of $5 million in 2020 and a net increase to revenues of $13 million in 2019.
The Emergency Medical Treatment and Labor Act (“EMTALA”) requires any hospital participating in the Medicare program to conduct an appropriate medical screening examination of every person who presents to the hospital’s emergency room for treatment and, if the individual is suffering from an emergency medical condition, to either stabilize the condition or make an appropriate transfer of the individual to a facility able to handle the condition. The obligation to screen and stabilize emergency medical conditions exists regardless of an individual’s ability to pay for treatment. Federal and state laws and regulations require, and our commitment to providing quality patient care encourages, us to provide services to patients who are financially unable to pay for the health care services they receive.
Patients treated at hospitals for
non-elective
care, who have income at or below 400% of the federal poverty level, are eligible for charity care, and we limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. Patients treated at hospitals for
non-elective
care, who have income above 400% of the federal poverty level, are eligible for certain other discounts which limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. We apply additional discounts to limit patient responsibility for certain emergency services. The federal poverty level is established by the federal government and is based on income and family size. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. We provide discounts to uninsured patients who do not qualify for Medicaid or charity care. We may attempt to provide assistance to uninsured patients to help determine whether they may qualify for Medicaid, other federal or state assistance, or charity care. If an uninsured patient does not qualify for these programs, the uninsured discount is applied.
The collection of outstanding receivables from Medicare, Medicaid, managed care payers, other third-party payers and patients is our primary source of cash and is critical to our operating performance. The primary collection risks relate to uninsured patient accounts, including patient accounts for which the primary insurance carrier has paid the amounts covered by the applicable agreement, but patient responsibility amounts (deductibles and copayments) remain outstanding. Implicit price concessions relate primarily to amounts due directly from patients. Estimated implicit price concessions are recorded for all uninsured accounts, regardless of the age of those accounts. Accounts are written off when all reasonable collection efforts have been performed.
The estimates for implicit price concessions are based upon management’s assessment of historical writeoffs and expected net collections, business and economic conditions, trends in federal, state and private employer health care coverage and other collection indicators. Management relies on the results of detailed reviews of historical writeoffs and collections at facilities that represent a majority of our revenues and accounts receivable (the “hindsight analysis”) as a primary source of information in estimating the collectability of our accounts receivable. We perform the hindsight analysis quarterly, utilizing rolling twelve-months accounts
receivable collection and writeoff data. We believe our quarterly updates to the estimated implicit price concession amounts at each of our hospital facilities provide reasonable estimates of our revenues and valuations of our accounts receivable. These routine, quarterly changes in estimates have not resulted in material adjustments to the valuations of our accounts receivable or
period-to-period
comparisons of our revenues. At December 31, 2021 and 2020, estimated implicit price concessions of $6.784 billion and $6.108 billion, respectively, had been recorded to adjust our revenues and accounts receivable to the estimated amounts we expect to collect.
To quantify the total impact of the trends related to uninsured patient accounts, we believe it is beneficial to view total uncompensated care, which is comprised of charity care, uninsured discounts and implicit price concessions. A summary of the estimated cost of total uncompensated care for the years ended December 31, follows (dollars in millions):
 
    
2021
     
2020
     
2019
  
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization)
   
$
49,074
 
    $ 44,271      $ 44,118  
    
 
 
     
 
 
     
 
 
  
Cost-to-charges
ratio (patient care costs as percentage of gross patient charges)
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Total uncompensated care
   
$
29,642
 
    $ 29,029      $ 31,105  
Multiply by the
cost-to-charges
ratio
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Estimated cost of total uncompensated care
   
$
3,350
 
    $ 3,483      $ 3,733  
    
 
 
     
 
 
     
 
 
  
The total uncompensated care amounts include charity care of $13.644 billion, $13.763 billion and $13.260 billion for the years ended December 31, 2021, 2020 and 2019, respectively. The estimated cost of charity care was $1.542 billion, $1.652 billion and $1.591 billion for the years ended December 31, 2021, 2020 and 2019, respectively.
Cash and Cash Equivalents
Cash and cash equivalents include highly liquid investments with a maturity of three months or less when purchased. Our insurance subsidiaries’ cash equivalent investments in excess of the amounts required to pay estimated professional liability claims during the next twelve months are not included in cash and cash equivalents as these funds are not available for general corporate purposes. Carrying values of cash and cash equivalents approximate fair value due to the short-term nature of these instruments.
Our cash management system provides for daily investment of available balances and the funding of outstanding checks when presented for payment. Outstanding, but unpresented, checks totaling $536 million and $495 million at December 31, 2021 and 2020, respectively, have been included in “accounts payable” in the consolidated balance sheets. Upon presentation for payment, these checks are funded through available cash balances or our credit facility.
 
Accounts Receivable
We receive payments for services rendered from federal and state agencies (under the Medicare and Medicaid programs), managed care health plans, commercial insurance companies, employers and patients. We recognize that revenues and receivables from government agencies are significant to our operations, but do not believe there are significant credit risks associated with these government agencies. We do not believe there are any other significant concentrations of revenues from any particular payer that would subject us to any significant credit risks in the collection of our accounts receivable. Days revenues in accounts receivable were 49 days, 45 days and 50
days at December 31, 2021, 2020 and 2019, respectively. The five-day decline during 2020 was primarily related to the COVID-19 impacts of continuing to collect our accounts receivable from the pre-COVID-19 period, while experiencing lower revenues (primarily during the first and second quarters of 2020) that slowed the return of our accounts receivable balances back to pre-COVID-19 levels in 2021. Changes in general economic conditions, patient accounting service center operations, payer mix, or federal or state governmental health care coverage could affect our collection of accounts receivable, cash flows and results of operations. 
Inventories
Inventories are stated at the lower of cost
(first-in,
first-out)
or market.
Property and Equipment
Depreciation expense, computed using the straight-line method, was $2.826 billion in 2021, $2.693 billion in 2020 and $2.579 billion in 2019. Buildings and improvements are depreciated over estimated useful lives ranging generally from 10 to 40 years. Estimated useful lives of equipment vary generally from four to 10 years.
When events, circumstances or operating results indicate the carrying values of certain long-lived assets expected to be held and used might be impaired, we prepare projections of the undiscounted future cash flows expected to result from the use of the assets and their eventual disposition. If the projections indicate the recorded amounts are not expected to be recoverable, such amounts are reduced to estimated fair value. Fair value may be estimated based upon internal evaluations that include quantitative analyses of revenues and cash flows, reviews of recent sales of similar assets and independent appraisals.
Long-lived assets to be disposed of are reported at the lower of their carrying amounts or fair value less costs to sell or close. The estimates of fair value are usually based upon recent sales of similar assets and market responses based upon discussions with and offers received from potential buyers.
Investments of Insurance Subsidiaries
At December 31, 2021 and 2020, the investment securities held by our insurance subsidiaries were classified as
“available-for-sale”
as defined in Accounting Standards Codification (“ASC”) No. 320,
Investments — Debt Securities
and are recorded at fair value. The investment securities are held for the purpose of providing a funding source to pay liability claims covered by the insurance subsidiaries. We perform quarterly assessments of individual investment securities to determine whether declines in fair value are due to credit-related or noncredit-related factors. Our investment securities evaluation process involves subjective judgments, often involves estimating the outcome of future events, and requires a significant level of professional judgment in determining whether a credit-related impairment has occurred. We evaluate, among other things, the financial position and
near term prospects of the issuer, conditions in the issuer’s industry, liquidity of the investment, changes in the amount or timing of expected future cash flows from the investment, and recent downgrades of the issuer by a rating agency, to determine if, and when, a decline in the fair value of an investment below amortized cost is considered to be a credit-related impairment. The extent to which the fair value of the investment is less than amortized cost and our ability and intent to retain the investment, to allow for any anticipated recovery of the investment’s fair value, are important components of our investment securities evaluation process
.

Goodwill and Intangible Assets
Goodwill is not amortized but is subject to annual impairment tests. In addition to the annual impairment review, impairment reviews are performed whenever circumstances indicate a possible impairment may exist. Impairment testing for goodwill is done at the reporting unit level. Reporting units are one level below the business segment level, and our impairment testing is performed at the operating division level. We compare the fair value of the reporting unit assets to the carrying amount, on at least an annual basis, to determine if there is potential impairment. If the fair value of the reporting unit assets is less than their carrying value, an impairment loss is recognized. Fair value is estimated based upon internal evaluations of each reporting unit that include quantitative analyses of market multiples, revenues and cash flows and reviews of recent sales of similar facilities. No goodwill impairments were recognized during 2021, 2020 or 2019.
During 2021, goodwill increased by $1.002 billion related to acquisitions and declined by $75 million related to foreign currency translation and other adjustments. During 2020, goodwill increased by $279 million related to acquisitions, including the finalization of the accounting for certain prior year acquisitions, and declined by $9 million related to foreign currency translation and other adjustments.
During 2021, identifiable intangible assets increased by $60 million related to acquisitions and declined by $25 million due to amortization and other adjustments. During 2020, identifiable intangible assets increased by $65 million related to acquisitions, including the finalization of the accounting for certain prior year acquisitions, and declined by $26 million due to amortization and other adjustments. Identifiable intangible assets
 with finite lives
are amortized over estimated lives ranging generally from three to 10 years. The gross carrying amounts of
 
amortizable
 
identifiable intangible assets at December 31, 2021 and 2020 were $274 million and $249 million, respectively, and accumulated amortization was
 
$175 million and $149 million, respectively. The gross carrying amounts of indefinite-lived identifiable intangible assets at December 31, 2021 and
 
2020 were $304 million and $269 million, respectively. Indefinite-lived identifiable intangible assets are not amortized but are
 
subject to annual
 
impairment tests, and impairment reviews are performed whenever circumstances indicate a possible impairment may exist.
Debt Issuance Costs and Discounts
Debt issuance costs and discounts are amortized based upon the terms of the respective debt obligations. The gross carrying amount of debt issuance costs and discounts at December 31, 2021 and 2020 was $446 million and $411 million, respectively, and accumulated amortization was $198 million and $175 million, respectively. Amortization of debt issuance costs and discounts is included in interest expense and was $27 million, $30 million and $30 million for 2021, 2020 and 2019, respectively.
 
Professional Liability Claims
Reserves for professional liability risks were $2.022 billion and $1.963 billion at December 31, 2021 and 2020, respectively. The current portion of the reserves, $508 million and $477 million at December 31, 2021 and 2020, respectively, is included in “other accrued expenses” in the consolidated balance sheets. Provisions for losses related to professional liability risks were $453 million, $435 million and $497 million for 2021, 2020 and 2019, respectively, and are included in “other operating expenses” in our consolidated income statements. Provisions for losses related to professional liability risks are based upon actuarially determined estimates. During 2021, 2020 and 2019, we recorded reductions to the provision for professional liability risks of $87 million, $112 million and $50 million, respectively, due to the receipt of updated actuarial information. Loss and loss expense reserves represent the estimated ultimate net cost of all reported and unreported losses incurred through the respective consolidated balance sheet dates. The reserves for unpaid losses and loss expenses are estimated using individual case-basis valuations and actuarial analyses. Those estimates are subject to the effects of trends in loss severity and frequency. The estimates are continually reviewed and adjustments are recorded as experience develops or new information becomes known. Adjustments to the estimated reserve amounts are included in current operating results. The reserves for professional liability risks cover approximately 2,100 and 2,300 individual claims at December 31, 2021 and 2020, respectively, and estimates for unreported potential claims. The time period required to resolve these claims can vary depending upon the jurisdiction and whether the claim is settled or litigated. During 2021 and 2020, $384 million and $292 million, respectively, of net payments were made for professional and general liability claims. The estimation of the timing of payments beyond a year can vary significantly. Although considerable variability is inherent in professional liability reserve estimates, we believe the reserves for losses and loss expenses are adequate; however, there can be no assurance the ultimate liability will not exceed our estimates.
A portion of our professional liability risks is insured through our insurance subsidiary. Subject, in most cases, to a $15 million per occurrence self-insured retention, our facilities are insured by our insurance subsidiary for losses up to $75 million per occurrence. The insurance subsidiary has obtained reinsurance for professional liability risks generally above a retention level of either $25 million or $35 million per occurrence, depending on the jurisdiction for the related claim. We also maintain professional liability insurance with unrelated commercial carriers for losses in excess of amounts insured by our insurance subsidiary.
The obligations covered by reinsurance and excess insurance contracts are included in the reserves for professional liability risks, as we remain liable to the extent the reinsurers and excess insurance carriers do not meet their obligations under the reinsurance and excess insurance contracts. The amounts receivable under the reinsurance contracts include $44 million and $31 million at December 31, 2021 and 2020, respectively, recorded in “other assets,” and $11 million and $8 million at December 31, 2021 and 2020, respectively, recorded in “other current assets.”
Financial Instruments
Derivative financial instruments are employed to manage interest rate risks, and are not used for trading or speculative purposes. We recognize our interest rate swap derivative instruments in the consolidated balance sheets at fair value. Changes in the fair value of derivatives are recognized periodically in stockholders’ equity, as a component of other comprehensive income (loss), provided the derivative financial instrument qualifies for hedge accounting. Gains and losses on derivatives designated as cash flow hedges, to the extent they are effective, are recorded in other comprehensive income (loss), and subsequently reclassified to earnings to offset
 
 
the impact of the forecasted transactions when they occur. In the event the forecasted transaction to which a cash flow hedge relates is no longer likely, the amount in other comprehensive income is recognized in earnings and generally the derivative is terminated.
The net interest paid or received on interest rate swaps is recognized as an adjustment to interest expense. Gains and losses resulting from the early termination of interest rate swap agreements are deferred and amortized as adjustments to interest expense over the remaining term of the debt originally associated with the terminated swap.
Noncontrolling Interests in Consolidated Entities
The consolidated financial statements include all assets, liabilities, revenues and expenses of less than 100% owned entities that we control. Accordingly, we have recorded noncontrolling interests in the earnings and equity of such entities.
v3.22.0.1
Share-Based Compensation
 12 Months Ended
Dec. 31, 2021
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]  
Share-Based Compensation
NOTE 2 — SHARE-BASED COMPENSATION
Stock Incentive Plans
Our stock incentive plans are designed to promote the long-term financial interests and growth of the Company by attracting and retaining management and other personnel, motivating them to achieve long range goals and aligning their interests with those of our stockholders through opportunities for stock-based compensation and stock ownership in the Company. Stock option, stock appreciation right (“SARs”) and restricted share unit (“RSUs”) grants vest solely based upon continued employment over a specific period of time, and performance share unit (“PSUs”) grants vest based upon both continued employment over a specific period of time and the achievement of predetermined financial targets over a specific period of time. At December 31, 2021 there were
16.290 million shares available for future grants.
Employee Stock Purchase Plan
Our employee stock purchase plan (“ESPP”) provides our participating employees an opportunity to obtain shares of our common stock at a discount (through payroll deductions over three-month periods). At December 31, 2021, 5.173 million shares of common stock were reserved for ESPP issuances. During 2021, 2020 and 2019, the Company recognized $15 million, $13 million and $12 million, respectively, of compensation expense related to the ESPP.
Stock Option, SAR, RSU and PSU Activity
The fair value of each stock option and SAR award is estimated on the grant date, using valuation models and the weighted average assumptions indicated in the following table. Awards under our stock incentive plans generally vest based on continued employment (“Time Stock Options and SARs” and “RSUs”) or based upon continued employment and the achievement of certain financial targets (“Performance Stock Options and SARs” and “PSUs”). PSUs have a three-year cumulative earnings per share target, and the number of PSUs earned can vary from zero (for actual performance of less than 90% of target for 2021, 2020 and 2019 grants) to two times the original PSU grant (for actual performance of 110% or more of target for 2021, 2020 and 2019 grants). Each
 
grant is valued as a single award with an expected term equal to the average expected term of the component vesting tranches. The expected term of the share-based award is limited by the contractual term. We use historical exercise behavior data and other factors to estimate the expected term of the options and SARs.
Compensation cost is recognized on the straight-line attribution method. The straight-line attribution method requires that total compensation expense recognized must at least equal the vested portion of the grant-date fair value. The expected volatility is derived using historical stock price information for our common stock and the volatility implied by the trading of options to purchase our stock on open-market exchanges. The risk-free interest rate is the approximate yield on United States Treasury Strips having a life equal to the expected share-based award life on the date of grant. The expected life is an estimate of the number of years a share-based award will be held before it is exercised. The expected dividend yield is estimated based on the assumption that the dividend yield at date of grant will be maintained over the expected life of the grant.
 
    
2021
    
2020
    
2019
  
Risk-free interest rate
   
 
0.68
% 
     1.44 %      2.50 % 
Expected volatility
   
 
36
% 
     27 %      27 % 
Expected life, in years
   
 
6.17
 
     6.15       6.18  
Expected dividend yield
   
 
1.10
% 
     1.19 %      1.16 % 
Information regarding Time Stock Options and SARs and Performance Stock Options and SARs activity during 2021, 2020 and 2019 is summarized below (share amounts in thousands):
 
    
Time
Stock
Options
and
SARs
    
Performance
Stock
Options and
SARs
    
Total
Stock
Options
and
SARs
    
Weighted
Average
Exercise
Price
     
Weighted
Average
Remaining
Contractual Term
     
Aggregate
Intrinsic Value
(dollars in millions)
  
Options and SARs outstanding, December 31, 2018
      9,360       2,667       12,027     $ 61.49                    
Granted
      1,349       —       1,349       138.31                    
Exercised
      (1,137 )      (523 )      (1,660 )      44.45                    
Cancelled
      (522 )      —       (522 )      93.26                    
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2019
      9,050       2,144       11,194       71.79                    
Granted
      1,120       —       1,120       144.47                    
Exercised
      (2,159 )      (1,325 )      (3,484 )      44.07                    
Cancelled
      (175 )      —       (175 )      111.69                    
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2020
      7,836       819       8,655       91.53                    
Granted
   
 
877
 
  
 
—
 
  
 
877
 
  
 
174.98
 
                  
Exercised
   
 
(2,443
) 
  
 
(533
) 
  
 
(2,976
) 
  
 
67.57
 
                  
Cancelled
   
 
(108
) 
  
 
—
 
  
 
(108
) 
  
 
138.32
 
                  
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2021
   
 
6,162
 
  
 
286
 
  
 
6,448
 
  
$
113.15
 
   
 
6.2 years
 
   
$
927
 
    
 
 
    
 
 
    
 
 
                            
Options and SARs exercisable, December 31, 2021
   
 
3,486
 
  
 
286
 
  
 
3,772
 
  
$
89.70
 
   
 
5.0 years
 
   
$
631
 
 
The weighted average fair values of stock options and SARs granted during 2021, 2020 and 2019 were $54.57, $35.98 and $38.21 per share, respectively. The total intrinsic value of stock options and SARs exercised during 2021, 2020 and 2019 was $404 million, $328 million and $153 million, respectively. As of December 31, 2021, the unrecognized compensation cost related to nonvested stock options and SARs was $46 million.
Information regarding RSUs and PSUs activity during 2021, 2020 and 2019 is summarized below (share amounts in thousands):
 
    
RSUs
     
PSUs
     
Total RSUs
and PSUs
     
Weighted
Average
Grant
Date Fair
Value
  
RSUs and PSUs outstanding, December 31, 2018
      3,123        3,422        6,545      $ 86.32  
Granted
      973        796        1,769        138.45  
Performance adjustment
      —        227        227        69.94  
Vested
      (1,216 )       (1,251 )       (2,467 )       75.97  
Cancelled
      (260 )       (159 )       (419 )       103.27  
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2019
      2,620        3,035        5,655        105.23  
Granted
      1,048        808        1,856        144.17  
Performance adjustment
      —        206        206        81.89  
Veste
d
      (1,030 )       (1,364 )       (2,394 )       88.63  
Cancelled
      (162 )       (93 )       (255 )       124.50  
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2020
      2,476        2,592        5,068        125.40  
Granted
   
 
899
 
   
 
689
 
   
 
1,588
 
   
 
174.34
 
Performance adjustment
   
 
—
 
   
 
684
 
   
 
684
 
   
 
102.02
 
Vested
   
 
(992
) 
   
 
(1,772
) 
   
 
(2,764
) 
   
 
106.62
 
Cancelled
   
 
(192
) 
   
 
(110
) 
   
 
(302
) 
   
 
149.07
 
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2021
   
 
2,191
 
   
 
2,083
 
   
 
4,274
 
   
$
150.32
 
    
 
 
     
 
 
     
 
 
           
The total fair value of RSUs and PSUs that vested during 2021, 2020 and 2019 was $475 million, $349 million and $346 million, respectively. As of December 31, 2021, the unrecognized compensation cost related to RSUs and PSUs was $420 million.
v3.22.0.1
Acquisitions and Dispositions
 12 Months Ended
Dec. 31, 2021
Business Combinations [Abstract]  
Acquisitions and Dispositions
NOTE 3 — ACQUISITIONS AND DISPOSITIONS
During 2021, we paid $67 million to acquire
two
hospital facilities, one in southern Georgia and one in Tennessee, $594 million to acquire a network of urgent care centers in Florida and $114 million to acquire other nonhospital health care entities (noncontrolling interests of $117 million were recorded).
The acquisition of the network of urgent care centers occurred during December 2021. At December 31, 2021, our purchase accounting procedures were not complete, and completion of these procedures will include an analysis of the leases assumed and our review for possible identifiable intangible assets acquired. 
We also paid $330 million and assumed certain liabilities to acquire an 80% interest (noncontrolling interests of $100 million were recorded) in a venture providing post-acute care services (home health and hospice). During 2020, we paid $568 million to acquire a hospital in New Hampshire and other nonhospital health care entities. During 2019, we paid $1.384 billion to
 
acquire a seven-hospital health system in North Carolina and $298 million to acquire nonhospital health care entities. Purchase price amounts have been allocated to the related assets acquired and liabilities
 
assumed based upon their respective fair values. The purchase price paid in excess of the fair value of identifiable net assets of these acquired entities aggregated $
1.002
 billion, $
279
 million and $
332
 million in
2021
,
2020
and
2019
, respectively. The consolidated financial statements include the accounts and operations of the acquired entities subsequent to the respective acquisition dates. The pro forma effects of these acquired entities on our results of operations for periods prior to the respective acquisition dates were not significant.
During 2021, we received proceeds of $1.502 billion and recognized a pretax gain of $1.226 billion ($920 million after tax) related to the sale of five
 
hospital facilities in Georgia, comprised of
three facilities from our American Group (northern Georgia market) and two facilities from our National Group (southern Georgia market). We also received proceeds of $658 million and recognized a pretax gain of $394 million ($294 million after tax) related to sales of other health care entity investments and real estate. During 2020, we received proceeds of $68 million and recognized a pretax loss of $7 million ($9 million after tax) related to the sale of a hospital facility from our American Group (Mississippi market) and sales of real estate and other investments. During 2019, we received proceeds of $61 million and recognized a pretax gain of $18 million ($13 million after tax) related to the sale of a hospital facility from our American Group (a Louisiana market) and sales of real estate and other investments.
v3.22.0.1
Income Taxes
 12 Months Ended
Dec. 31, 2021
Income Tax Disclosure [Abstract]  
Income Taxes
NOTE 4 — INCOME TAXES
The provision for income taxes consists of the following (dollars in millions):
 
    
2021
     
2020
     
2019
  
Current:
                           
Federal
   
$
1,769
 
    $ 1,021      $ 670  
State
   
 
311
 
      126        134  
Foreign
   
 
15
 
      5        17  
Deferred:
                           
Federal
   
 
24
 
      (73 )       254  
State
   
 
(18
) 
      (39 )       29  
Foreign
   
 
11
 
      3        (5 ) 
    
 
 
     
 
 
     
 
 
  
    
$
2,112
 
    $ 1,043      $ 1,099  
    
 
 
     
 
 
     
 
 
  
Our provision for income taxes for the years ended December 31, 2021, 2020 and 2019 included tax benefits of $119 million, $92 million and $65 million, respectively, related to the settlement of employee equity awards. Our foreign pretax income was $64 million, $9 million and $50 million for the years ended December 31, 2021, 2020 and 2019, respectively.
A reconciliation of the federal statutory rate to the effective income tax rate follows:
 
    
  2021  
    
  2020  
    
  2019  
  
Federal statutory rate
   
 
21.0
% 
     21.0 %      21.0 % 
State income taxes, net of federal tax benefit
   
 
2.0
 
     1.9       2.7  
Change in liability for uncertain tax positions
   
 
0.7
 
     (0.2 )      0.4  
Tax benefit from settlements of employee equity awards
   
 
(1.2
) 
     (1.8 )      (1.3 ) 
Other items, net
   
 
0.8
 
     0.8       1.1  
    
 
 
    
 
 
    
 
 
  
Effective income tax rate on income attributable to HCA Healthcare, Inc.
   
 
23.3
 
     21.7       23.9  
Income attributable to noncontrolling interests from consolidated partnerships
   
 
(1.8
) 
     (2.5 )      (2.9 ) 
    
 
 
    
 
 
    
 
 
  
Effective income tax rate on income before income taxes
   
 
21.5
% 
     19.2 %      21.0 % 
    
 
 
    
 
 
    
 
 
  
A summary of the items comprising the deferred tax assets and liabilities at December 31 follows (dollars in millions):
 
    
2021
     
2020
  
    
Assets
     
Liabilities
     
Assets
     
Liabilities
  
Depreciation and fixed asset basis differences
   
$
—
 
   
$
737
 
    $ —      $ 678  
Allowances for professional liability and other risks
   
 
426
 
   
 
—
 
      407        —  
Accounts receivable
   
 
348
 
   
 
—
 
      283        —  
Compensation
   
 
502
 
   
 
—
 
      487        —  
Right-of-use
lease assets and obligations
   
 
428
 
   
 
419
 
      416        409  
Other
   
 
499
 
   
 
652
 
      485        606  
    
 
 
     
 
 
     
 
 
     
 
 
  
    
$
2,203
 
   
$
1,808
 
    $ 2,078      $ 1,693  
    
 
 
     
 
 
     
 
 
     
 
 
  
At December 31, 2021, federal and state net operating loss carryforwards (expiring in years 2024 through 2040) available to offset future taxable income approximated $31 million and $99 million, respectively. Utilization of net operating loss carryforwards in any one year may be limited.
The following table summarizes the activity related to our unrecognized tax benefits (dollars in millions):
 
    
2021
     
2020
  
Balance at January 1
   
$
469
 
    $ 522  
Additions based on tax positions related to the current year
   
 
57
 
      (3 ) 
Additions for tax positions of prior years
     
66
        13  
Reductions for tax positions of prior years
   
 
(6
) 
      (30 ) 
Settlements
   
 
(3
) 
      (22 ) 
Lapse of applicable statutes of limitations
   
 
(7
) 
      (11 ) 
    
 
 
     
 
 
  
Balance at December 31
   
$
576
 
    $ 469  
    
 
 
     
 
 
  
 
Our liability for unrecognized tax benefits was $642 million, including accrued interest of $99 million and excluding $33 million that was recorded as reductions of the related deferred tax assets, as of December 31, 2021 ($508 million, $73 million and $34 million, respectively, as of December 31, 2020). Unrecognized tax benefits of $217 million as of December 31, 2021 ($157 million as of December 31, 2020) would affect the effective rate, if recognized.
The Internal Revenue Service (“IRS”) was conducting an examination of the Company’s 2016, 2017 and 2018 federal income tax returns and the 2019 return for one affiliated partnership at December 31, 2021. We are also subject to examination by state and foreign taxing authorities. Depending on the resolution of any federal, state and foreign tax disputes, the completion of examinations by federal, state or foreign taxing authorities, or the expiration of statutes of limitation for specific taxing jurisdictions, we believe it is reasonably possible that our liability for unrecognized tax benefits may significantly increase or decrease within the next 12 months. However, we are currently unable to estimate the range of any possible change.
v3.22.0.1
Earnings Per Share
 12 Months Ended
Dec. 31, 2021
Earnings Per Share [Abstract]  
Earnings Per Share
NOTE 5 — EARNINGS PER SHARE
We compute basic earnings per share using the weighted average number of common shares outstanding. We compute diluted earnings per share using the weighted average number of common shares outstanding plus the dilutive effect of outstanding stock options, SARs, RSUs and PSUs, computed using the treasury stock method. During 2021, 2020 and 2019, we repurchased 37.812 million shares, 3.287 million shares and 7.949 million shares, respectively, of our common stock. The following table sets forth the computations of basic and diluted earnings per share for the years ended December 31, 2021, 2020 and 2019 (dollars and shares in millions, except per share amounts):
 
    
2021
     
2020
     
2019
  
Net income attributable to HCA Healthcare, Inc.
   
$
6,956
 
    $ 3,754      $ 3,505  
       
Weighted average common shares outstanding
   
 
323.315
 
      338.274        341.210  
Effect of dilutive incremental shares
   
 
5.437
 
      5.331        7.016  
    
 
 
     
 
 
     
 
 
  
Shares used for diluted earnings per share
   
 
328.752
 
      343.605        348.226  
    
 
 
     
 
 
     
 
 
  
Earnings per share:
                           
Basic earnings per share
   
$
21.52
 
    $ 11.10      $ 10.27  
Diluted earnings per share
   
$
21.16
 
    $ 10.93      $ 10.07  
v3.22.0.1
Investments of Insurance Subsidiaries
 12 Months Ended
Dec. 31, 2021
Investments, Debt and Equity Securities [Abstract]  
Investments of Insurance Subsidiaries
NOTE 6 — INVESTMENTS OF INSURANCE SUBSIDIARIES
A summary of the insurance subsidiaries’ investments at December 31 follows (dollars in millions):
 
    
2021
  
    
Amortized
Cost
     
Unrealized
Amounts
     
Fair
Value
  
    
Gains
     
Losses
  
Debt securities
   
$
400
 
   
$
18
 
   
$
(2
) 
   
$
416
 
Money market funds and other
   
 
125
 
   
 
—
 
   
 
—
 
   
 
125
 
    
 
 
     
 
 
     
 
 
     
 
 
  
    
$
525
 
   
$
18
 
   
$
(2
) 
   
 
541
 
    
 
 
     
 
 
     
 
 
           
Amounts classified as current assets
                              
 
(103
) 
                               
 
 
  
Investment carrying value
                              
$
438
 
                               
 
 
  
   
    
2020
  
    
Amortized
Cost
     
Unrealized
Amounts
     
Fair
Value
  
    
Gains
     
Losses
  
Debt securities
    $ 384      $ 32      $ —      $ 416  
Money market funds and other
      88        —        —        88  
    
 
 
     
 
 
     
 
 
     
 
 
  
     $ 472      $ 32      $ —        504  
    
 
 
     
 
 
     
 
 
           
Amounts classified as current assets
                                 (116 ) 
                               
 
 
  
Investment carrying value
                               $ 388  
                               
 
 
  
At December 31, 2021 and 2020, the investments in debt securities of our insurance subsidiaries were classified as
“available-for-sale.”
Changes in unrealized gains and losses are recorded as adjustments to other comprehensive income (loss).
Scheduled maturities of investments in debt securities at December 31, 2021 were as follows (dollars in millions):
 
    
Amortized
Cost
     
Fair
Value
  
Due in one year or less
    $ 3      $ 3  
Due after one year through five years
      128        135  
Due after five years through ten years
      176        183  
Due after ten years
      93        95  
    
 
 
     
 
 
  
     $ 400      $ 416  
    
 
 
     
 
 
  
The average expected maturity of the investments in debt securities at December 31, 2021 was 6.1 years, compared to the average scheduled maturity of 9.5 years. Expected and scheduled maturities may differ because the issuers of certain securities have the right to call, prepay or otherwise redeem such obligations prior to their scheduled maturity date.
 
v3.22.0.1
Financial Instruments
 12 Months Ended
Dec. 31, 2021
Derivative Instruments and Hedging Activities Disclosure [Abstract]  
Financial Instruments
NOTE 7 — FINANCIAL INSTRUMENTS
Interest Rate Swap Agreements
We have entered into interest rate swap agreements to manage our exposure to fluctuations in interest rates. These swap agreements involve the exchange of fixed and variable rate interest payments between us and our counterparties based on common notional principal amounts and maturity dates.
Pay-fixed
interest rate swaps effectively convert variable rate obligations to fixed interest rate obligations. The interest payments under these agreements are settled on a net basis. The net interest payments, based on the notional amounts in these agreements, generally match the timing of the related liabilities for the interest rate swap agreements which have been designated as cash flow hedges. The notional amounts of the swap agreements represent amounts used to calculate the exchange of cash flows and are not our assets or liabilities. Our credit risk related to these agreements is considered low because the swap agreements are with creditworthy financial institutions.
The following table sets forth our interest rate swap agreement, which has been designated as a cash flow hedge, at December 31, 2021 (dollars in millions):
 
    
Notional
Amount
     
Maturity Date
     
Fair
Value
  
Pay-fixed
interest rate swap
    $ 500        December 2022      $ (8 ) 
During the next 12 months, we estimate $8 million will be reclassified from accumulated other comprehensive income (“OCI”) and will be included in interest expense.
Derivatives — Results of Operations
The following table presents the effect of our interest rate swaps on our results of operations for the year ended December 31, 2021 (dollars in millions):
 
Derivatives in Cash Flow Hedging
Relationships
   
Amount of Gain
Recognized in OCI on
Derivatives, Net of Tax
     
Location of Loss
Reclassified from
Accumulated OCI
into Operations
     
Amount of Loss
Reclassified from
Accumulated OCI
into Operations
  
Interest rate swaps
    $ 1        Interest expense      $ 37  
Credit-risk-related Contingent Features
We have an agreement with our derivative counterparty that contains a provision where we could be declared in default on our derivative obligation if repayment of the underlying indebtedness is accelerated by the lender due to our default on the indebtedness. As of December 31, 2021, we have not been required to post any collateral related to this agreement. If we had breached this provision at December 31, 2021, we would have been required to settle our obligation under the agreement at the estimated termination value of $8 million.
v3.22.0.1
Assets and Liabilities Measured at Fair Value
 12 Months Ended
Dec. 31, 2021
Fair Value Disclosures [Abstract]  
Assets and Liabilities Measured at Fair Value
NOTE 8 — ASSETS AND LIABILITIES MEASURED AT FAIR VALUE

Accounting Standards Codification 820,
Fair Value Measurements and Disclosures
(“ASC 820”) emphasizes fair value is a market-based measurement, and fair value measurements should be determined based on the assumptions market participants would use in pricing assets or liabilities. ASC 820 utilizes a fair value hierarchy that distinguishes between market participant assumptions based on market data obtained from sources independent of the reporting entity (observable inputs classified within Levels 1 and 2 of the hierarchy) and the reporting entity’s own assumptions about market participant assumptions (unobservable inputs classified within Level 3 of the hierarchy).
Level 1 inputs utilize quoted prices (unadjusted) in active markets for identical assets or liabilities. Level 2 inputs are inputs other than quoted prices included in Level 1 that are observable for the asset or liability, either directly or indirectly. Level 2 inputs may include quoted prices for similar assets and liabilities in active markets, as well as inputs observable for the asset or liability (other than quoted prices), such as interest rates, foreign exchange rates, and yield curves observable at commonly quoted intervals. Level 3 inputs are unobservable inputs for the asset or liability, which are typically based on an entity’s own assumptions, as there is little, if any, related market activity. In instances where the determination of the fair value measurement is based on inputs from different levels of the fair value hierarchy, the level in the fair value hierarchy within which the entire fair value measurement falls is based on the lowest level input significant to the fair value measurement in its entirety. Our assessment of the significance of a particular input to the fair value measurement in its entirety requires judgment.
Investment Securities
The investments of our insurance subsidiaries are generally classified within Level 1 or Level 2 of the fair value hierarchy because they are valued using quoted market prices, broker or dealer quotations, or alternative pricing sources with reasonable levels of price transparency.
Derivative Financial Instruments
We have entered into interest rate swap agreements to manage our exposure to fluctuations in interest rates. The valuation of these instruments is determined using widely accepted valuation techniques, including discounted cash flow analysis on the expected cash flows of each derivative. This analysis reflects the contractual terms of the derivatives, including the period to maturity, and uses observable market-based inputs, including interest rate curves and implied volatilities. We incorporate credit valuation adjustments to reflect both our own nonperformance risk and the respective counterparty’s nonperformance risk in the fair value measurements of these instruments.
The following tables summarize our assets and liabilities measured at fair value on a recurring basis as of December 31, 2021 and 2020, aggregated by the level in the fair value hierarchy within which those measurements fall (dollars in millions):
 
   
December 31, 2021
  
   
Fair Value
    
Fair Value Measurements Using
  
   
Quoted Prices in
Active Markets for
Identical Assets
and Liabilities
(Level 1)
    
Significant
Other
Observable
Inputs
(Level 2)
    
Significant
Unobservable
Inputs
(Level 3)
  
Assets:
                                
Investments of insurance subsidiaries:
                                
Debt securities
  
$
416
 
  
$
—
 
  
$
416
 
  
$
—
 
Money market funds and other
  
 
125
 
  
 
125
 
  
 
—
 
  
 
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
Investments of insurance subsidiaries
  
 
541
 
  
 
125
 
  
 
416
 
  
 
—
 
Less amounts classified as current assets
  
 
(103
) 
  
 
(103
) 
  
 
—
 
  
 
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
   
$
438
 
  
 
22
 
  
$
416
 
  
$
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
Liabilities:
                                
Interest rate swap (Other accrued expenses)
  
$
8
 
  
$
—
 
  
$
8
 
  
$
—
 
 
   
December 31, 2020
  
   
Fair Value
    
Fair Value Measurements Using
  
   
Quoted Prices in
Active Markets for
Identical Assets
and Liabilities
(Level 1)
    
Significant
Other
Observable
Inputs
(Level 2)
    
Significant
Unobservable
Inputs
(Level 3)
  
Assets:
                                
Investments of insurance subsidiaries:
                                
Debt securities
   $ 416     $ —     $ 416     $ —  
Money market funds and other
     88       88       —       —  
   
 
 
    
 
 
    
 
 
    
 
 
  
Investments of insurance subsidiaries
     504       88       416       —  
Less amounts classified as current assets
     (116 )      (87 )      (29 )      —  
   
 
 
    
 
 
    
 
 
    
 
 
  
    $ 388       1     $ 387     $ —  
   
 
 
    
 
 
    
 
 
    
 
 
  
Liabilities:
                                
Interest rate swaps (Income taxes and other liabilities)
   $ 46     $ —     $ 46     $ —  
The estimated fair value of our long-term debt was $38.541 billion and $35.814 billion at December 31, 2021 and 2020, respectively, compared to carrying amounts, excluding debt issuance costs and discounts, aggregating $34.827 billion and $31.240 billion, respectively. The estimates of fair value are generally based upon the quoted market prices or quoted market prices for similar issues of long-term debt with the same maturities.
v3.22.0.1
Long-Term Debt
 12 Months Ended
Dec. 31, 2021
Debt Disclosure [Abstract]  
Long-Term Debt
NOTE 9 — LONG-TERM DEBT
A summary of long-term debt at December 31, including related interest rates at December 31, 2021, follows (dollars in millions):
 
    
2021
    
2020
  
Senior secured asset-based revolving credit facility (effective interest rate of
1.4
%)
   
$
2,780
 
   $ —  
Senior secured revolving credit facility
  
 
—
 
     —  
Senior secured term loan facilities (effective interest rate of 2.1%)
   
 
1,960
 
     3,671  
Senior secured notes (effective interest rate of 4.8%)
   
 
16,200
 
     13,850  
Other senior secured debt (effective interest rate of 4.3%)
   
 
935
 
     767  
    
 
 
    
 
 
  
Senior secured debt
   
 
21,875
 
     18,288  
Senior unsecured notes (effective interest rate of 5.5%)
   
 
12,952
 
     12,952  
Debt issuance costs and discounts
   
 
(248
) 
     (236 ) 
    
 
 
    
 
 
  
Total debt (average life of 8.9 years, rates averaging 4.6%)
   
 
34,579
 
     31,004  
Less amounts due within one year
   
 
237
 
     209  
    
 
 
    
 
 
  
    
$
34,342
 
   $ 30,795  
    
 
 
    
 
 
  
During June 2021, we issued $2.350 billion aggregate principal amount of senior secured notes comprised of $850 million aggregate principal amount of
2 3/8
% notes due 2031 and $1.500 billion aggregate principal amount of
3 1/2
% notes due 2051 (the “June 2021 Notes”). We also amended and restated our senior secured revolving credit facility and our senior secured asset-based revolving credit facility, including increasing availability under the asset-based revolving credit facility to $4.500 billion, extending the maturity date on both facilities to June 30, 2026 and entering into a new $1.500 billion term
loan A
 facility and a new $500 
million term loan B facility (the “Credit Agreement Transactions”). We used the net proceeds from the June 2021 Notes and the Credit Agreement Transactions to retire $3.657 billion of term loan facilities. The pretax loss on retirement of debt was
 $12 million.
Senior Secured Credit Facilities And Other Senior Secured Debt
We have entered into the following senior secured credit facilities: (i) a $4.500 billion asset-based revolving credit facility maturing on June 30, 2026 with a borrowing base of 85% of eligible accounts receivable, subject to customary reserves and eligibility criteria ($2.780 billion outstanding at December 31, 2021) (the “ABL credit facility”); (ii) a $2.000 billion senior secured revolving credit facility maturing on June 30, 2026 (none outstanding at December 31, 2021 without giving effect to certain outstanding letters of credit); (iii) a $1.462 billion senior secured term loan
A
 facility maturing on June 30, 2026; and (iv) a $498 million senior secured term loan
B
 facility maturing on June 30, 2028. We refer to the facilities described under (ii) through (iv) above, collectively, as the “cash flow credit facility” and, together with the ABL credit facility, the “senior secured credit facilities.”
Borrowings under the senior secured credit facilities bear interest at a rate equal to, at our option, either (a) a base rate determined by reference to the higher of (1) the federal funds rate plus 0.50% or (2) the prime rate of Bank of America or (b) a LIBOR rate for the currency of such borrowing for the relevant interest period, plus, in each case, an applicable margin. The applicable margin for borrowings under the senior secured credit facilities may be reduced subject to attaining certain leverage ratios.
The senior secured credit facilities contain a number of covenants that restrict, subject to certain exceptions, our (and some or all of our subsidiaries’) ability to incur additional indebtedness, repay subordinated indebtedness, create liens on assets, sell assets, make investments, loans or advances, engage in certain transactions with affiliates, pay dividends and distributions, and enter into sale and leaseback transactions. In addition, we are required to satisfy and maintain a maximum total leverage ratio covenant under the cash flow credit facility and, in certain situations under the ABL credit facility, a minimum interest coverage ratio covenant.
Senior secured notes consist of
(i) $1.250 billion aggregate principal amount of 4.75% first lien notes due 2023; (ii) $2.000 billion aggregate principal amount of 5.00% first lien notes due 2024; (iii) $1.400 billion aggregate principal amount of 5.25% first lien notes due 2025; (iv) $1.500 billion aggregate principal amount of 5.25% first lien notes due 2026; (v) $1.200 billion aggregate principal amount of 4.50% first lien notes due 2027; (vi) $2.000 billion aggregate principal amount of 4 1/8% first lien notes due 2029; (vii) $850 million aggregate principal amount of 2 3/8% first lien notes due 2031; (viii) $1.000 billion aggregate principal amount of 5 1/8% first lien notes due 2039; (ix) $1.500 billion aggregate principal amount of 5.50% first lien notes due 2047; (x) $2.000 billion aggregate principal amount of 5 1/4% first lien notes due 2049; and (xi) $1.500 billion aggregate principal amount of 3 1/2% first lien notes due 2051. Finance leases and other secured debt totaled $935 million at December 31, 2021.
We use interest rate swap agreements to manage the variable rate exposure of our debt portfolio. At December 31, 2021, we had entered into an effective interest rate swap agreement, in a notional amount of $500 million, in order to hedge a portion of our exposure to variable rate interest payments associated with the senior secured credit facilities. The effect of the interest rate swap is reflected in the effective interest rates for the senior secured credit facilities.
Senior Unsecured Notes
Senior unsecured notes consist of (i) $12.091 billion aggregate principal amount of senior notes with maturities ranging from 2023 to 2033; (ii) an aggregate principal amount of $125 million medium-term notes maturing 2025; and (iii) an aggregate principal amount of $736 million debentures with maturities ranging from 2023 to 2095.
General Debt Information
The senior secured credit facilities and senior secured notes are fully and unconditionally guaranteed by substantially all existing and future, direct and indirect, 100% owned material domestic subsidiaries that are “Unrestricted Subsidiaries” under our Indenture (the “1993 Indenture”) dated December 16, 1993 (except for certain special purpose subsidiaries that only guarantee and pledge their assets under our ABL credit facility).
All obligations under the ABL credit facility, and the guarantees of those obligations, are secured, subject to permitted liens and other exceptions, by a first-priority lien on substantially all of the receivables of the borrowers and each guarantor under such ABL credit facility (the “Receivables Collateral”).
All obligations under the cash flow credit facility and the guarantees of such obligations are secured, subject to permitted liens and other exceptions, by:
 
  •  
a first-priority lien on the capital stock owned by HCA Inc., or by any guarantor, in each of their respective first-tier subsidiaries;
 
  •  
a first-priority lien on substantially all present and future assets of HCA Inc. and of each guarantor other than (i) “Principal Properties” (as defined in the 1993 Indenture), (ii) certain other real properties and (iii) deposit accounts, other bank or securities accounts, cash, leaseholds, motor-vehicles and certain other exceptions; and
 
  •  
a second-priority lien on certain of the Receivables Collateral.
Our senior secured notes and the related guarantees are secured by first-priority liens, subject to permitted liens, on our and our subsidiary guarantors’ assets, subject to certain exceptions, that secure our cash flow credit facility on a first-priority basis and are secured by second-priority liens, subject to permitted liens, on our and our subsidiary guarantors’ assets that secure our ABL credit facility on a first-priority basis and our other cash flow credit facility on a second-priority basis.
Maturities of long-term debt in years 2023 through 2026 are $2.857 
b
illion, $2.353 billion, $4.607 billion and $5.279 billion, respectively.
v3.22.0.1
Leases
 12 Months Ended
Dec. 31, 2021
Leases [Abstract]  
Leases
NOTE 10 — LEASES
We lease property and equipment under finance and operating leases. For leases with terms greater than 12 months, we record the related assets and obligations at the present value of lease payments over the term. Many of our leases include rental escalation clauses and renewal options that are factored into our determination of lease payments, when appropriate. We do not separate lease and nonlease components of contracts. Generally, we use our estimated incremental borrowing rate to discount the lease payments, as most of our leases do not provide a readily determinable implicit interest rate.
 
The following table presents our lease-related assets and liabilities at December 31, 2021 and 2020 (dollars in millions):
 
    
Balance Sheet Classification
     
2021
    
2020
  
Assets:
                          
Operating leases
     
Right-of-use operating lease assets
     
$
2,113
 
   $ 2,024  
Finance leases
      Property and equipment     
 
637
 
     553  
             
 
 
    
 
 
  
Total lease assets
            
$
2,750
 
   $ 2,577  
             
 
 
    
 
 
  
Liabilities:
                          
Current:
                          
Operating leases
      Other accrued expenses     
$
392
 
   $ 379  
Finance leases
      Long-term debt due within one year     
 
143
 
     128  
Noncurrent:
                          
Operating leases
     
Right-of-use operating lease obligations
     
 
1,755
 
     1,673  
Finance leases
      Long-term debt     
 
577
 
     494  
             
 
 
    
 
 
  
Total lease liabilities
            
$
2,867
 
   $ 2,674  
             
 
 
    
 
 
  
Weighted-average remaining term:
                          
Operating leases
            
 
10.2 years
 
     10.4 years  
Finance leases
            
 
10.4 years
 
     11.5 years  
Weighted-average discount rate:
                          
Operating leases
            
 
4.4
% 
     4.8 % 
Finance leases
            
 
4.4
% 
     5.4 % 
The following table presents certain information related to lease expense for finance and operating leases for the years ended December 31, 2021, 2020 and 2019 (dollars in millions):
 
    
2021
     
2020
     
2019
  
Finance lease expense:
                           
Depreciation and amortization
   
$
135
 
    $ 106      $ 93  
Interest
   
 
29
 
      31        32  
Operating leases(1)
   
 
478
 
      447        389  
Short-term lease expense(1)
   
 
354
 
      322        316  
Variable lease expense(1)
   
 
157
 
      154        150  
    
 
 
     
 
 
     
 
 
  
    
$
1,153
 
    $ 1,060      $ 980  
    
 
 
     
 
 
     
 
 
  
 
(1)
Expenses are included in “other operating expenses” in our consolidated income statements.
The following table presents supplemental cash flow information for the years ended December 31, 2021, 2020 and 2019 (dollars in millions):
 
    
2021
     
2020
     
2019
  
Cash paid for amounts included in the measurement of lease liabilities:
                           
Operating cash flows for operating leases
   
$
474
 
    $ 445      $ 404  
Operating cash flows for finance leases
   
 
29
 
      31        32  
Financing cash flows for finance leases
   
 
123
 
      86        79  
 
Maturities of Lease Liabilities
The following table reconciles the undiscounted minimum lease payment amounts to the operating and finance lease liabilities recorded on the balance sheet at December 31, 2021 and 2020 (dollars in millions):
 
    
2021
     
2020
  
    
Operating
Leases
     
Finance
Leases
     
Operating
Leases
     
Finance
Leases
  
Year 1
   
$
438
 
   
$
165
 
    $ 431      $ 155  
Year 2
   
 
378
 
   
 
126
 
      366        125  
Year 3
   
 
320
 
   
 
132
 
      307        81  
Year 4
   
 
267
 
   
 
98
 
      255        82  
Year 5
   
 
219
 
   
 
70
 
      207        51  
Thereafter
   
 
1,148
 
   
 
350
 
      1,136        353  
    
 
 
     
 
 
     
 
 
     
 
 
  
Total minimum lease payments
   
 
2,770
 
   
 
941
 
      2,702        847  
Less: amount of lease payments representing interest
   
 
(623
) 
   
 
(221
) 
      (650 )       (225 ) 
    
 
 
     
 
 
     
 
 
     
 
 
  
Present value of future minimum lease payments
   
 
2,147
 
   
 
720
 
      2,052        622  
Less: current lease obligations
   
 
(392
) 
   
 
(143
) 
      (379 )       (128 ) 
    
 
 
     
 
 
     
 
 
     
 
 
  
Long-term lease obligations
   
$
1,755
 
   
$
577
 
    $ 1,673      $ 494  
    
 
 
     
 
 
     
 
 
     
 
 
  
v3.22.0.1
Contingencies
 12 Months Ended
Dec. 31, 2021
Commitments and Contingencies Disclosure [Abstract]  
Contingencies
NOTE 11 — CONTINGENCIES
We operate in a highly regulated and litigious industry. As a result, various lawsuits, claims and legal and regulatory proceedings have been and can be expected to be instituted or asserted against us. We are also subject to claims and suits arising in the ordinary course of business, including claims for personal injuries or wrongful restriction of, or interference with, physicians’ staff privileges. In certain of these actions the claimants may seek punitive damages against us, which may not be covered by insurance. We are also subject to claims by various taxing authorities for additional taxes and related interest and penalties. The resolution of any such lawsuits, claims or legal and regulatory proceedings could have a material, adverse effect on our results of operations, financial position or liquidity.
Government Investigations, Claims and Litigation
Health care companies are subject to numerous investigations by various governmental agencies. Under the federal False Claims Act (“FCA”), private parties have the right to bring
qui tam
, or “whistleblower,” suits against companies that submit false claims for payments to, or improperly retain overpayments from, the government. Some states have adopted similar state whistleblower and false claims provisions. Certain of our individual facilities have received, and from time to time, other facilities may receive, government inquiries from, and may be subject to investigation by, federal and state agencies. Depending on whether the underlying conduct in these or future inquiries or investigations could be considered systemic, their resolution could have a material, adverse effect on our results of operations, financial position or liquidity.
 
Texas operates a state Medicaid program pursuant to a waiver from the Centers for Medicare & Medicaid Services under Section 1115 of the Social Security Act (“Program”). The Program includes uncompensated-care pools; payments from these pools are intended to defray the uncompensated costs of services provided by our and other hospitals to Medicaid eligible or uninsured individuals. Separately, we and other hospitals provide charity care services in several communities in the state. In 2018, the Civil Division of the U.S. Department of Justice and the U.S. Attorney’s Office for the Southern District of Texas requested information about whether the Program, as operated in Harris County, complied with the laws and regulations applicable to provider related donations, and the Company cooperated with that request. On May 21, 2019, a
qui tam
lawsuit asserting violations of the FCA and the Texas Medicaid Fraud Prevention Act related to the Program, as operated in Harris County, was unsealed by the U.S. District Court for the Southern District of Texas. Both the federal and state governments declined to intervene in the
qui tam
lawsuit. The Company believes that our participation is and has been consistent with the requirements of the Program and is vigorously defending against the lawsuit being pursued by the relator. We cannot predict what effect, if any, the
qui tam
lawsuit could have on the Company.
v3.22.0.1
Capital Stock
 12 Months Ended
Dec. 31, 2021
Federal Home Loan Banks [Abstract]  
Capital Stock
NOTE 12 — CAPITAL STOCK
The amended and restated certificate of incorporation authorizes the Company to issue up to 1,800,000,000 shares of common stock, and our amended and restated
by-laws
set the number of directors constituting the board of directors of the Company at not less than three members, the exact number to be determined from time to time by resolution adopted by the affirmative vote of a majority of the total number of directors then in office.
Share Repurchase Transactions
During January 2022 and February 2021, our Board of Directors authorized share repurchase programs for up to $8 billion and $6 billion, respectively, of the Company’s outstanding common stock. During January 2020, January 2019 and October 2017, our Board of Directors authorized share repurchase programs for up to $6 billion ($2 billion for each authorization) of our outstanding common stock.
During 2021, we repurchased 37.812 million shares of our common stock at an average price of $217.25 per share through market purchases pursuant to the $2 billion share repurchase program authorized during January 2019 (which was completed during 2021), the $2 billion share repurchase program authorized during January 2020 (which was completed during 2021) and the $6 billion share repurchase program authorized during February 2021. At December 31, 2021, we had $586 million of repurchase authorization available under the February 2021 authorization. During 2020, we repurchased 3.287 million shares of our common stock at an average price of $134.18 per share through market purchases pursuant to the $2 billion share repurchase program authorized during January 2019. During 2019, we repurchased 7.949 million shares of our common stock at an average price of $129.71 per share through market purchases pursuant to the October 2017 authorization (which was completed during 2019) and the January 2019 authorization.
v3.22.0.1
Employee Benefit Plans
 12 Months Ended
Dec. 31, 2021
Retirement Benefits [Abstract]  
Employee Benefit Plans
 
NOTE 13 — EMPLOYEE BENEFIT PLANS​​​​​​​
We maintain defined contribution benefit plans that are available
to employees who
meet certain minimum requirements. Certain of the plans require that we match specified percentages of participant contributions up to certain maximum levels (generally, 100% of the first 3% to 9
%, depending upon years of vesting service, of compensation deferred by participants). Benefits expense under these plans totaled
 $560 million for 2021, $552 million for 2020 and $532 million for 2019. Our matching contributions are funded during the year following the participant contributions.​​​​​​​
We maintain the noncontributory, nonqualified Restoration Plan to provide certain retirement benefits for eligible employees. Eligibility for the Restoration Plan is based upon earning eligible compensation in excess of a base amount and attaining 1,000 or more hours of service during the plan year. Company credits to participants’ hypothetical account balances (the Restoration Plan is not funded) depend upon participants’ compensation, years of vesting service, hypothetical investment returns (gains or losses) and certain IRS limitations. Benefits expense under this plan was $38 million for 2021, $35 million for 2020 and $44 million for 2019. Accrued benefits liabilities under this plan totaled $258 million at December 31, 2021 and $242 million at December 31, 2020.
We maintain a Supplemental Executive Retirement Plan (“SERP”) for certain executives (the SERP is not funded). The plan is designed to ensure that upon retirement the participant receives the value of a prescribed life annuity from the combination of the SERP and our other benefit plans. Benefits expense under the plan was $22 million for 2021, $24 million for 2020 and $19 million for 2019. Accrued benefits liabilities under this plan totaled $201 million at December 31, 2021 and $204 million at December 31, 2020.
We maintain defined benefit pension plans which resulted from certain hospital acquisitions in prior years. Benefits expense under these plans was $4 million for 2021, $8 million for 2020, and $11 million for 2019. Accrued benefits liabilities under these plans totaled $9 million at December 31, 2021 and $96 million at December 31, 2020.
v3.22.0.1
Segment and Geographic Information
 12 Months Ended
Dec. 31, 2021
Segment Reporting [Abstract]  
Segment and Geographic Information
NOTE 14 — SEGMENT AND GEOGRAPHIC INFORMATION
We operate in one line of business, which is operating hospitals and related health care entities. We operate in two geographically organized groups: the National and American Groups. At December 31, 2021, the National Group included 96 hospitals located in Alaska, California, Florida, Georgia, Idaho, Indiana, northern Kentucky, Nevada, New Hampshire, North Carolina, South Carolina, Utah and Virginia, and the American Group included 79 hospitals located in Colorado, Kansas, southern Kentucky, Louisiana, Missouri, Tennessee and Texas. We also operate seven hospitals in England, and these facilities are included in the Corporate and other group.
Adjusted segment EBITDA is defined as income before depreciation
 
and amortization, interest expense, losses and gains on sales of facilities, losses on retirement of debt, income taxes and net income attributable to noncontrolling interests. We use adjusted segment EBITDA as an analytical indicator for purposes of allocating resources to geographic areas and assessing their performance. Adjusted segment EBITDA is commonly used as an analytical indicator within the health care industry, and also serves as a measure of leverage capacity and debt service ability. Adjusted segment EBITDA should not be considered as a measure of financial performance under generally accepted accounting principles, and the items excluded from adjusted segment EBITDA are significant components in understanding and assessing financial performance. Because adjusted segment EBITDA is not a measurement determined in accordance with generally accepted accounting principles and is thus susceptible to varying calculations, adjusted segment EBITDA, as presented, may not be comparable to other similarly titled measures of other companies. The geographic distributions of our revenues, equity in earnings of affiliates, adjusted segment EBITDA, depreciation and amortization, assets and goodwill and other intangible assets are summarized in the following table (dollars in millions):
 
    
For the Years Ended December 31,
  
    
2021
     
2020
     
2019
  
Revenues:
                           
National Group
   
$
29,826
 
    $ 25,694      $ 25,913  
American Group
   
 
26,152
 
      23,593        23,173  
Corporate and other
   
 
2,774
 
      2,246        2,250  
    
 
 
     
 
 
     
 
 
  
    
$
58,752
 
    $ 51,533      $ 51,336  
    
 
 
     
 
 
     
 
 
  
Equity in earnings of affiliates:
                           
National Group
   
$
(33
) 
    $ (28 )     $ (2 ) 
American Group
   
 
(53
) 
      (42 )       (44 ) 
Corporate and other
   
 
(27
) 
      16        3  
    
 
 
     
 
 
     
 
 
  
    
$
(113
) 
    $ (54 )     $ (43 ) 
    
 
 
     
 
 
     
 
 
  
Adjusted segment EBITDA:
                           
National Group
   
$
7,200
 
    $ 5,532      $ 5,634  
American Group
   
 
6,156
 
      5,333        4,904  
Corporate and other
   
 
(712
) 
      (828 )       (681 ) 
    
 
 
     
 
 
     
 
 
  
    
$
12,644
 
    $ 10,037      $ 9,857  
    
 
 
     
 
 
     
 
 
  
Depreciation and amortization:
                           
National Group
   
$
1,359
 
    $ 1,216      $ 1,161  
American Group
   
 
1,183
 
      1,164        1,117  
Corporate and other
   
 
311
 
      341        318  
    
 
 
     
 
 
     
 
 
  
    
$
2,853
 
    $ 2,721      $ 2,596  
    
 
 
     
 
 
     
 
 
  
 
 
    
For the Years Ended December 31,
  
    
2021
     
2020
     
2019
  
Adjusted segment EBITDA
   
$
12,644
 
    $ 10,037      $ 9,857  
Depreciation and amortization
   
 
2,853
 
      2,721        2,596  
Interest expense
   
 
1,566
 
      1,584        1,824  
Losses (gains) on sales of facilities
   
 
(1,620
) 
      7        (18 ) 
Losses on retirement of debt
   
 
12
 
      295        211  
    
 
 
     
 
 
     
 
 
  
Income before income taxes
   
$
9,833
 
    $ 5,430      $ 5,244  
    
 
 
     
 
 
     
 
 
  
   
    
December 31,
  
    
2021
     
2020
     
2019
  
Assets:
                           
National Group
   
$
21,205
 
    $ 18,913      $ 18,290  
American Group
   
 
21,428
 
      20,760        20,608  
Corporate and other
   
 
8,109
 
      7,817        6,160  
    
 
 
     
 
 
     
 
 
  
    
$
50,742
 
    $ 47,490      $ 45,058  
    
 
 
     
 
 
     
 
 
  
    
National
Group
    
American
Group
    
Corporate
and Other
    
Total
  
Goodwill and other intangible assets:
                                 
Balance at December 31, 2018
    $ 1,597     $ 5,729     $ 627     $ 7,953  
Acquisitions
      155       39       138       332  
Foreign currency translation, amortization and other
      (13 )      (3 )      —       (16 ) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2019
      1,739       5,765       765       8,269  
Acquisitions
      38       27       279       344  
Foreign currency translation, amortization and other
      (2 )      (17 )      (16 )      (35 ) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2020
      1,775       5,775       1,028       8,578  
Acquisitions
   
 
735
 
  
 
67
 
  
 
260
 
  
 
1,062
 
Foreign currency translation, amortization and other
   
 
(18
) 
  
 
(10
) 
  
 
(72
) 
  
 
(100
) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2021
   
$
2,492
 
  
$
5,832
 
  
$
1,216
 
  
$
9,540
 
    
 
 
    
 
 
    
 
 
    
 
 
  
v3.22.0.1
Other Comprehensive Loss
 12 Months Ended
Dec. 31, 2021
Equity [Abstract]  
Other Comprehensive Loss
NOTE 15 — OTHER COMPREHENSIVE LOSS
The components of accumulated other comprehensive loss are as follows (dollars in millions):
 
 
  
Unrealized
Gains on
Available-
for-Sale

Securities
 
 
Foreign
Currency
Translation
Adjustments
 
 
Defined
Benefit
Plans
 
 
Change
in Fair
Value of
Derivative
Instruments
 
 
Total
 
Balances at December 31, 2018
    $ 3      $ (283 )    $ (148 )    $ 47     $ (381 ) 
Unrealized gains on
available-for-sale
securities, net of $4 of income taxes
      11        —       —       —       11  
Foreign currency translation adjustments, net of $5 of income taxes
      —        —       —       —       —  
Defined benefit plans, net of $14 income tax benefit
      —        —       (49 )      —       (49 ) 
Change in fair value of derivative instruments, net of $13 income tax benefit
      —        —       —       (37 )      (37 ) 
Expense (income) reclassified into operations from other comprehensive income, net of $3 income tax benefit and $3 of income taxes, respectively
      —        —       10       (14 )      (4 ) 
    
 
 
     
 
 
    
 
 
    
 
 
    
 
 
  
Balances at December 31, 2019
      14        (283 )      (187 )      (4 )      (460 ) 
Unrealized gains on
available-for-sale
securities, net of $3 of income taxes
      11        —       —       —       11  
Foreign currency translation adjustments, net of $6 of income taxes
      —        12       —       —       12  
Defined benefit plans, net of $16 income tax benefit
      —        —       (55 )      —       (55 ) 
Change in fair value of derivative instruments, net of $15 income tax benefit
      —        —       —       (51 )      (51 ) 
Expense reclassified into operations from other comprehensive income, net of $6 and $5 of income tax benefits, respectively
      —        —       22       19       41  
    
 
 
     
 
 
    
 
 
    
 
 
    
 
 
  
Balances at December 31, 2020
  
25
 
 
(271
) 
 
(220
) 
 
(36
) 
 
(502
) 
Unrealized losses on
available-for-sale
securities, net of $3 income tax benefit
  
 
(13
) 
 
 
—
 
 
 
—
 
 
 
—
 
 
 
(13
) 
Foreign currency translation adjustments, net of $2 income tax benefit
  
 
—
 
 
 
(7
) 
 
 
—
 
 
 
—
 
 
 
(7
) 
Defined benefit plans, net of $20 of income taxes
  
 
—
 
 
 
—
 
 
 
67
 
 
 
—
 
 
 
67
 
Change in fair value of derivative instruments
  
 
—
 
 
 
—
 
 
 
—
 
 
 
1
 
 
 
1
 
Expense reclassified into operations from other comprehensive income, net of $7 and $8 income tax benefits, respectively
  
 
—
 
 
 
—
 
 
 
21
 
 
 
29
 
 
 
50
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Balances at December 31, 2021
  
$
12
 
 
$
(278
) 
 
$
(132
) 
 
$
(6
) 
 
$
(404
) 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
v3.22.0.1
Accrued Expenses
 12 Months Ended
Dec. 31, 2021
Text Block [Abstract]  
Accrued Expenses
NOTE 16 — ACCRUED EXPENSES
A summary of other accrued expenses
 
at December 31 follows (dollars in millions):
 
    
2021
     
2020
  
Professional liability risks
   
$
508
 
    $ 477  
Defined contribution benefit plans
   
 
549
 
      547  
Right-of-use
operating leases
   
 
392
 
      379  
Taxes other than income
   
 
361
 
      343  
Interest
   
 
353
 
      315  
Government stimulus refund liability
   
 
79
 
      83  
Other
   
 
1,080
 
      1,096  
    
 
 
     
 
 
  
    
$
3,322
 
    $ 3,240  
    
 
 
     
 
 
  
v3.22.0.1
Accounting Policies (Policies)
 12 Months Ended
Dec. 31, 2021
Basis of Presentation
Basis of Presentation
The preparation of financial statements in conformity with generally accepted accounting principles requires management to make estimates and assumptions that affect the amounts reported in the consolidated financial statements and accompanying notes. Actual results could differ from those estimates.
The consolidated financial statements include all subsidiaries and entities controlled by HCA. We generally define “control” as ownership of a majority of the voting interest of an entity. The consolidated financial statements include entities in which we absorb a majority of the entity’s expected losses, receive a majority of the entity’s expected residual returns, or both, as a result of ownership, contractual or other financial interests in the entity. The accounts of acquired entities are included in our consolidated financial statements for periods subsequent to our acquisition of controlling interests. Significant intercompany transactions have been eliminated. Investments in entities we do not control, but in which we have a substantial ownership interest and can exercise significant influence, are accounted for using the equity method.
The majority of our expenses are “cost of revenue” items. Costs that could be classified as general and administrative include our corporate office costs, which were $400 million, $416 million and $370 million for the years ended December 31, 2021, 2020 and 2019, respectively.
COVID-19
Pandemic
On March 11, 2020, the World Health Organization designated
COVID-19
as a global pandemic. Patient volumes and the related revenues for most of our services were significantly impacted during the latter portion of the first quarter and the first half of the second quarter of 2020 and have continued to be impacted as various policies were implemented by federal, state and local governments in response to the
COVID-19
pandemic. During the second quarter of 2021, our patient volumes improved as the effects of the pandemic moderated and certain pandemic-related restrictions and policies were eased. For the remainder of 2021, our patient volumes exhibited consistent growth over the prior year, with the exception of inpatient surgeries, and included a resurgence of
COVID-19
admissions and the
re-imposition
of pandemic-related restrictions in certain markets. We believe the extent of the
COVID-19
pandemic’s impact on our operating results and financial condition has been and will continue to be driven by many factors, most of which are beyond our control and ability to forecast. Because of these uncertainties, we cannot estimate how long or to what extent the pandemic will impact our operations.
 
Revenues
Revenues
Our revenues generally relate to contracts with patients in which our performance obligations are to provide health care services to the patients. Revenues are recorded during the period our obligations to provide health care services are satisfied. Our performance obligations for inpatient services are generally satisfied over periods that average approximately five days, and revenues are recognized based on charges incurred in relation to total expected charges. Our performance obligations for outpatient services are generally satisfied over a period of less than one day. The contractual relationships with patients, in most cases, also involve a third-party payer (Medicare, Medicaid, managed care health plans and commercial insurance companies, including plans offered through the health insurance exchanges) and the transaction prices for the services provided are dependent upon the terms provided by (Medicare and Medicaid) or negotiated with (managed care health plans and commercial insurance companies) the third-party payers. The payment arrangements with third-party payers for the services we provide to the related patients typically specify payments at amounts less than our standard charges. Medicare generally pays for inpatient and outpatient services at prospectively determined rates based on clinical, diagnostic and other factors. Services provided to patients having Medicaid coverage are generally paid at prospectively determined rates per discharge, per identified service or per covered member. Agreements with commercial insurance carriers, managed care and preferred provider organizations generally provide for payments based upon predetermined rates per diagnosis, per diem rates or discounted
fee-for-service
rates. Management continually reviews the contractual estimation process to consider and incorporate updates to laws and regulations and the frequent changes in managed care contractual terms resulting from contract renegotiations and renewals.
Our revenues are based upon the estimated amounts we expect to be entitled to receive from patients and third-party payers. Estimates of contractual adjustments under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured discounts and contractual discounts). We also record estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record these revenues at the estimated amounts we expect to collect. Our revenues by primary third-party payer classification and other (including uninsured patients) for the years ended December 31, are summarized in the following table (dollars in millions):
 
   
Years Ended December 31,
  
   
2021
    
Ratio
    
2020
    
Ratio
    
2019
    
Ratio
  
Medicare
  
$
10,447
 
  
 
17.8
% 
   $ 10,420       20.2 %    $ 10,798       21.0 % 
Managed Medicare
  
 
8,424
 
  
 
14.3
 
     6,997       13.6       6,452       12.6  
Medicaid
  
 
2,290
 
  
 
3.9
 
     1,965       3.8       1,572       3.1  
Managed Medicaid
  
 
3,124
 
  
 
5.3
 
     2,621       5.1       2,450       4.8  
Managed care and other insurers
  
 
30,295
 
  
 
51.6
 
     26,535       51.5       26,544       51.6  
International (managed care and other insurers)
  
 
1,336
 
  
 
2.3
 
     1,120       2.2       1,162       2.3  
Other
  
 
2,836
 
  
 
4.8
 
     1,875       3.6       2,358       4.6  
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Revenues
  
$
58,752
 
  
 
100.0
% 
   $ 51,533       100.0 %    $ 51,336       100.0 % 
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Laws and regulations governing the Medicare and Medicaid programs are complex and subject to interpretation. Estimated reimbursement amounts are adjusted in subsequent periods as cost reports are prepared and filed and as final settlements are determined (in relation to certain government programs, primarily
 
Medicare, this is generally referred to as the “cost report” filing and settlement process). The adjustments to estimated Medicare and Medicaid reimbursement amounts and disproportionate-share funds related primarily to cost reports filed during the respective year resulted in net increases to revenues of $53 million, $70 million and $51 million in 2021, 2020 and 2019, respectively. The adjustments to estimated reimbursement amounts related primarily to cost reports filed during previous years resulted in a net increase to revenues of $19 million in 2021, a net reduction to revenues of $5 million in 2020 and a net increase to revenues of $13 million in 2019.
The Emergency Medical Treatment and Labor Act (“EMTALA”) requires any hospital participating in the Medicare program to conduct an appropriate medical screening examination of every person who presents to the hospital’s emergency room for treatment and, if the individual is suffering from an emergency medical condition, to either stabilize the condition or make an appropriate transfer of the individual to a facility able to handle the condition. The obligation to screen and stabilize emergency medical conditions exists regardless of an individual’s ability to pay for treatment. Federal and state laws and regulations require, and our commitment to providing quality patient care encourages, us to provide services to patients who are financially unable to pay for the health care services they receive.
Patients treated at hospitals for
non-elective
care, who have income at or below 400% of the federal poverty level, are eligible for charity care, and we limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. Patients treated at hospitals for
non-elective
care, who have income above 400% of the federal poverty level, are eligible for certain other discounts which limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. We apply additional discounts to limit patient responsibility for certain emergency services. The federal poverty level is established by the federal government and is based on income and family size. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. We provide discounts to uninsured patients who do not qualify for Medicaid or charity care. We may attempt to provide assistance to uninsured patients to help determine whether they may qualify for Medicaid, other federal or state assistance, or charity care. If an uninsured patient does not qualify for these programs, the uninsured discount is applied.
The collection of outstanding receivables from Medicare, Medicaid, managed care payers, other third-party payers and patients is our primary source of cash and is critical to our operating performance. The primary collection risks relate to uninsured patient accounts, including patient accounts for which the primary insurance carrier has paid the amounts covered by the applicable agreement, but patient responsibility amounts (deductibles and copayments) remain outstanding. Implicit price concessions relate primarily to amounts due directly from patients. Estimated implicit price concessions are recorded for all uninsured accounts, regardless of the age of those accounts. Accounts are written off when all reasonable collection efforts have been performed.
The estimates for implicit price concessions are based upon management’s assessment of historical writeoffs and expected net collections, business and economic conditions, trends in federal, state and private employer health care coverage and other collection indicators. Management relies on the results of detailed reviews of historical writeoffs and collections at facilities that represent a majority of our revenues and accounts receivable (the “hindsight analysis”) as a primary source of information in estimating the collectability of our accounts receivable. We perform the hindsight analysis quarterly, utilizing rolling twelve-months accounts
receivable collection and writeoff data. We believe our quarterly updates to the estimated implicit price concession amounts at each of our hospital facilities provide reasonable estimates of our revenues and valuations of our accounts receivable. These routine, quarterly changes in estimates have not resulted in material adjustments to the valuations of our accounts receivable or
period-to-period
comparisons of our revenues. At December 31, 2021 and 2020, estimated implicit price concessions of $6.784 billion and $6.108 billion, respectively, had been recorded to adjust our revenues and accounts receivable to the estimated amounts we expect to collect.
To quantify the total impact of the trends related to uninsured patient accounts, we believe it is beneficial to view total uncompensated care, which is comprised of charity care, uninsured discounts and implicit price concessions. A summary of the estimated cost of total uncompensated care for the years ended December 31, follows (dollars in millions):
 
    
2021
     
2020
     
2019
  
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization)
   
$
49,074
 
    $ 44,271      $ 44,118  
    
 
 
     
 
 
     
 
 
  
Cost-to-charges
ratio (patient care costs as percentage of gross patient charges)
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Total uncompensated care
   
$
29,642
 
    $ 29,029      $ 31,105  
Multiply by the
cost-to-charges
ratio
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Estimated cost of total uncompensated care
   
$
3,350
 
    $ 3,483      $ 3,733  
    
 
 
     
 
 
     
 
 
  
The total uncompensated care amounts include charity care of $13.644 billion, $13.763 billion and $13.260 billion for the years ended December 31, 2021, 2020 and 2019, respectively. The estimated cost of charity care was $1.542 billion, $1.652 billion and $1.591 billion for the years ended December 31, 2021, 2020 and 2019, respectively.
Cash and Cash Equivalents
Cash and Cash Equivalents
Cash and cash equivalents include highly liquid investments with a maturity of three months or less when purchased. Our insurance subsidiaries’ cash equivalent investments in excess of the amounts required to pay estimated professional liability claims during the next twelve months are not included in cash and cash equivalents as these funds are not available for general corporate purposes. Carrying values of cash and cash equivalents approximate fair value due to the short-term nature of these instruments.
Our cash management system provides for daily investment of available balances and the funding of outstanding checks when presented for payment. Outstanding, but unpresented, checks totaling $536 million and $495 million at December 31, 2021 and 2020, respectively, have been included in “accounts payable” in the consolidated balance sheets. Upon presentation for payment, these checks are funded through available cash balances or our credit facility.
 
Accounts Receivable
Accounts Receivable
We receive payments for services rendered from federal and state agencies (under the Medicare and Medicaid programs), managed care health plans, commercial insurance companies, employers and patients. We recognize that revenues and receivables from government agencies are significant to our operations, but do not believe there are significant credit risks associated with these government agencies. We do not believe there are any other significant concentrations of revenues from any particular payer that would subject us to any significant credit risks in the collection of our accounts receivable. Days revenues in accounts receivable were 49 days, 45 days and 50
days at December 31, 2021, 2020 and 2019, respectively. The five-day decline during 2020 was primarily related to the COVID-19 impacts of continuing to collect our accounts receivable from the pre-COVID-19 period, while experiencing lower revenues (primarily during the first and second quarters of 2020) that slowed the return of our accounts receivable balances back to pre-COVID-19 levels in 2021. Changes in general economic conditions, patient accounting service center operations, payer mix, or federal or state governmental health care coverage could affect our collection of accounts receivable, cash flows and results of operations. 
Inventories
Inventories
Inventories are stated at the lower of cost
(first-in,
first-out)
or market.
Property and Equipment
Property and Equipment
Depreciation expense, computed using the straight-line method, was $2.826 billion in 2021, $2.693 billion in 2020 and $2.579 billion in 2019. Buildings and improvements are depreciated over estimated useful lives ranging generally from 10 to 40 years. Estimated useful lives of equipment vary generally from four to 10 years.
When events, circumstances or operating results indicate the carrying values of certain long-lived assets expected to be held and used might be impaired, we prepare projections of the undiscounted future cash flows expected to result from the use of the assets and their eventual disposition. If the projections indicate the recorded amounts are not expected to be recoverable, such amounts are reduced to estimated fair value. Fair value may be estimated based upon internal evaluations that include quantitative analyses of revenues and cash flows, reviews of recent sales of similar assets and independent appraisals.
Long-lived assets to be disposed of are reported at the lower of their carrying amounts or fair value less costs to sell or close. The estimates of fair value are usually based upon recent sales of similar assets and market responses based upon discussions with and offers received from potential buyers.
Investments of Insurance Subsidiaries
Investments of Insurance Subsidiaries
At December 31, 2021 and 2020, the investment securities held by our insurance subsidiaries were classified as
“available-for-sale”
as defined in Accounting Standards Codification (“ASC”) No. 320,
Investments — Debt Securities
and are recorded at fair value. The investment securities are held for the purpose of providing a funding source to pay liability claims covered by the insurance subsidiaries. We perform quarterly assessments of individual investment securities to determine whether declines in fair value are due to credit-related or noncredit-related factors. Our investment securities evaluation process involves subjective judgments, often involves estimating the outcome of future events, and requires a significant level of professional judgment in determining whether a credit-related impairment has occurred. We evaluate, among other things, the financial position and
near term prospects of the issuer, conditions in the issuer’s industry, liquidity of the investment, changes in the amount or timing of expected future cash flows from the investment, and recent downgrades of the issuer by a rating agency, to determine if, and when, a decline in the fair value of an investment below amortized cost is considered to be a credit-related impairment. The extent to which the fair value of the investment is less than amortized cost and our ability and intent to retain the investment, to allow for any anticipated recovery of the investment’s fair value, are important components of our investment securities evaluation process
.
Goodwill and Intangible Assets
Goodwill and Intangible Assets
Goodwill is not amortized but is subject to annual impairment tests. In addition to the annual impairment review, impairment reviews are performed whenever circumstances indicate a possible impairment may exist. Impairment testing for goodwill is done at the reporting unit level. Reporting units are one level below the business segment level, and our impairment testing is performed at the operating division level. We compare the fair value of the reporting unit assets to the carrying amount, on at least an annual basis, to determine if there is potential impairment. If the fair value of the reporting unit assets is less than their carrying value, an impairment loss is recognized. Fair value is estimated based upon internal evaluations of each reporting unit that include quantitative analyses of market multiples, revenues and cash flows and reviews of recent sales of similar facilities. No goodwill impairments were recognized during 2021, 2020 or 2019.
During 2021, goodwill increased by $1.002 billion related to acquisitions and declined by $75 million related to foreign currency translation and other adjustments. During 2020, goodwill increased by $279 million related to acquisitions, including the finalization of the accounting for certain prior year acquisitions, and declined by $9 million related to foreign currency translation and other adjustments.
During 2021, identifiable intangible assets increased by $60 million related to acquisitions and declined by $25 million due to amortization and other adjustments. During 2020, identifiable intangible assets increased by $65 million related to acquisitions, including the finalization of the accounting for certain prior year acquisitions, and declined by $26 million due to amortization and other adjustments. Identifiable intangible assets
 with finite lives
are amortized over estimated lives ranging generally from three to 10 years. The gross carrying amounts of
 
amortizable
 
identifiable intangible assets at December 31, 2021 and 2020 were $274 million and $249 million, respectively, and accumulated amortization was
 
$175 million and $149 million, respectively. The gross carrying amounts of indefinite-lived identifiable intangible assets at December 31, 2021 and
 
2020 were $304 million and $269 million, respectively. Indefinite-lived identifiable intangible assets are not amortized but are
 
subject to annual
 
impairment tests, and impairment reviews are performed whenever circumstances indicate a possible impairment may exist.
Debt Issuance Costs and Discounts
Debt Issuance Costs and Discounts
Debt issuance costs and discounts are amortized based upon the terms of the respective debt obligations. The gross carrying amount of debt issuance costs and discounts at December 31, 2021 and 2020 was $446 million and $411 million, respectively, and accumulated amortization was $198 million and $175 million, respectively. Amortization of debt issuance costs and discounts is included in interest expense and was $27 million, $30 million and $30 million for 2021, 2020 and 2019, respectively.
 
Professional Liability Claims
Professional Liability Claims
Reserves for professional liability risks were $2.022 billion and $1.963 billion at December 31, 2021 and 2020, respectively. The current portion of the reserves, $508 million and $477 million at December 31, 2021 and 2020, respectively, is included in “other accrued expenses” in the consolidated balance sheets. Provisions for losses related to professional liability risks were $453 million, $435 million and $497 million for 2021, 2020 and 2019, respectively, and are included in “other operating expenses” in our consolidated income statements. Provisions for losses related to professional liability risks are based upon actuarially determined estimates. During 2021, 2020 and 2019, we recorded reductions to the provision for professional liability risks of $87 million, $112 million and $50 million, respectively, due to the receipt of updated actuarial information. Loss and loss expense reserves represent the estimated ultimate net cost of all reported and unreported losses incurred through the respective consolidated balance sheet dates. The reserves for unpaid losses and loss expenses are estimated using individual case-basis valuations and actuarial analyses. Those estimates are subject to the effects of trends in loss severity and frequency. The estimates are continually reviewed and adjustments are recorded as experience develops or new information becomes known. Adjustments to the estimated reserve amounts are included in current operating results. The reserves for professional liability risks cover approximately 2,100 and 2,300 individual claims at December 31, 2021 and 2020, respectively, and estimates for unreported potential claims. The time period required to resolve these claims can vary depending upon the jurisdiction and whether the claim is settled or litigated. During 2021 and 2020, $384 million and $292 million, respectively, of net payments were made for professional and general liability claims. The estimation of the timing of payments beyond a year can vary significantly. Although considerable variability is inherent in professional liability reserve estimates, we believe the reserves for losses and loss expenses are adequate; however, there can be no assurance the ultimate liability will not exceed our estimates.
A portion of our professional liability risks is insured through our insurance subsidiary. Subject, in most cases, to a $15 million per occurrence self-insured retention, our facilities are insured by our insurance subsidiary for losses up to $75 million per occurrence. The insurance subsidiary has obtained reinsurance for professional liability risks generally above a retention level of either $25 million or $35 million per occurrence, depending on the jurisdiction for the related claim. We also maintain professional liability insurance with unrelated commercial carriers for losses in excess of amounts insured by our insurance subsidiary.
The obligations covered by reinsurance and excess insurance contracts are included in the reserves for professional liability risks, as we remain liable to the extent the reinsurers and excess insurance carriers do not meet their obligations under the reinsurance and excess insurance contracts. The amounts receivable under the reinsurance contracts include $44 million and $31 million at December 31, 2021 and 2020, respectively, recorded in “other assets,” and $11 million and $8 million at December 31, 2021 and 2020, respectively, recorded in “other current assets.”
Financial Instruments
Financial Instruments
Derivative financial instruments are employed to manage interest rate risks, and are not used for trading or speculative purposes. We recognize our interest rate swap derivative instruments in the consolidated balance sheets at fair value. Changes in the fair value of derivatives are recognized periodically in stockholders’ equity, as a component of other comprehensive income (loss), provided the derivative financial instrument qualifies for hedge accounting. Gains and losses on derivatives designated as cash flow hedges, to the extent they are effective, are recorded in other comprehensive income (loss), and subsequently reclassified to earnings to offset
 
the impact of the forecasted transactions when they occur. In the event the forecasted transaction to which a cash flow hedge relates is no longer likely, the amount in other comprehensive income is recognized in earnings and generally the derivative is terminated.
The net interest paid or received on interest rate swaps is recognized as an adjustment to interest expense. Gains and losses resulting from the early termination of interest rate swap agreements are deferred and amortized as adjustments to interest expense over the remaining term of the debt originally associated with the terminated swap.
Noncontrolling Interests in Consolidated Entities
Noncontrolling Interests in Consolidated Entities
The consolidated financial statements include all assets, liabilities, revenues and expenses of less than 100% owned entities that we control. Accordingly, we have recorded noncontrolling interests in the earnings and equity of such entities.
Earning Per Share We compute basic earnings per share using the weighted average number of common shares outstanding. We compute diluted earnings per share using the weighted average number of common shares outstanding plus the dilutive effect of outstanding stock options, SARs, RSUs and PSUs, computed using the treasury stock method.
Fair Value Measurements and Disclosures
Accounting Standards Codification 820,
Fair Value Measurements and Disclosures
(“ASC 820”) emphasizes fair value is a market-based measurement, and fair value measurements should be determined based on the assumptions market participants would use in pricing assets or liabilities. ASC 820 utilizes a fair value hierarchy that distinguishes between market participant assumptions based on market data obtained from sources independent of the reporting entity (observable inputs classified within Levels 1 and 2 of the hierarchy) and the reporting entity’s own assumptions about market participant assumptions (unobservable inputs classified within Level 3 of the hierarchy).
Level 1 inputs utilize quoted prices (unadjusted) in active markets for identical assets or liabilities. Level 2 inputs are inputs other than quoted prices included in Level 1 that are observable for the asset or liability, either directly or indirectly. Level 2 inputs may include quoted prices for similar assets and liabilities in active markets, as well as inputs observable for the asset or liability (other than quoted prices), such as interest rates, foreign exchange rates, and yield curves observable at commonly quoted intervals. Level 3 inputs are unobservable inputs for the asset or liability, which are typically based on an entity’s own assumptions, as there is little, if any, related market activity. In instances where the determination of the fair value measurement is based on inputs from different levels of the fair value hierarchy, the level in the fair value hierarchy within which the entire fair value measurement falls is based on the lowest level input significant to the fair value measurement in its entirety. Our assessment of the significance of a particular input to the fair value measurement in its entirety requires judgment.
Investment Securities
Investment Securities
The investments of our insurance subsidiaries are generally classified within Level 1 or Level 2 of the fair value hierarchy because they are valued using quoted market prices, broker or dealer quotations, or alternative pricing sources with reasonable levels of price transparency.
Derivative Financial Instruments
Derivative Financial Instruments
We have entered into interest rate swap agreements to manage our exposure to fluctuations in interest rates. The valuation of these instruments is determined using widely accepted valuation techniques, including discounted cash flow analysis on the expected cash flows of each derivative. This analysis reflects the contractual terms of the derivatives, including the period to maturity, and uses observable market-based inputs, including interest rate curves and implied volatilities. We incorporate credit valuation adjustments to reflect both our own nonperformance risk and the respective counterparty’s nonperformance risk in the fair value measurements of these instruments.
Interest Rate Swaps [Member]  
Financial Instruments
Interest Rate Swap Agreements
We have entered into interest rate swap agreements to manage our exposure to fluctuations in interest rates. These swap agreements involve the exchange of fixed and variable rate interest payments between us and our counterparties based on common notional principal amounts and maturity dates.
Pay-fixed
interest rate swaps effectively convert variable rate obligations to fixed interest rate obligations. The interest payments under these agreements are settled on a net basis. The net interest payments, based on the notional amounts in these agreements, generally match the timing of the related liabilities for the interest rate swap agreements which have been designated as cash flow hedges. The notional amounts of the swap agreements represent amounts used to calculate the exchange of cash flows and are not our assets or liabilities. Our credit risk related to these agreements is considered low because the swap agreements are with creditworthy financial institutions.
v3.22.0.1
Accounting Policies (Tables)
 12 Months Ended
Dec. 31, 2021
Accounting Policies [Abstract]  
Schedule of Revenues from Third Party Payers, Uninsured and Other Payers Our revenues by primary third-party payer classification and other (including uninsured patients) for the years ended December 31, are summarized in the following table (dollars in millions):
   
Years Ended December 31,
  
   
2021
    
Ratio
    
2020
    
Ratio
    
2019
    
Ratio
  
Medicare
  
$
10,447
 
  
 
17.8
% 
   $ 10,420       20.2 %    $ 10,798       21.0 % 
Managed Medicare
  
 
8,424
 
  
 
14.3
 
     6,997       13.6       6,452       12.6  
Medicaid
  
 
2,290
 
  
 
3.9
 
     1,965       3.8       1,572       3.1  
Managed Medicaid
  
 
3,124
 
  
 
5.3
 
     2,621       5.1       2,450       4.8  
Managed care and other insurers
  
 
30,295
 
  
 
51.6
 
     26,535       51.5       26,544       51.6  
International (managed care and other insurers)
  
 
1,336
 
  
 
2.3
 
     1,120       2.2       1,162       2.3  
Other
  
 
2,836
 
  
 
4.8
 
     1,875       3.6       2,358       4.6  
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Revenues
  
$
58,752
 
  
 
100.0
% 
   $ 51,533       100.0 %    $ 51,336       100.0 % 
   
 
 
    
 
 
    
 
 
    
 
 
    
 
 
    
 
 
  
Schedule of Estimated Cost of Uncompensated Care A summary of the estimated cost of total uncompensated care for the years ended December 31, follows (dollars in millions):
 
    
2021
     
2020
     
2019
  
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization)
   
$
49,074
 
    $ 44,271      $ 44,118  
    
 
 
     
 
 
     
 
 
  
Cost-to-charges
ratio (patient care costs as percentage of gross patient charges)
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Total uncompensated care
   
$
29,642
 
    $ 29,029      $ 31,105  
Multiply by the
cost-to-charges
ratio
   
 
11.3
% 
      12.0 %       12.0 % 
    
 
 
     
 
 
     
 
 
  
Estimated cost of total uncompensated care
   
$
3,350
 
    $ 3,483      $ 3,733  
    
 
 
     
 
 
     
 
 
  
v3.22.0.1
Share-Based Compensation (Tables)
 12 Months Ended
Dec. 31, 2021
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]  
Schedule of Fair Value of Each Stock Option Award is Estimated on Grant Date, Using Option Valuation Models The expected dividend yield is estimated based on the assumption that the dividend yield at date of grant will be maintained over the expected life of the grant.
 
    
2021
    
2020
    
2019
  
Risk-free interest rate
   
 
0.68
% 
     1.44 %      2.50 % 
Expected volatility
   
 
36
% 
     27 %      27 % 
Expected life, in years
   
 
6.17
 
     6.15       6.18  
Expected dividend yield
   
 
1.10
% 
     1.19 %      1.16 % 
Schedule of Stock Option Activity
Information regarding Time Stock Options and SARs and Performance Stock Options and SARs activity during 2021, 2020 and 2019 is summarized below (share amounts in thousands):
 
    
Time
Stock
Options
and
SARs
    
Performance
Stock
Options and
SARs
    
Total
Stock
Options
and
SARs
    
Weighted
Average
Exercise
Price
     
Weighted
Average
Remaining
Contractual Term
     
Aggregate
Intrinsic Value
(dollars in millions)
  
Options and SARs outstanding, December 31, 2018
      9,360       2,667       12,027     $ 61.49                    
Granted
      1,349       —       1,349       138.31                    
Exercised
      (1,137 )      (523 )      (1,660 )      44.45                    
Cancelled
      (522 )      —       (522 )      93.26                    
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2019
      9,050       2,144       11,194       71.79                    
Granted
      1,120       —       1,120       144.47                    
Exercised
      (2,159 )      (1,325 )      (3,484 )      44.07                    
Cancelled
      (175 )      —       (175 )      111.69                    
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2020
      7,836       819       8,655       91.53                    
Granted
   
 
877
 
  
 
—
 
  
 
877
 
  
 
174.98
 
                  
Exercised
   
 
(2,443
) 
  
 
(533
) 
  
 
(2,976
) 
  
 
67.57
 
                  
Cancelled
   
 
(108
) 
  
 
—
 
  
 
(108
) 
  
 
138.32
 
                  
    
 
 
    
 
 
    
 
 
                            
Options and SARs outstanding, December 31, 2021
   
 
6,162
 
  
 
286
 
  
 
6,448
 
  
$
113.15
 
   
 
6.2 years
 
   
$
927
 
    
 
 
    
 
 
    
 
 
                            
Options and SARs exercisable, December 31, 2021
   
 
3,486
 
  
 
286
 
  
 
3,772
 
  
$
89.70
 
   
 
5.0 years
 
   
$
631
 
Schedule of Restricted Stock Units Activity
Information regarding RSUs and PSUs activity during 2021, 2020 and 2019 is summarized below (share amounts in thousands):
 
    
RSUs
     
PSUs
     
Total RSUs
and PSUs
     
Weighted
Average
Grant
Date Fair
Value
  
RSUs and PSUs outstanding, December 31, 2018
      3,123        3,422        6,545      $ 86.32  
Granted
      973        796        1,769        138.45  
Performance adjustment
      —        227        227        69.94  
Vested
      (1,216 )       (1,251 )       (2,467 )       75.97  
Cancelled
      (260 )       (159 )       (419 )       103.27  
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2019
      2,620        3,035        5,655        105.23  
Granted
      1,048        808        1,856        144.17  
Performance adjustment
      —        206        206        81.89  
Veste
d
      (1,030 )       (1,364 )       (2,394 )       88.63  
Cancelled
      (162 )       (93 )       (255 )       124.50  
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2020
      2,476        2,592        5,068        125.40  
Granted
   
 
899
 
   
 
689
 
   
 
1,588
 
   
 
174.34
 
Performance adjustment
   
 
—
 
   
 
684
 
   
 
684
 
   
 
102.02
 
Vested
   
 
(992
) 
   
 
(1,772
) 
   
 
(2,764
) 
   
 
106.62
 
Cancelled
   
 
(192
) 
   
 
(110
) 
   
 
(302
) 
   
 
149.07
 
    
 
 
     
 
 
     
 
 
           
RSUs and PSUs outstanding, December 31, 2021
   
 
2,191
 
   
 
2,083
 
   
 
4,274
 
   
$
150.32
 
    
 
 
     
 
 
     
 
 
           
v3.22.0.1
Income Taxes (Tables)
 12 Months Ended
Dec. 31, 2021
Income Tax Disclosure [Abstract]  
Schedule of Provision for Income Taxes
The provision for income taxes consists of the following (dollars in millions):
 
    
2021
     
2020
     
2019
  
Current:
                           
Federal
   
$
1,769
 
    $ 1,021      $ 670  
State
   
 
311
 
      126        134  
Foreign
   
 
15
 
      5        17  
Deferred:
                           
Federal
   
 
24
 
      (73 )       254  
State
   
 
(18
) 
      (39 )       29  
Foreign
   
 
11
 
      3        (5 ) 
    
 
 
     
 
 
     
 
 
  
    
$
2,112
 
    $ 1,043      $ 1,099  
    
 
 
     
 
 
     
 
 
  
Schedule of Reconciliation of Federal Statutory Rate to Effective Income Tax Rate
A reconciliation of the federal statutory rate to the effective income tax rate follows:
 
    
  2021  
    
  2020  
    
  2019  
  
Federal statutory rate
   
 
21.0
% 
     21.0 %      21.0 % 
State income taxes, net of federal tax benefit
   
 
2.0
 
     1.9       2.7  
Change in liability for uncertain tax positions
   
 
0.7
 
     (0.2 )      0.4  
Tax benefit from settlements of employee equity awards
   
 
(1.2
) 
     (1.8 )      (1.3 ) 
Other items, net
   
 
0.8
 
     0.8       1.1  
    
 
 
    
 
 
    
 
 
  
Effective income tax rate on income attributable to HCA Healthcare, Inc.
   
 
23.3
 
     21.7       23.9  
Income attributable to noncontrolling interests from consolidated partnerships
   
 
(1.8
) 
     (2.5 )      (2.9 ) 
    
 
 
    
 
 
    
 
 
  
Effective income tax rate on income before income taxes
   
 
21.5
% 
     19.2 %      21.0 % 
    
 
 
    
 
 
    
 
 
  
Schedule of Deferred Tax Assets and Liabilities
A summary of the items comprising the deferred tax assets and liabilities at December 31 follows (dollars in millions):
 
    
2021
     
2020
  
    
Assets
     
Liabilities
     
Assets
     
Liabilities
  
Depreciation and fixed asset basis differences
   
$
—
 
   
$
737
 
    $ —      $ 678  
Allowances for professional liability and other risks
   
 
426
 
   
 
—
 
      407        —  
Accounts receivable
   
 
348
 
   
 
—
 
      283        —  
Compensation
   
 
502
 
   
 
—
 
      487        —  
Right-of-use
lease assets and obligations
   
 
428
 
   
 
419
 
      416        409  
Other
   
 
499
 
   
 
652
 
      485        606  
    
 
 
     
 
 
     
 
 
     
 
 
  
    
$
2,203
 
   
$
1,808
 
    $ 2,078      $ 1,693  
    
 
 
     
 
 
     
 
 
     
 
 
  
Schedule of Activity Related to Unrecognized Tax Benefits
The following table summarizes the activity related to our unrecognized tax benefits (dollars in millions):
 
    
2021
     
2020
  
Balance at January 1
   
$
469
 
    $ 522  
Additions based on tax positions related to the current year
   
 
57
 
      (3 ) 
Additions for tax positions of prior years
     
66
        13  
Reductions for tax positions of prior years
   
 
(6
) 
      (30 ) 
Settlements
   
 
(3
) 
      (22 ) 
Lapse of applicable statutes of limitations
   
 
(7
) 
      (11 ) 
    
 
 
     
 
 
  
Balance at December 31
   
$
576
 
    $ 469  
    
 
 
     
 
 
  
v3.22.0.1
Earnings Per Share (Tables)
 12 Months Ended
Dec. 31, 2021
Earnings Per Share [Abstract]  
Schedule of Computations of Basic and Diluted Earnings Per Share The following table sets forth the computations of basic and diluted earnings per share for the years ended December 31, 2021, 2020 and 2019 (dollars and shares in millions, except per share amounts):
 
    
2021
     
2020
     
2019
  
Net income attributable to HCA Healthcare, Inc.
   
$
6,956
 
    $ 3,754      $ 3,505  
       
Weighted average common shares outstanding
   
 
323.315
 
      338.274        341.210  
Effect of dilutive incremental shares
   
 
5.437
 
      5.331        7.016  
    
 
 
     
 
 
     
 
 
  
Shares used for diluted earnings per share
   
 
328.752
 
      343.605        348.226  
    
 
 
     
 
 
     
 
 
  
Earnings per share:
                           
Basic earnings per share
   
$
21.52
 
    $ 11.10      $ 10.27  
Diluted earnings per share
   
$
21.16
 
    $ 10.93      $ 10.07  
v3.22.0.1
Investments of Insurance Subsidiaries (Tables)
 12 Months Ended
Dec. 31, 2021
Investments, Debt and Equity Securities [Abstract]  
Schedule of Investments
A summary of the insurance subsidiaries’ investments at December 31 follows (dollars in millions):
 
    
2021
  
    
Amortized
Cost
     
Unrealized
Amounts
     
Fair
Value
  
    
Gains
     
Losses
  
Debt securities
   
$
400
 
   
$
18
 
   
$
(2
) 
   
$
416
 
Money market funds and other
   
 
125
 
   
 
—
 
   
 
—
 
   
 
125
 
    
 
 
     
 
 
     
 
 
     
 
 
  
    
$
525
 
   
$
18
 
   
$
(2
) 
   
 
541
 
    
 
 
     
 
 
     
 
 
           
Amounts classified as current assets
                              
 
(103
) 
                               
 
 
  
Investment carrying value
                              
$
438
 
                               
 
 
  
   
    
2020
  
    
Amortized
Cost
     
Unrealized
Amounts
     
Fair
Value
  
    
Gains
     
Losses
  
Debt securities
    $ 384      $ 32      $ —      $ 416  
Money market funds and other
      88        —        —        88  
    
 
 
     
 
 
     
 
 
     
 
 
  
     $ 472      $ 32      $ —        504  
    
 
 
     
 
 
     
 
 
           
Amounts classified as current assets
                                 (116 ) 
                               
 
 
  
Investment carrying value
                               $ 388  
                               
 
 
  
Schedule of Maturities of Investments
Scheduled maturities of investments in debt securities at December 31, 2021 were as follows (dollars in millions):
 
    
Amortized
Cost
     
Fair
Value
  
Due in one year or less
    $ 3      $ 3  
Due after one year through five years
      128        135  
Due after five years through ten years
      176        183  
Due after ten years
      93        95  
    
 
 
     
 
 
  
     $ 400      $ 416  
    
 
 
     
 
 
  
v3.22.0.1
Financial Instruments (Tables)
 12 Months Ended
Dec. 31, 2021
Derivative Instruments and Hedging Activities Disclosure [Abstract]  
Schedule of Interest Rate Swap Agreements Designated as Cash Flow Hedges
The following table sets forth our interest rate swap agreement, which has been designated as a cash flow hedge, at December 31, 2021 (dollars in millions):
 
    
Notional
Amount
     
Maturity Date
     
Fair
Value
  
Pay-fixed
interest rate swap
    $ 500        December 2022      $ (8 ) 
Effect of Interest Rate on Results of Operations
The following table presents the effect of our interest rate swaps on our results of operations for the year ended December 31, 2021 (dollars in millions):
 
Derivatives in Cash Flow Hedging
Relationships
   
Amount of Gain
Recognized in OCI on
Derivatives, Net of Tax
     
Location of Loss
Reclassified from
Accumulated OCI
into Operations
     
Amount of Loss
Reclassified from
Accumulated OCI
into Operations
  
Interest rate swaps
    $ 1        Interest expense      $ 37  
v3.22.0.1
Assets and Liabilities Measured at Fair Value (Tables)
 12 Months Ended
Dec. 31, 2021
Fair Value Disclosures [Abstract]  
Schedule of Assets Measured at Fair Value on Recurring Basis
The following tables summarize our assets and liabilities measured at fair value on a recurring basis as of December 31, 2021 and 2020, aggregated by the level in the fair value hierarchy within which those measurements fall (dollars in millions):
 
   
December 31, 2021
  
   
Fair Value
    
Fair Value Measurements Using
  
   
Quoted Prices in
Active Markets for
Identical Assets
and Liabilities
(Level 1)
    
Significant
Other
Observable
Inputs
(Level 2)
    
Significant
Unobservable
Inputs
(Level 3)
  
Assets:
                                
Investments of insurance subsidiaries:
                                
Debt securities
  
$
416
 
  
$
—
 
  
$
416
 
  
$
—
 
Money market funds and other
  
 
125
 
  
 
125
 
  
 
—
 
  
 
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
Investments of insurance subsidiaries
  
 
541
 
  
 
125
 
  
 
416
 
  
 
—
 
Less amounts classified as current assets
  
 
(103
) 
  
 
(103
) 
  
 
—
 
  
 
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
   
$
438
 
  
 
22
 
  
$
416
 
  
$
—
 
   
 
 
    
 
 
    
 
 
    
 
 
  
Liabilities:
                                
Interest rate swap (Other accrued expenses)
  
$
8
 
  
$
—
 
  
$
8
 
  
$
—
 
 
   
December 31, 2020
  
   
Fair Value
    
Fair Value Measurements Using
  
   
Quoted Prices in
Active Markets for
Identical Assets
and Liabilities
(Level 1)
    
Significant
Other
Observable
Inputs
(Level 2)
    
Significant
Unobservable
Inputs
(Level 3)
  
Assets:
                                
Investments of insurance subsidiaries:
                                
Debt securities
   $ 416     $ —     $ 416     $ —  
Money market funds and other
     88       88       —       —  
   
 
 
    
 
 
    
 
 
    
 
 
  
Investments of insurance subsidiaries
     504       88       416       —  
Less amounts classified as current assets
     (116 )      (87 )      (29 )      —  
   
 
 
    
 
 
    
 
 
    
 
 
  
    $ 388       1     $ 387     $ —  
   
 
 
    
 
 
    
 
 
    
 
 
  
Liabilities:
                                
Interest rate swaps (Income taxes and other liabilities)
   $ 46     $ —     $ 46     $ —  
v3.22.0.1
Long-Term Debt (Tables)
 12 Months Ended
Dec. 31, 2021
Debt Disclosure [Abstract]  
Schedule of Long-Term Debt
A summary of long-term debt at December 31, including related interest rates at December 31, 2021, follows (dollars in millions):
 
    
2021
    
2020
  
Senior secured asset-based revolving credit facility (effective interest rate of
1.4
%)
   
$
2,780
 
   $ —  
Senior secured revolving credit facility
  
 
—
 
     —  
Senior secured term loan facilities (effective interest rate of 2.1%)
   
 
1,960
 
     3,671  
Senior secured notes (effective interest rate of 4.8%)
   
 
16,200
 
     13,850  
Other senior secured debt (effective interest rate of 4.3%)
   
 
935
 
     767  
    
 
 
    
 
 
  
Senior secured debt
   
 
21,875
 
     18,288  
Senior unsecured notes (effective interest rate of 5.5%)
   
 
12,952
 
     12,952  
Debt issuance costs and discounts
   
 
(248
) 
     (236 ) 
    
 
 
    
 
 
  
Total debt (average life of 8.9 years, rates averaging 4.6%)
   
 
34,579
 
     31,004  
Less amounts due within one year
   
 
237
 
     209  
    
 
 
    
 
 
  
    
$
34,342
 
   $ 30,795  
    
 
 
    
 
 
  
v3.22.0.1
Leases (Tables)
 12 Months Ended
Dec. 31, 2021
Leases [Abstract]  
Schedule of lease-related assets and liabilities
The following table presents our lease-related assets and liabilities at December 31, 2021 and 2020 (dollars in millions):
 
    
Balance Sheet Classification
     
2021
    
2020
  
Assets:
                          
Operating leases
     
Right-of-use operating lease assets
     
$
2,113
 
   $ 2,024  
Finance leases
      Property and equipment     
 
637
 
     553  
             
 
 
    
 
 
  
Total lease assets
            
$
2,750
 
   $ 2,577  
             
 
 
    
 
 
  
Liabilities:
                          
Current:
                          
Operating leases
      Other accrued expenses     
$
392
 
   $ 379  
Finance leases
      Long-term debt due within one year     
 
143
 
     128  
Noncurrent:
                          
Operating leases
     
Right-of-use operating lease obligations
     
 
1,755
 
     1,673  
Finance leases
      Long-term debt     
 
577
 
     494  
             
 
 
    
 
 
  
Total lease liabilities
            
$
2,867
 
   $ 2,674  
             
 
 
    
 
 
  
Weighted-average remaining term:
                          
Operating leases
            
 
10.2 years
 
     10.4 years  
Finance leases
            
 
10.4 years
 
     11.5 years  
Weighted-average discount rate:
                          
Operating leases
            
 
4.4
% 
     4.8 % 
Finance leases
            
 
4.4
% 
     5.4 % 
Schedule of lease expense for finance and operating leases
The following table presents certain information related to lease expense for finance and operating leases for the years ended December 31, 2021, 2020 and 2019 (dollars in millions):
 
    
2021
     
2020
     
2019
  
Finance lease expense:
                           
Depreciation and amortization
   
$
135
 
    $ 106      $ 93  
Interest
   
 
29
 
      31        32  
Operating leases(1)
   
 
478
 
      447        389  
Short-term lease expense(1)
   
 
354
 
      322        316  
Variable lease expense(1)
   
 
157
 
      154        150  
    
 
 
     
 
 
     
 
 
  
    
$
1,153
 
    $ 1,060      $ 980  
    
 
 
     
 
 
     
 
 
  
 
(1)
Expenses are included in “other operating expenses” in our consolidated income statements.
Schedule of supplemental cash flow information
The following table presents supplemental cash flow information for the years ended December 31, 2021, 2020 and 2019 (dollars in millions):
 
    
2021
     
2020
     
2019
  
Cash paid for amounts included in the measurement of lease liabilities:
                           
Operating cash flows for operating leases
   
$
474
 
    $ 445      $ 404  
Operating cash flows for finance leases
   
 
29
 
      31        32  
Financing cash flows for finance leases
   
 
123
 
      86        79  
Schedule of undiscounted cash flows to the finance lease liabilities and operating lease liabilities recorded on balance sheet
The following table reconciles the undiscounted minimum lease payment amounts to the operating and finance lease liabilities recorded on the balance sheet at December 31, 2021 and 2020 (dollars in millions):
 
    
2021
     
2020
  
    
Operating
Leases
     
Finance
Leases
     
Operating
Leases
     
Finance
Leases
  
Year 1
   
$
438
 
   
$
165
 
    $ 431      $ 155  
Year 2
   
 
378
 
   
 
126
 
      366        125  
Year 3
   
 
320
 
   
 
132
 
      307        81  
Year 4
   
 
267
 
   
 
98
 
      255        82  
Year 5
   
 
219
 
   
 
70
 
      207        51  
Thereafter
   
 
1,148
 
   
 
350
 
      1,136        353  
    
 
 
     
 
 
     
 
 
     
 
 
  
Total minimum lease payments
   
 
2,770
 
   
 
941
 
      2,702        847  
Less: amount of lease payments representing interest
   
 
(623
) 
   
 
(221
) 
      (650 )       (225 ) 
    
 
 
     
 
 
     
 
 
     
 
 
  
Present value of future minimum lease payments
   
 
2,147
 
   
 
720
 
      2,052        622  
Less: current lease obligations
   
 
(392
) 
   
 
(143
) 
      (379 )       (128 ) 
    
 
 
     
 
 
     
 
 
     
 
 
  
Long-term lease obligations
   
$
1,755
 
   
$
577
 
    $ 1,673      $ 494  
    
 
 
     
 
 
     
 
 
     
 
 
  
v3.22.0.1
Segment and Geographic Information (Tables)
 12 Months Ended
Dec. 31, 2021
Segment Reporting [Abstract]  
Schedule of Geographic Distributions of Revenues, Equity in Earnings of Affiliates, Adjusted Segment EBITDA, Depreciation and Amortization, Assets and Goodwill and other intangible assets. The geographic distributions of our revenues, equity in earnings of affiliates, adjusted segment EBITDA, depreciation and amortization, assets and goodwill and other intangible assets are summarized in the following table (dollars in millions):
 
    
For the Years Ended December 31,
  
    
2021
     
2020
     
2019
  
Revenues:
                           
National Group
   
$
29,826
 
    $ 25,694      $ 25,913  
American Group
   
 
26,152
 
      23,593        23,173  
Corporate and other
   
 
2,774
 
      2,246        2,250  
    
 
 
     
 
 
     
 
 
  
    
$
58,752
 
    $ 51,533      $ 51,336  
    
 
 
     
 
 
     
 
 
  
Equity in earnings of affiliates:
                           
National Group
   
$
(33
) 
    $ (28 )     $ (2 ) 
American Group
   
 
(53
) 
      (42 )       (44 ) 
Corporate and other
   
 
(27
) 
      16        3  
    
 
 
     
 
 
     
 
 
  
    
$
(113
) 
    $ (54 )     $ (43 ) 
    
 
 
     
 
 
     
 
 
  
Adjusted segment EBITDA:
                           
National Group
   
$
7,200
 
    $ 5,532      $ 5,634  
American Group
   
 
6,156
 
      5,333        4,904  
Corporate and other
   
 
(712
) 
      (828 )       (681 ) 
    
 
 
     
 
 
     
 
 
  
    
$
12,644
 
    $ 10,037      $ 9,857  
    
 
 
     
 
 
     
 
 
  
Depreciation and amortization:
                           
National Group
   
$
1,359
 
    $ 1,216      $ 1,161  
American Group
   
 
1,183
 
      1,164        1,117  
Corporate and other
   
 
311
 
      341        318  
    
 
 
     
 
 
     
 
 
  
    
$
2,853
 
    $ 2,721      $ 2,596  
    
 
 
     
 
 
     
 
 
  
 
 
    
For the Years Ended December 31,
  
    
2021
     
2020
     
2019
  
Adjusted segment EBITDA
   
$
12,644
 
    $ 10,037      $ 9,857  
Depreciation and amortization
   
 
2,853
 
      2,721        2,596  
Interest expense
   
 
1,566
 
      1,584        1,824  
Losses (gains) on sales of facilities
   
 
(1,620
) 
      7        (18 ) 
Losses on retirement of debt
   
 
12
 
      295        211  
    
 
 
     
 
 
     
 
 
  
Income before income taxes
   
$
9,833
 
    $ 5,430      $ 5,244  
    
 
 
     
 
 
     
 
 
  
   
    
December 31,
  
    
2021
     
2020
     
2019
  
Assets:
                           
National Group
   
$
21,205
 
    $ 18,913      $ 18,290  
American Group
   
 
21,428
 
      20,760        20,608  
Corporate and other
   
 
8,109
 
      7,817        6,160  
    
 
 
     
 
 
     
 
 
  
    
$
50,742
 
    $ 47,490      $ 45,058  
    
 
 
     
 
 
     
 
 
  
    
National
Group
    
American
Group
    
Corporate
and Other
    
Total
  
Goodwill and other intangible assets:
                                 
Balance at December 31, 2018
    $ 1,597     $ 5,729     $ 627     $ 7,953  
Acquisitions
      155       39       138       332  
Foreign currency translation, amortization and other
      (13 )      (3 )      —       (16 ) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2019
      1,739       5,765       765       8,269  
Acquisitions
      38       27       279       344  
Foreign currency translation, amortization and other
      (2 )      (17 )      (16 )      (35 ) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2020
      1,775       5,775       1,028       8,578  
Acquisitions
   
 
735
 
  
 
67
 
  
 
260
 
  
 
1,062
 
Foreign currency translation, amortization and other
   
 
(18
) 
  
 
(10
) 
  
 
(72
) 
  
 
(100
) 
    
 
 
    
 
 
    
 
 
    
 
 
  
Balance at December 31, 2021
   
$
2,492
 
  
$
5,832
 
  
$
1,216
 
  
$
9,540
 
    
 
 
    
 
 
    
 
 
    
 
 
  
v3.22.0.1
Other Comprehensive Loss (Tables)
 12 Months Ended
Dec. 31, 2021
Equity [Abstract]  
Components of Accumulated Other Comprehensive Loss
The components of accumulated other comprehensive loss are as follows (dollars in millions):
 
 
  
Unrealized
Gains on
Available-
for-Sale

Securities
 
 
Foreign
Currency
Translation
Adjustments
 
 
Defined
Benefit
Plans
 
 
Change
in Fair
Value of
Derivative
Instruments
 
 
Total
 
Balances at December 31, 2018
    $ 3      $ (283 )    $ (148 )    $ 47     $ (381 ) 
Unrealized gains on
available-for-sale
securities, net of $4 of income taxes
      11        —       —       —       11  
Foreign currency translation adjustments, net of $5 of income taxes
      —        —       —       —       —  
Defined benefit plans, net of $14 income tax benefit
      —        —       (49 )      —       (49 ) 
Change in fair value of derivative instruments, net of $13 income tax benefit
      —        —       —       (37 )      (37 ) 
Expense (income) reclassified into operations from other comprehensive income, net of $3 income tax benefit and $3 of income taxes, respectively
      —        —       10       (14 )      (4 ) 
    
 
 
     
 
 
    
 
 
    
 
 
    
 
 
  
Balances at December 31, 2019
      14        (283 )      (187 )      (4 )      (460 ) 
Unrealized gains on
available-for-sale
securities, net of $3 of income taxes
      11        —       —       —       11  
Foreign currency translation adjustments, net of $6 of income taxes
      —        12       —       —       12  
Defined benefit plans, net of $16 income tax benefit
      —        —       (55 )      —       (55 ) 
Change in fair value of derivative instruments, net of $15 income tax benefit
      —        —       —       (51 )      (51 ) 
Expense reclassified into operations from other comprehensive income, net of $6 and $5 of income tax benefits, respectively
      —        —       22       19       41  
    
 
 
     
 
 
    
 
 
    
 
 
    
 
 
  
Balances at December 31, 2020
  
25
 
 
(271
) 
 
(220
) 
 
(36
) 
 
(502
) 
Unrealized losses on
available-for-sale
securities, net of $3 income tax benefit
  
 
(13
) 
 
 
—
 
 
 
—
 
 
 
—
 
 
 
(13
) 
Foreign currency translation adjustments, net of $2 income tax benefit
  
 
—
 
 
 
(7
) 
 
 
—
 
 
 
—
 
 
 
(7
) 
Defined benefit plans, net of $20 of income taxes
  
 
—
 
 
 
—
 
 
 
67
 
 
 
—
 
 
 
67
 
Change in fair value of derivative instruments
  
 
—
 
 
 
—
 
 
 
—
 
 
 
1
 
 
 
1
 
Expense reclassified into operations from other comprehensive income, net of $7 and $8 income tax benefits, respectively
  
 
—
 
 
 
—
 
 
 
21
 
 
 
29
 
 
 
50
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Balances at December 31, 2021
  
$
12
 
 
$
(278
) 
 
$
(132
) 
 
$
(6
) 
 
$
(404
) 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
v3.22.0.1
Accrued Expenses (Tables)
 12 Months Ended
Dec. 31, 2021
Text Block [Abstract]  
Summary of Other Accrued Expenses
A summary of other accrued expenses
 
at December 31 follows (dollars in millions):
 
    
2021
     
2020
  
Professional liability risks
   
$
508
 
    $ 477  
Defined contribution benefit plans
   
 
549
 
      547  
Right-of-use
operating leases
   
 
392
 
      379  
Taxes other than income
   
 
361
 
      343  
Interest
   
 
353
 
      315  
Government stimulus refund liability
   
 
79
 
      83  
Other
   
 
1,080
 
      1,096  
    
 
 
     
 
 
  
    
$
3,322
 
    $ 3,240  
    
 
 
     
 
 
  
v3.22.0.1
Accounting Policies - Additional Information (Detail)
$ in Millions
 1 Months Ended 12 Months Ended
Nov. 30, 2017
Dec. 31, 2021
USD ($)
Hospital
Endoscopy_Center
State
Claim
Surgery_Center
Dec. 31, 2020
USD ($)
Claim
Dec. 31, 2019
USD ($)
Summary Of Significant Accounting Policies [Line Items]        
Number of owned and operated hospitals | Hospital   182    
Number of freestanding surgery centers | Surgery_Center   125    
Number of freestanding endoscopy centers | Endoscopy_Center   21    
Number of facilities locations | State   20    
General and administrative expense   $ 400 $ 416 $ 370
Adjustments to estimated reimbursement filed during respective year   53 70 51
Adjustments to estimated reimbursement filed during previous years   (19) 5 13
Estimated implicit price concessions recorded as reductions to revenues and accounts receivable   6,784 6,108  
Charity care amount   13,644 13,763 13,260
Estimated costs of charity care   1,542 1,652 $ 1,591
Outstanding checks unpresented for payment   $ 536 $ 495  
Days revenues in accounts receivable   49 days 45 days 50 days
Depreciation expense   $ 2,826 $ 2,693 $ 2,579
Goodwill impairments   0 0 0
Goodwill acquired during period   1,002 279  
Intangible assets increased   60 65  
Intangible assets decreased due to amortization and other adjustments   25 26  
Gross carrying amount of intangible assets   274 249  
Accumulated amortization of intangible assets   175 149  
Gross carrying amount of indefinite-lived intangible assets   304 269  
Deferred loan costs   446 411  
Deferred loan costs, accumulated amortization   198 175  
Amortization of debt issuance costs   27 30 30
Reserves for professional liability risks   2,022 1,963  
Current portion of professional liability risks reserves   508 477  
Provisions for losses related to professional liability risks   453 435 497
Decrease in provision for professional liability risks   $ 87 $ 112 $ 50
Reserves for professional liability risks cover individual claims | Claim   2,300 2,100  
Net payments of professional and general liability claims   $ 384 $ 292  
Self-insured retention amount per occurrence   15    
Maximum amount losses per occurrence   75    
Reinsurance for professional liability risks retention minimum level of amount per occurrence   25    
Reinsurance for professional liability risks retention level of amount per occurrence   35    
Amounts receivable under reinsurance contracts recorded in other assets   44 31  
Amounts receivable under reinsurance contracts recorded in other current assets   11 8  
Foreign Currency Translation And Other [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Goodwill increase (decrease)   $ 75 $ 9  
Inpatient Services [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Performance obligations for inpatient/ outpatient services satisfied period   Our performance obligations for inpatient services are generally satisfied over periods that average approximately five days    
Maximum [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Percentage of income of federal poverty level eligible for charity care 400.00%      
Finite lived intangible asset useful life   10 years    
Maximum [Member] | Outpatient Services [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Performance obligations for inpatient/ outpatient services satisfied period   Our performance obligations for outpatient services are generally satisfied over a period of less than one day    
Maximum [Member] | Building and Improvements [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Estimated useful lives in years   40 years    
Maximum [Member] | Equipment [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Estimated useful lives in years   10 years    
Minimum [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Finite lived intangible asset useful life   3 years    
Minimum [Member] | Building and Improvements [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Estimated useful lives in years   10 years    
Minimum [Member] | Equipment [Member]        
Summary Of Significant Accounting Policies [Line Items]        
Estimated useful lives in years   4 years    
v3.22.0.1
Accounting Policies - Schedule of Revenues from Third Party Payers, Uninsured and Other Payers (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 58,752 $ 51,533 $ 51,336
Revenues ratio from third party payers 100.00% 100.00% 100.00%
Medicare [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 10,447 $ 10,420 $ 10,798
Revenues from third party payers, Ratio 17.80% 20.20% 21.00%
Managed Medicare [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 8,424 $ 6,997 $ 6,452
Revenues from third party payers, Ratio 14.30% 13.60% 12.60%
Medicaid [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 2,290 $ 1,965 $ 1,572
Revenues from third party payers, Ratio 3.90% 3.80% 3.10%
Managed Medicaid [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 3,124 $ 2,621 $ 2,450
Revenues from third party payers, Ratio 5.30% 5.10% 4.80%
Managed Care and Other Insurers [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 30,295 $ 26,535 $ 26,544
Revenues from third party payers, Ratio 51.60% 51.50% 51.60%
International (Managed Care and Other Insurers) [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 1,336 $ 1,120 $ 1,162
Revenues from third party payers, Ratio 2.30% 2.20% 2.30%
Product and Service, Other [Member]      
Revenues From Third Party Payers [Line Items]      
Revenues from third party payers $ 2,836 $ 1,875 $ 2,358
Other, Ratio 4.80% 3.60% 4.60%
v3.22.0.1
Accounting Policies - Schedule of Estimated Cost of Uncompensated Care (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Accounting Policies [Abstract]      
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization) $ 49,074 $ 44,271 $ 44,118
Cost-to-charges ratio (patient care costs as percentage of gross patient charges) 11.30% 12.00% 12.00%
Total uncompensated care $ 29,642 $ 29,029 $ 31,105
Multiply by the cost-to-charges ratio 11.30% 12.00% 12.00%
Estimated cost of total uncompensated care $ 3,350 $ 3,483 $ 3,733
v3.22.0.1
Share-Based Compensation - Additional Information (Detail) - USD ($)
$ / shares in Units, $ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Weighted Average Fair Value of Stock Options Granted $ 54.57 $ 35.98 $ 38.21
Total Intrinsic Value of Stock Options $ 404 $ 328 $ 153
Unrecognized Compensation Cost Related to Nonvested Awards $ 46    
Employee Stock Purchase Plan ("ESPP") [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Common stock were reserved for issuance 5,173,000    
Compensation expense $ 15 13 12
Stock Appreciation Rights (SARs) [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Shares Available for Future Grants 16,290,000    
Restricted Stock Units and Performance Stock Units [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
RSUs and PSUs, Vested, value $ 475 $ 349 $ 346
Unrecognized Compensation Cost Related to Nonvested Awards $ 420    
v3.22.0.1
Share-Based Compensation - Schedule of Fair Value of Each Stock Option Award is Estimated on Grant Date, Using Option Valuation Models (Detail)
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Disclosure of Compensation Related Costs, Share-based Payments [Abstract]      
Risk-free interest rate 0.68% 1.44% 2.50%
Expected volatility 36.00% 27.00% 27.00%
Expected life, in years 6 years 2 months 1 day 6 years 1 month 24 days 6 years 2 months 4 days
Expected dividend yield 1.10% 1.19% 1.16%
v3.22.0.1
Share-Based Compensation - Schedule of Stock Option Activity (Detail) - USD ($)
$ / shares in Units, shares in Thousands, $ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Stock Options outstanding, Weighted Average Exercise Price, Beginning Balance $ 91.53 $ 71.79 $ 61.49
Granted, Weighted Average Exercise Price 174.98 144.47 138.31
Exercised, Weighted Average Exercise Price 67.57 44.07 44.45
Cancelled, Weighted Average Exercise Price 138.32 111.69 93.26
Stock Options outstanding, Weighted Average Exercise Price, Ending Balance 113.15 $ 91.53 $ 71.79
Options exercisable, Weighted Average Exercise Price $ 89.70    
Options outstanding, Weighted Average Remaining Contractual Term 6 years 2 months 12 days    
Options exercisable, Weighted Average Remaining Contractual Term 5 years    
Options outstanding, Aggregate Intrinsic Value $ 927    
Options exercisable, Aggregate Intrinsic Value $ 631    
Time Based Stock Options and SARs [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Stock Options Outstanding, Beginning Balance 7,836 9,050 9,360
Granted, Stock Options 877 1,120 1,349
Exercised, Stock Options (2,443) (2,159) (1,137)
Cancelled, Stock Options (108) (175) (522)
Stock Options Outstanding, Ending Balance 6,162 7,836 9,050
Stock Options Exercisable, Ending Balance 3,486    
Performance Stock Options and SARs [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Stock Options Outstanding, Beginning Balance 819 2,144 2,667
Exercised, Stock Options (533) (1,325) (523)
Stock Options Outstanding, Ending Balance 286 819 2,144
Stock Options Exercisable, Ending Balance 286    
Total Stock Options and Stock SARs [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
Stock Options Outstanding, Beginning Balance 8,655 11,194 12,027
Granted, Stock Options 877 1,120 1,349
Exercised, Stock Options (2,976) (3,484) (1,660)
Cancelled, Stock Options (108) (175) (522)
Stock Options Outstanding, Ending Balance 6,448 8,655 11,194
Stock Options Exercisable, Ending Balance 3,772    
v3.22.0.1
Share-Based Compensation - Schedule of Restricted Stock Units Activity (Detail) - $ / shares
shares in Thousands
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Restricted Stock Units (RSUs) [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
RSUs and PSUs Outstanding, Beginning Balance 2,476 2,620 3,123
RSUs and PSUs, Granted 899 1,048 973
RSUs and PSUs, Vested (992) (1,030) (1,216)
RSUs and PSUs, Cancelled (192) (162) (260)
RSUs and PSUs Outstanding, Ending Balance 2,191 2,476 2,620
Performance Shares PSUs [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
RSUs and PSUs Outstanding, Beginning Balance 2,592 3,035 3,422
RSUs and PSUs, Granted 689 808 796
Performance adjustment 684 206 227
RSUs and PSUs, Vested (1,772) (1,364) (1,251)
RSUs and PSUs, Cancelled (110) (93) (159)
RSUs and PSUs Outstanding, Ending Balance 2,083 2,592 3,035
Restricted Stock Units and Performance Stock Units [Member]      
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]      
RSUs and PSUs Outstanding, Beginning Balance 5,068 5,655 6,545
RSUs and PSUs, Granted 1,588 1,856 1,769
Performance adjustment 684 206 227
RSUs and PSUs, Vested (2,764) (2,394) (2,467)
RSUs and PSUs, Cancelled (302) (255) (419)
RSUs and PSUs Outstanding, Ending Balance 4,274 5,068 5,655
Weighted Average Grant Date Fair Value, RSUs and PSUs, Beginning balance $ 125.40 $ 105.23 $ 86.32
Weighted Average Grant Date Fair Value, RSUs and PSUs, Granted 174.34 144.17 138.45
Performance adjustment 102.02 81.89 69.94
Weighted Average Grant Date Fair Value, RSUs and PSUs, Vested 106.62 88.63 75.97
Weighted Average Grant Date Fair Value, RSUs and PSUs, Cancelled 149.07 124.50 103.27
Weighted Average Grant Date Fair Value, RSUs and PSUs, Ending balance $ 150.32 $ 125.40 $ 105.23
v3.22.0.1
Acquisitions and Dispositions - Additional Information (Detail)
$ in Millions
 12 Months Ended
Dec. 31, 2021
USD ($)
Hospital
Dec. 31, 2020
USD ($)
Hospital
Dec. 31, 2019
USD ($)
Hospital
Business Acquisition [Line Items]      
Proceeds from sale of business $ 2,160 $ 68 $ 61
Real Estate and Other Investments [Member]      
Business Acquisition [Line Items]      
Pretax gain (loss) before tax 394    
Pretax gain (loss) after tax 294    
Proceeds from sale of business $ 658    
Discontinued Operations, Disposed of by Sale [Member] | Louisiana [Member]      
Business Acquisition [Line Items]      
Pretax gain (loss) before tax     18
Pretax gain (loss) after tax     13
Proceeds from sale of business     $ 61
Number of hospitals sold | Hospital     1
Discontinued Operations, Disposed of by Sale [Member] | Mississippi [Member]      
Business Acquisition [Line Items]      
Pretax gain (loss) before tax   (7)  
Pretax gain (loss) after tax   (9)  
Proceeds from sale of business   $ 68  
Number of hospitals sold | Hospital   1  
Discontinued Operations, Disposed of by Sale [Member] | Southern Georgia [Member]      
Business Acquisition [Line Items]      
Number of hospitals sold | Hospital 2    
Discontinued Operations, Disposed of by Sale [Member] | TENNESSEE      
Business Acquisition [Line Items]      
Pretax gain (loss) after tax $ 920    
Discontinued Operations, Disposed of by Sale [Member] | GEORGIA, REPUBLIC OF      
Business Acquisition [Line Items]      
Pretax gain (loss) before tax 1,226    
Proceeds from sale of business $ 1,502    
Number of hospitals sold | Hospital 5    
Discontinued Operations, Disposed of by Sale [Member] | Northern Georgia [Member]      
Business Acquisition [Line Items]      
Number of hospitals sold | Hospital 3    
Hospitals [Member]      
Business Acquisition [Line Items]      
Aggregate purchase price $ 67   $ 1,384
Number of hospitals purchased | Hospital 2 1 7
Hospitals [Member] | Southern Georgia [Member]      
Business Acquisition [Line Items]      
Number of hospitals purchased | Hospital 1    
Hospitals [Member] | TENNESSEE      
Business Acquisition [Line Items]      
Number of hospitals purchased | Hospital 1    
Nonhospital Health Care [Member]      
Business Acquisition [Line Items]      
Aggregate purchase price     $ 298
Other [Member]      
Business Acquisition [Line Items]      
Goodwill $ 1,002 $ 279 $ 332
Hospital and other nonhospital health care entities [Member]      
Business Acquisition [Line Items]      
Aggregate purchase price   $ 568  
Number of hospitals purchased | Hospital   1  
Urgent Care Centers [Member]      
Business Acquisition [Line Items]      
Aggregate purchase price 594    
Home Health And Hospice [Member]      
Business Acquisition [Line Items]      
Fair value of the noncontrolling interest in the acquiree at the acquisition date 100    
Payment to acquire venture providing post acute care services $ 330    
Business acquisition percentage of voting interests acquired 80.00%    
Other Nonhospital Health Care Entities [Member]      
Business Acquisition [Line Items]      
Aggregate purchase price $ 114    
Fair value of the noncontrolling interest in the acquiree at the acquisition date $ 117    
v3.22.0.1
Income Taxes - Schedule of Provision for Income Taxes (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Income Tax Disclosure [Abstract]      
Current, Federal $ 1,769 $ 1,021 $ 670
Current, State 311 126 134
Current, Foreign 15 5 17
Deferred, Federal 24 (73) 254
Deferred, State (18) (39) 29
Deferred, Foreign 11 3 (5)
Provision for income taxes $ 2,112 $ 1,043 $ 1,099
v3.22.0.1
Income Taxes - Additional Information (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Income Tax Contingency [Line Items]      
Provision for tax benefits related to settlement of employee awards $ 119 $ 92 $ 65
Foreign pretax income 64 9 $ 50
State net operating loss carryforwards 31    
Federal net operating loss carryforwards 99    
Liability for unrecognized tax benefits 642 508  
Unrecognized tax benefits, accrued interest 99 73  
Unrecognized tax benefits that would impact effective tax rate 217 157  
Deferred tax assets, reductions $ 33 $ 34  
State and Local Jurisdiction [Member] | Minimum [Member]      
Income Tax Contingency [Line Items]      
Net operating loss carryforwards, expiration date 2024    
State and Local Jurisdiction [Member] | Maximum [Member]      
Income Tax Contingency [Line Items]      
Net operating loss carryforwards, expiration date 2040    
v3.22.0.1
Income Taxes - Schedule of Reconciliation of Federal Statutory Rate to Effective Income Tax Rate (Detail)
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Income Tax Disclosure [Abstract]      
Federal statutory rate 21.00% 21.00% 21.00%
State income taxes, net of federal tax benefit 2.00% 1.90% 2.70%
Change in liability for uncertain tax positions 0.70% (0.20%) 0.40%
Tax benefit from settlements of employee equity awards (1.20%) (1.80%) (1.30%)
Other items, net 0.80% 0.80% 1.10%
Effective income tax rate on income attributable to HCA Healthcare, Inc. 23.30% 21.70% 23.90%
Income attributable to noncontrolling interests from consolidated partnerships (1.80%) (2.50%) (2.90%)
Effective income tax rate on income before income taxes 21.50% 19.20% 21.00%
v3.22.0.1
Income Taxes - Schedule of Deferred Tax Assets and Liabilities (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Income Tax Disclosure [Abstract]    
Depreciation and fixed asset basis differences, Assets $ 0 $ 0
Allowances for professional liability and other risks, Assets 426 407
Accounts receivable, Assets 348 283
Compensation, Assets 502 487
Right-of-use lease obligations 428 416
Other, Assets 499 485
Deferred tax assets 2,203 2,078
Depreciation and fixed asset basis differences, Liabilities 737 678
Allowances for professional liability and other risks, Liabilities 0 0
Accounts receivable, Liabilities 0 0
Compensation, Liabilities 0 0
Right-of-use lease assets and obligations 419 409
Other, Liabilities 652 606
Deferred tax liabilities $ 1,808 $ 1,693
v3.22.0.1
Income Taxes - Schedule of Activity Related to Unrecognized Tax Benefits (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Income Tax Disclosure [Abstract]    
Beginning Balance $ 469 $ 522
Additions based on tax positions related to the current year 57 (3)
Additions for tax positions of prior years 66 13
Reductions for tax positions of prior years (6) (30)
Settlements (3) (22)
Lapse of applicable statutes of limitations (7) (11)
Ending Balance $ 576 $ 469
v3.22.0.1
Earnings Per Share - Additional information (Detail) - shares
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Earnings Per Share [Abstract]      
Common stock repurchased 37,812,000 3,287,000 7,949,000
v3.22.0.1
Earnings Per Share - Schedule of Computations of Basic and Diluted Earnings Per Share (Detail) - USD ($)
$ / shares in Units, shares in Thousands, $ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Earnings Per Share [Abstract]      
Net income attributable to HCA Healthcare, Inc. $ 6,956 $ 3,754 $ 3,505
Weighted average common shares outstanding 323,315 338,274 341,210
Effect of dilutive incremental shares 5,437 5,331 7,016
Shares used for diluted earnings per share 328,752 343,605 348,226
Basic earnings per share $ 21.52 $ 11.10 $ 10.27
Diluted earnings per share $ 21.16 $ 10.93 $ 10.07
v3.22.0.1
Investments of Insurance Subsidiaries - Schedule of Investments (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Debt Securities, Available-for-sale [Line Items]    
Amounts classified as current assets $ (103) $ (116)
Investment carrying value 438 388
Amortized Cost 525 472
Unrealized Amounts, Gains 18 32
Unrealized Amounts, Losses (2)  
Fair Value 541 504
Money Market Funds and Other [Member]    
Debt Securities, Available-for-sale [Line Items]    
Amortized Cost 125 88
Fair Value 125 88
Debt Securities [Member] | States and Municipalities [Member]    
Debt Securities, Available-for-sale [Line Items]    
Amortized Cost 400 384
Unrealized Amounts, Gains 18 32
Unrealized Amounts, Losses (2)  
Fair Value $ 416 $ 416
v3.22.0.1
Investments of Insurance Subsidiaries - Schedule of Maturities of Investments (Detail)
$ in Millions
Dec. 31, 2021
USD ($)
Investments, Debt and Equity Securities [Abstract]  
Due in one year or less, Amortized Cost $ 3
Due after one year through five years, Amortized Cost 128
Due after five years through ten years, Amortized Cost 176
Due after ten years, Amortized Cost 93
Amortized Cost, Total 400
Due in one year or less, Fair Value 3
Due after one year through five years, Fair Value 135
Due after five years through ten years, Fair Value 183
Due after ten years, Fair Value 95
Fair Value, Total $ 416
v3.22.0.1
Investments of Insurance Subsidiaries - Additional Information (Detail)
 12 Months Ended
Dec. 31, 2021
Investments, Debt and Equity Securities [Abstract]  
Available for sale securities expected maturity of debt securities 6 years 1 month 6 days
Available for sale securities average scheduled maturity 9 years 6 months
v3.22.0.1
Financial Instruments - Schedule of Interest Rate Swap Agreements Designated as Cash Flow Hedges (Detail) - Maturity Date, 2022 [Member] - Pay-Fixed Interest Rate Swap [Member]
$ in Millions
 12 Months Ended
Dec. 31, 2021
USD ($)
Derivative Instruments, Gain (Loss) [Line Items]  
Notional Amount $ 500
Fair Value $ (8)
Maturity Date 2022-12
v3.22.0.1
Financial Instruments - Additional Information (Detail)
$ in Millions
 12 Months Ended
Dec. 31, 2021
USD ($)
Derivative Instruments and Hedging Activities Disclosure [Abstract]  
Estimated amount reclassified from other comprehensive income and reduce interest expense $ 8
Estimated termination value $ 8
v3.22.0.1
Financial Instruments - Effect of Interest Rate Swaps on Results of Operations (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Derivative Instruments, Gain (Loss) [Line Items]      
Amount of Loss Recognized in OCI on Derivatives, Net of Tax $ (1) $ 66 $ 50
Interest Rate Swaps [Member]      
Derivative Instruments, Gain (Loss) [Line Items]      
Amount of Loss Recognized in OCI on Derivatives, Net of Tax 1    
Interest Rate Swaps [Member] | Reclassification out of Accumulated Other Comprehensive Income [Member]      
Derivative Instruments, Gain (Loss) [Line Items]      
Interest rate swaps $ 37    
v3.22.0.1
Assets and Liabilities Measured at Fair Value - Schedule of Assets Measured at Fair Value on Recurring Basis (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Assets, Fair Value Disclosure $ 541 $ 504
Less amounts classified as current assets (103) (116)
Investments of insurance subsidiaries, noncurrent 438 388
Interest Rate Swaps [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Derivative Liability 8 46
Money Market Funds and Other [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Assets, Fair Value Disclosure 125 88
Debt Securities [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Debt Securities, Available-for-sale Securities 416 416
Quoted Prices in Active Markets for Identical Assets and Liabilities (Level 1) [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Assets, Fair Value Disclosure 125 88
Less amounts classified as current assets (103) (87)
Investments of insurance subsidiaries, noncurrent 22 1
Quoted Prices in Active Markets for Identical Assets and Liabilities (Level 1) [Member] | Money Market Funds and Other [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Assets, Fair Value Disclosure 125 88
Significant Other Observable Inputs (Level 2) [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Assets, Fair Value Disclosure 416 416
Less amounts classified as current assets 0 (29)
Investments of insurance subsidiaries, noncurrent 416 387
Significant Other Observable Inputs (Level 2) [Member] | Interest Rate Swaps [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Derivative Liability 8 46
Significant Other Observable Inputs (Level 2) [Member] | Debt Securities [Member]    
Fair Value, Net Derivative Asset (Liability) Measured on Recurring Basis, Unobservable Input Reconciliation [Line Items]    
Debt Securities, Available-for-sale Securities $ 416 $ 416
v3.22.0.1
Assets and Liabilities Measured at Fair Value - Additional Information (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Fair Value Disclosures [Abstract]    
Estimated fair value of long-term debt $ 38,541 $ 35,814
Carrying amounts of long-term debt $ 34,827 $ 31,240
v3.22.0.1
Long-Term Debt - Schedule of Long-Term Debt (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Debt Instrument [Line Items]    
Senior secured debt $ 21,875 $ 18,288
Debt issuance costs and discounts (248) (236)
Total debt (average life of 8.9 years, rates averaging 4.6%) 34,579 31,004
Less amounts due within one year 237 209
Long-term debt 34,342 30,795
Senior Secured Asset-Based Revolving Credit Facility [Member]    
Debt Instrument [Line Items]    
Long-term line of credit 2,780 0
Senior Secured Revolving Credit Facility [Member]    
Debt Instrument [Line Items]    
Long-term line of credit 0 0
Senior Secured Term Loan Facilities [Member]    
Debt Instrument [Line Items]    
Senior secured debt 1,960 3,671
Senior Secured Notes [Member]    
Debt Instrument [Line Items]    
Senior secured debt 16,200 13,850
Other Senior Secured Debt [Member]    
Debt Instrument [Line Items]    
Other senior secured debt 935 767
Senior Unsecured Notes [Member]    
Debt Instrument [Line Items]    
Senior unsecured notes $ 12,952 $ 12,952
v3.22.0.1
Long-Term Debt - Schedule of Long-Term Debt (Parenthetical) (Detail)
 12 Months Ended
Dec. 31, 2021
Debt Instrument [Line Items]  
Total debt average term 8 years 10 months 24 days
Total debt average rate 4.60%
Senior Secured Asset-Based Revolving Credit Facility [Member]  
Debt Instrument [Line Items]  
Effective interest rate 1.40%
Senior Secured Term Loan Facilities [Member]  
Debt Instrument [Line Items]  
Effective interest rate 2.10%
Senior Secured Notes [Member]  
Debt Instrument [Line Items]  
Effective interest rate 4.80%
Other Senior Secured Debt [Member]  
Debt Instrument [Line Items]  
Effective interest rate 4.30%
Senior Unsecured Notes [Member]  
Debt Instrument [Line Items]  
Effective interest rate 5.50%
v3.22.0.1
Long-Term Debt - Additional Information (Detail) - USD ($)
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Debt Instrument [Line Items]      
Gain (loss) on extinguishment of debt $ 12,000,000 $ 295,000,000 $ 211,000,000
Maximum borrowing capacity 3,657,000,000    
Capital leases and other secured debt 935,000,000    
Maturity of long-term debt in 2023 2,857,000,000    
Maturity of long-term debt in 2024 2,353,000,000    
Maturity of long-term debt in 2025 4,607,000,000    
Maturity of long-term debt in 2026 $ 5,279,000,000    
Minimum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2023    
Maximum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2026    
Interest Rate Swaps [Member]      
Debt Instrument [Line Items]      
Notional amount, total $ 500,000,000,000    
Federal Fund Rate [Member]      
Debt Instrument [Line Items]      
Debt instrument basis spread 0.50%    
Asset-Based Revolving Credit Facility Maturing on June 28, 2022 [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity $ 4,500,000,000    
Percentage of senior secured credit facility over eligible accounts receivable 85.00%    
Senior Secured Revolving Credit Facility Maturing On June 28, 2022 [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity $ 2,000,000,000.000    
Asset Based Revolving Credit Facility [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity $ 4,500,000,000    
Asset Based Revolving Credit Facility Maturing On June Thirty Two Thousand Twenty Six [Member]      
Debt Instrument [Line Items]      
Debt instrument maturity date Jun. 30, 2026    
Line of credit outstanding $ 2,780,000,000    
Senior Secured Revolving Credit Facility Maturing On June Thirty Two Thousand Twenty Six [Member]      
Debt Instrument [Line Items]      
Debt instrument maturity date Jun. 30, 2026    
Line of credit outstanding $ 0    
Asset Based Revolving Credit Facility Maturing On June Thirty Two Thousand Twenty Six One [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity $ 1,462,000,000    
Debt instrument maturity date Jun. 30, 2026    
Asset Based Revolving Credit Facility Maturing On June Thirty Two Thousand Twenty Six Eight [Member]      
Debt Instrument [Line Items]      
Debt instrument maturity date Jun. 30, 2028    
Line of credit outstanding $ 498,000,000    
Senior Secured Term Loan A Facility [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity 1,500,000,000    
Senior Secured Term Loan B Facility [Member]      
Debt Instrument [Line Items]      
Maximum borrowing capacity 500,000,000    
Senior Unsecured Note Maturities Ranging 2021 to 2033 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 12,091,000,000.000    
Senior Unsecured Note Maturities Ranging 2021 to 2033 [Member] | Minimum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2023    
Senior Unsecured Note Maturities Ranging 2021 to 2033 [Member] | Maximum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2033    
Senior Unsecured Note Maturity Year 2025 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 125,000,000    
Senior Unsecured Note Maturities Ranging 2023 to 2095 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 736,000,000    
Senior Unsecured Note Maturities Ranging 2023 to 2095 [Member] | Minimum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2023    
Senior Unsecured Note Maturities Ranging 2023 to 2095 [Member] | Maximum [Member]      
Debt Instrument [Line Items]      
Debt instrument, maturities range 2095    
Senior Notes [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 2,350,000,000    
Senior Notes [Member] | Senior Secured Notes Due 2023 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,250,000,000    
Debt instrument, stated interest 4.75%    
Senior Notes [Member] | Senior Secured Notes Due 2024 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 2,000,000,000.000    
Debt instrument, stated interest 5.00%    
Senior Notes [Member] | Senior Secured Notes Due 2025 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,400,000,000    
Debt instrument, stated interest 5.25%    
Senior Notes [Member] | Senior Secured Notes Due 2026 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,500,000,000    
Debt instrument, stated interest 5.25%    
Senior Notes [Member] | Senior Secured Notes Due 2027 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,200,000,000    
Debt instrument, stated interest 4.50%    
Senior Notes [Member] | Senior Secured Notes Due 2029 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 2,000,000,000.000    
Debt instrument, stated interest 4.125%    
Senior Notes [Member] | Senior Secured Notes Due 2047 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,500,000,000    
Debt instrument, stated interest 5.50%    
Senior Notes [Member] | Senior Secured Notes Due 2049 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 2,000,000,000.000    
Senior Notes [Member] | Senior Secured Notes Due 2031 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 850,000,000    
Debt instrument, stated interest 2.375%    
Senior Notes [Member] | Senior Secured Notes Due 2051 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,500,000,000    
Debt instrument, stated interest 3.50%    
Senior Notes [Member] | Senior Secured Notes Due 2039 [Member]      
Debt Instrument [Line Items]      
Debt instrument, principal amount $ 1,000,000,000.000    
Debt instrument, stated interest 5.125%    
v3.22.0.1
Leases - Schedule Of Lease-Related Assets And Liabilities (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Assets:    
Operating leases $ 2,113 $ 2,024
Finance leases 637 553
Total lease assets $ 2,750 $ 2,577
Finance Lease, Right-of-Use Asset, Statement of Financial Position [Extensible Enumeration] Property, Plant and Equipment, Net Property, Plant and Equipment, Net
Operating Lease, Right-of-Use Asset, Statement of Financial Position [Extensible Enumeration] Operating leases Operating leases
Liabilities    
Operating leases $ 392 $ 379
Finance leases 143 128
Right-of-use operating lease obligations 1,755 1,673
Finance leases 577 494
Total lease liabilities $ 2,867 $ 2,674
Finance Lease, Liability, Current, Statement of Financial Position [Extensible Enumeration] Less amounts due within one year Less amounts due within one year
Finance Lease, Liability, Noncurrent, Statement of Financial Position [Extensible Enumeration] Long-term Debt, Excluding Current Maturities Long-term Debt, Excluding Current Maturities
Operating Lease, Liability, Current, Statement of Financial Position [Extensible List] Other Accrued Liabilities, Current Other Accrued Liabilities, Current
Operating Lease, Liability, Noncurrent, Statement of Financial Position [Extensible Enumeration] Right-of-use operating lease obligations Right-of-use operating lease obligations
Weighted-average remaining term:    
Operating leases 10 years 2 months 12 days 10 years 4 months 24 days
Finance leases 10 years 4 months 24 days 11 years 6 months
Weighted-average discount rate:    
Operating leases 4.40% 4.80%
Finance leases 4.40% 5.40%
v3.22.0.1
Leases - Schedule Of Lease Expense For Finance And Operating Leases (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Finance lease expense:      
Depreciation and amortization $ 135 $ 106 $ 93
Interest 29 31 32
Operating leases [1] 478 447 389
Short-term lease expense [1] 354 322 316
Variable lease expense [1] 157 154 150
Total lease expense $ 1,153 $ 1,060 $ 980
[1] Expenses are included in “other operating expenses” in our consolidated income statements.
v3.22.0.1
Leases - Schedule Of Supplemental Cash Flow Information (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Cash Paid For Amounts Included In Measurement Of Lease Liabilities [Abstract]      
Operating cash flows for operating leases $ 474 $ 445 $ 404
Operating cash flows for finance leases 29 31 32
Financing cash flows for finance leases $ 123 $ 86 $ 79
v3.22.0.1
Leases - Schedule of undiscounted cash flows to the finance lease liabilities and operating lease liabilities (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Operating Lease Liabilities, Payments Due [Abstract]    
Year 1 $ 438 $ 431
Year 2 378 366
Year 3 320 307
Year 4 267 255
Year 5 219 207
Thereafter 1,148 1,136
Total minimum lease payments 2,770 2,702
Less: amount of lease payments representing interest (623) (650)
Present value of future minimum lease payments 2,147 2,052
Less: current obligations under leases (392) (379)
Long-term lease obligations 1,755 1,673
Finance Lease Liabilities, Payments, Due [Abstract]    
Year 1 165 155
Year 2 126 125
Year 3 132 81
Year 4 98 82
Year 5 70 51
Thereafter 350 353
Total minimum lease payments 941 847
Less: amount of lease payments representing interest (221) (225)
Present value of future minimum lease payments 720 622
Less: current obligations under leases (143) (128)
Long-term lease obligations $ 577 $ 494
v3.22.0.1
Capital Stock - Additional Information (Detail)
$ / shares in Units, $ in Millions
 12 Months Ended
Dec. 31, 2021
USD ($)
$ / shares
Directors
shares
Dec. 31, 2020
$ / shares
shares
Dec. 31, 2019
$ / shares
shares
Jan. 31, 2022
USD ($)
Feb. 28, 2021
USD ($)
Jan. 31, 2021
USD ($)
Jan. 31, 2020
USD ($)
Jan. 31, 2019
USD ($)
Oct. 31, 2017
USD ($)
Capital Structure [Line Items]                  
Common stock, shares authorized | shares 1,800,000,000 1,800,000,000              
Repurchase of common stock, shares | shares 37,812,000 3,287,000 7,949,000            
Repurchase price of common stock, per share | $ / shares $ 217.25 $ 134.18 $ 129.71            
Share repurchase program authorized amount         $ 6,000        
Share repurchase program, remaining authorized repurchase amount $ 586       $ 6,000   $ 2,000 $ 2,000 $ 2,000
Board of Directors Chairman [Member]                  
Capital Structure [Line Items]                  
Share repurchase program authorized amount           $ 2,000   $ 2,000 $ 2,000
Subsequent Event [Member]                  
Capital Structure [Line Items]                  
Share repurchase program authorized amount       $ 8,000          
Minimum [Member]                  
Capital Structure [Line Items]                  
Number of directors as per the amended and restated by-laws | Directors 3                
v3.22.0.1
Employee Benefit Plans - Additional Information (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Defined Contribution Benefit Plans [Member]      
Pension Plans, Postretirement and Other Employee Benefits [Line Items]      
Percentage of employer contribution to match participant contribution in defined contribution plan, net 100.00%    
Benefits expense of defined benefit plans $ 560 $ 552 $ 532
Defined benefit plan cost 4 8 11
Defined benefit plan obligation $ 9 96  
Defined Contribution Benefit Plans [Member] | Minimum [Member]      
Pension Plans, Postretirement and Other Employee Benefits [Line Items]      
Percentage of employer contribution to match participant contribution in defined contribution plan 3.00%    
Defined Contribution Benefit Plans [Member] | Maximum [Member]      
Pension Plans, Postretirement and Other Employee Benefits [Line Items]      
Percentage of employer contribution to match participant contribution in defined contribution plan 9.00%    
Restoration Plan [Member]      
Pension Plans, Postretirement and Other Employee Benefits [Line Items]      
Number of hours of service required to qualify for the plan 1,000 or more    
Noncontributory and nonqualified plan, benefit expense $ 38 35 44
Noncontributory and nonqualified plan, accrued benefits liabilities 258 242  
Supplemental Executive Retirement Plan [Member]      
Pension Plans, Postretirement and Other Employee Benefits [Line Items]      
Defined benefit plan cost 22 24 $ 19
Defined benefit plan obligation $ 201 $ 204  
v3.22.0.1
Segment and Geographic Information - Additional Information (Detail)
 12 Months Ended
Dec. 31, 2021
Hospital
Segment Reporting Information [Line Items]  
Number of geographically organized groups 2
Number of owned and operated hospitals 182
Reorganization Group [Member] | National Group [Member]  
Segment Reporting Information [Line Items]  
Number of owned and operated hospitals 96
Reorganization Group [Member] | American Group [Member]  
Segment Reporting Information [Line Items]  
Number of owned and operated hospitals 79
Reorganization Group [Member] | Corporate and Other [Member]  
Segment Reporting Information [Line Items]  
Number of owned and operated hospitals 7
v3.22.0.1
Segment and Geographic Information - Schedule of Geographic Distributions of Revenues, Equity in Earnings of Affiliates, Adjusted Segment EBITDA, Depreciation and Amortization and Assets (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Segment Reporting Information [Line Items]      
Revenues $ 58,752 $ 51,533 $ 51,336
Equity in earnings of affiliates (113) (54) (43)
Adjusted segment EBITDA 12,644 10,037 9,857
Depreciation and amortization 2,853 2,721 2,596
Interest expense 1,566 1,584 1,824
Losses (gains) on sales of facilities (1,620) 7 (18)
Losses on retirement of debt 12 295 211
Income before income taxes 9,833 5,430 5,244
Assets 50,742 47,490 45,058
Goodwill and other intangible assets, Beginning Balance 8,578 8,269 7,953
Goodwill and other intangible assets, Acquisitions 1,062 344 332
Goodwill and other intangible assets, Foreign currency translation, amortization and other (100) (35) (16)
Goodwill and other intangible assets, Ending Balance 9,540 8,578 8,269
National Group [Member]      
Segment Reporting Information [Line Items]      
Revenues 29,826 25,694 25,913
Equity in earnings of affiliates (33) (28) (2)
Adjusted segment EBITDA 7,200 5,532 5,634
Depreciation and amortization 1,359 1,216 1,161
Assets 21,205 18,913 18,290
Goodwill and other intangible assets, Beginning Balance 1,775 1,739 1,597
Goodwill and other intangible assets, Acquisitions 735 38 155
Goodwill and other intangible assets, Foreign currency translation, amortization and other (18) (2) (13)
Goodwill and other intangible assets, Ending Balance 2,492 1,775 1,739
American Group [Member]      
Segment Reporting Information [Line Items]      
Revenues 26,152 23,593 23,173
Equity in earnings of affiliates (53) (42) (44)
Adjusted segment EBITDA 6,156 5,333 4,904
Depreciation and amortization 1,183 1,164 1,117
Assets 21,428 20,760 20,608
Goodwill and other intangible assets, Beginning Balance 5,775 5,765 5,729
Goodwill and other intangible assets, Acquisitions 67 27 39
Goodwill and other intangible assets, Foreign currency translation, amortization and other (10) (17) (3)
Goodwill and other intangible assets, Ending Balance 5,832 5,775 5,765
Corporate and Other [Member]      
Segment Reporting Information [Line Items]      
Revenues 2,774 2,246 2,250
Equity in earnings of affiliates (27) 16 3
Adjusted segment EBITDA (712) (828) (681)
Depreciation and amortization 311 341 318
Assets 8,109 7,817 6,160
Goodwill and other intangible assets, Beginning Balance 1,028 765 627
Goodwill and other intangible assets, Acquisitions 260 279 138
Goodwill and other intangible assets, Foreign currency translation, amortization and other (72) (16)  
Goodwill and other intangible assets, Ending Balance $ 1,216 $ 1,028 $ 765
v3.22.0.1
Other Comprehensive Loss - Components of Accumulated Other Comprehensive Loss (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Equity [Abstract]      
Unrealized gains on available-for-sale securities, beginning balances $ 25 $ 14 $ 3
Unrealized gains (losses) on available-for-sale securities (13) 11 11
Unrealized gains on available-for-sale securities, ending balances 12 25 14
Foreign currency translation adjustments, beginning balances (271) (283) (283)
Foreign currency translation adjustments (7) 12  
Foreign currency translation adjustments, ending balances (278) (271) (283)
Defined benefit plans, beginning balances (220) (187) (148)
Defined benefit plans 67 (55) (49)
Defined benefit plans, (income) expense reclassified into operations from other comprehensive income 21 22 10
Defined benefit plans, ending balances (132) (220) (187)
Change in fair value of derivative instruments, beginning balances (36) (4) 47
Change in fair value of derivative instruments 1 (51) (37)
Change in fair value of derivatives instruments, (income) expense reclassified into operations from other comprehensive income 29 19 (14)
Change in fair value of derivative instruments, ending balances (6) (36) (4)
Accumulated other comprehensive income (loss), net of tax, beginning balances (502) (460) (381)
Unrealized gains (losses) on available-for-sale securities, net of income taxes (13) 11 11
Foreign currency translation adjustments (7) 12  
Defined benefit plans 67 (55) (49)
Change in fair value of derivative instruments, net of income tax benefit 1 (51) (37)
Expense (income) reclassified into operations from other comprehensive income, Total 50 41 (4)
Accumulated other comprehensive income (loss), net of tax, ending balances $ (404) $ (502) $ (460)
v3.22.0.1
Other Comprehensive Loss - Components of Accumulated Other Comprehensive Loss (Parenthetical) (Detail) - USD ($)
$ in Millions
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Equity [Abstract]      
Unrealized gains (losses) on available-for-sale securities, tax benefit $ 3    
Unrealized gains (losses) on available-for-sale securities, tax expense   $ 3 $ 4
Foreign currency translation adjustments, income tax benefit 2    
Foreign currency translation adjustments, income tax expense   6 5
Defined benefit plans, income tax benefit   16 14
Defined benefit plans, income tax expense 20    
Change in fair value of derivative instruments, income tax benefit   15 13
Defined benefit plans, benefit reclassified into operations from other comprehensive income 7 6 3
Interest expense on derivative instruments, benefit reclassified into operations from other comprehensive income $ 8 $ 5  
Interest benefit on derivative instruments, expense reclassified into operations from other comprehensive income     $ 3
v3.22.0.1
Accrued Expenses - Summary of Other Accrued Expenses (Detail) - USD ($)
$ in Millions
Dec. 31, 2021
Dec. 31, 2020
Payables and Accruals [Abstract]    
Professional liability risks $ 508 $ 477
Defined contribution benefit plans 549 547
Right-of-use operating lease 392 379
Taxes other than income 361 343
Interest 353 315
Government stimulus refund liability 79 83
Other 1,080 1,096
Other accrued expenses $ 3,322 $ 3,240