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        <TitleTxt>PRESIDENT</TitleTxt>
        <AverageHoursPerWeekRt>2.00</AverageHoursPerWeekRt>
        <AverageHoursPerWeekRltdOrgRt>0.00</AverageHoursPerWeekRltdOrgRt>
        <IndividualTrusteeOrDirectorInd>X</IndividualTrusteeOrDirectorInd>
        <OfficerInd>X</OfficerInd>
        <ReportableCompFromOrgAmt>0</ReportableCompFromOrgAmt>
        <ReportableCompFromRltdOrgAmt>0</ReportableCompFromRltdOrgAmt>
        <OtherCompensationAmt>0</OtherCompensationAmt>
      </Form990PartVIISectionAGrp>
      <Form990PartVIISectionAGrp>
        <PersonNm>JOHN BRANDT</PersonNm>
        <TitleTxt>VICE PRESIDENT</TitleTxt>
        <AverageHoursPerWeekRt>2.00</AverageHoursPerWeekRt>
        <AverageHoursPerWeekRltdOrgRt>0.00</AverageHoursPerWeekRltdOrgRt>
        <IndividualTrusteeOrDirectorInd>X</IndividualTrusteeOrDirectorInd>
        <OfficerInd>X</OfficerInd>
        <ReportableCompFromOrgAmt>0</ReportableCompFromOrgAmt>
        <ReportableCompFromRltdOrgAmt>0</ReportableCompFromRltdOrgAmt>
        <OtherCompensationAmt>0</OtherCompensationAmt>
      </Form990PartVIISectionAGrp>
      <Form990PartVIISectionAGrp>
        <PersonNm>LEYA NEEMA</PersonNm>
        <TitleTxt>SECRETARY</TitleTxt>
        <AverageHoursPerWeekRt>2.00</AverageHoursPerWeekRt>
        <AverageHoursPerWeekRltdOrgRt>0.00</AverageHoursPerWeekRltdOrgRt>
        <IndividualTrusteeOrDirectorInd>X</IndividualTrusteeOrDirectorInd>
        <OfficerInd>X</OfficerInd>
        <ReportableCompFromOrgAmt>0</ReportableCompFromOrgAmt>
        <ReportableCompFromRltdOrgAmt>0</ReportableCompFromRltdOrgAmt>
        <OtherCompensationAmt>0</OtherCompensationAmt>
      </Form990PartVIISectionAGrp>
      <Form990PartVIISectionAGrp>
        <PersonNm>JOHN HEAVENS</PersonNm>
        <TitleTxt>TREASURER</TitleTxt>
        <AverageHoursPerWeekRt>2.00</AverageHoursPerWeekRt>
        <AverageHoursPerWeekRltdOrgRt>0.00</AverageHoursPerWeekRltdOrgRt>
        <IndividualTrusteeOrDirectorInd>X</IndividualTrusteeOrDirectorInd>
        <OfficerInd>X</OfficerInd>
        <ReportableCompFromOrgAmt>0</ReportableCompFromOrgAmt>
        <ReportableCompFromRltdOrgAmt>0</ReportableCompFromRltdOrgAmt>
        <OtherCompensationAmt>0</OtherCompensationAmt>
      </Form990PartVIISectionAGrp>
      <TotalReportableCompFromOrgAmt>2756395</TotalReportableCompFromOrgAmt>
      <TotReportableCompRltdOrgAmt>0</TotReportableCompRltdOrgAmt>
      <TotalOtherCompensationAmt>183622</TotalOtherCompensationAmt>
      <IndivRcvdGreaterThan100KCnt>21</IndivRcvdGreaterThan100KCnt>
      <FormerOfcrEmployeesListedInd>false</FormerOfcrEmployeesListedInd>
      <TotalCompGreaterThan150KInd>true</TotalCompGreaterThan150KInd>
      <CompensationFromOtherSrcsInd>false</CompensationFromOtherSrcsInd>
      <ContractorCompensationGrp>
        <ContractorName>
          <PersonNm>Forvis</PersonNm>
        </ContractorName>
        <ContractorAddress>
          <USAddress>
            <AddressLine1Txt>PO Box 200870</AddressLine1Txt>
            <CityNm>Dallas</CityNm>
            <StateAbbreviationCd>TX</StateAbbreviationCd>
            <ZIPCd>75320</ZIPCd>
          </USAddress>
        </ContractorAddress>
        <ServicesDesc>Accounting</ServicesDesc>
        <CompensationAmt>131793</CompensationAmt>
      </ContractorCompensationGrp>
      <ContractorCompensationGrp>
        <ContractorName>
          <PersonNm>Aethna Health</PersonNm>
        </ContractorName>
        <ContractorAddress>
          <USAddress>
            <AddressLine1Txt>PO Box 415615</AddressLine1Txt>
            <CityNm>Boston</CityNm>
            <StateAbbreviationCd>MA</StateAbbreviationCd>
            <ZIPCd>02241</ZIPCd>
          </USAddress>
        </ContractorAddress>
        <ServicesDesc>EHR</ServicesDesc>
        <CompensationAmt>596019</CompensationAmt>
      </ContractorCompensationGrp>
      <ContractorCompensationGrp>
        <ContractorName>
          <PersonNm>AMN Healthcare Language Services</PersonNm>
        </ContractorName>
        <ContractorAddress>
          <USAddress>
            <AddressLine1Txt>PO Box 674954</AddressLine1Txt>
            <CityNm>Detroit</CityNm>
            <StateAbbreviationCd>MI</StateAbbreviationCd>
            <ZIPCd>48267</ZIPCd>
          </USAddress>
        </ContractorAddress>
        <ServicesDesc>Video Language</ServicesDesc>
        <CompensationAmt>284095</CompensationAmt>
      </ContractorCompensationGrp>
      <ContractorCompensationGrp>
        <ContractorName>
          <PersonNm>Iowa Solutions</PersonNm>
        </ContractorName>
        <ContractorAddress>
          <USAddress>
            <AddressLine1Txt>1045 Sherman Rd</AddressLine1Txt>
            <CityNm>Hiawatha</CityNm>
            <StateAbbreviationCd>IA</StateAbbreviationCd>
            <ZIPCd>52233</ZIPCd>
          </USAddress>
        </ContractorAddress>
        <ServicesDesc>IT services</ServicesDesc>
        <CompensationAmt>315417</CompensationAmt>
      </ContractorCompensationGrp>
      <ContractorCompensationGrp>
        <ContractorName>
          <PersonNm>Horizons</PersonNm>
        </ContractorName>
        <ContractorAddress>
          <USAddress>
            <AddressLine1Txt>819 5th St SE</AddressLine1Txt>
            <CityNm>Cedar Rapids</CityNm>
            <StateAbbreviationCd>IA</StateAbbreviationCd>
            <ZIPCd>52401</ZIPCd>
          </USAddress>
        </ContractorAddress>
        <ServicesDesc>Transportion Serv</ServicesDesc>
        <CompensationAmt>166089</CompensationAmt>
      </ContractorCompensationGrp>
      <CntrctRcvdGreaterThan100KCnt>5</CntrctRcvdGreaterThan100KCnt>
      <GovernmentGrantsAmt>2401454</GovernmentGrantsAmt>
      <AllOtherContributionsAmt>379771</AllOtherContributionsAmt>
      <TotalContributionsAmt>2781225</TotalContributionsAmt>
      <ProgramServiceRevenueGrp>
        <Desc>NET PATIENT REVENUE</Desc>
        <BusinessCd>621990</BusinessCd>
        <TotalRevenueColumnAmt>12423855</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>12423855</RelatedOrExemptFuncIncomeAmt>
      </ProgramServiceRevenueGrp>
      <ProgramServiceRevenueGrp>
        <Desc>CONTRACT REV</Desc>
        <BusinessCd>621990</BusinessCd>
        <TotalRevenueColumnAmt>11889</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>11889</RelatedOrExemptFuncIncomeAmt>
      </ProgramServiceRevenueGrp>
      <ProgramServiceRevenueGrp>
        <Desc>INCENTIVES</Desc>
        <BusinessCd>621990</BusinessCd>
        <TotalRevenueColumnAmt>406990</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>406990</RelatedOrExemptFuncIncomeAmt>
      </ProgramServiceRevenueGrp>
      <TotalProgramServiceRevenueAmt>12842734</TotalProgramServiceRevenueAmt>
      <InvestmentIncomeGrp>
        <TotalRevenueColumnAmt>81372</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>81372</RelatedOrExemptFuncIncomeAmt>
      </InvestmentIncomeGrp>
      <FundraisingGrossIncomeAmt>29632</FundraisingGrossIncomeAmt>
      <FundraisingDirectExpensesAmt>10381</FundraisingDirectExpensesAmt>
      <NetIncmFromFundraisingEvtGrp>
        <TotalRevenueColumnAmt>19251</TotalRevenueColumnAmt>
        <ExclusionAmt>19251</ExclusionAmt>
      </NetIncmFromFundraisingEvtGrp>
      <OtherRevenueMiscGrp>
        <Desc>MISC</Desc>
        <BusinessCd>621990</BusinessCd>
        <TotalRevenueColumnAmt>25754</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>25754</RelatedOrExemptFuncIncomeAmt>
      </OtherRevenueMiscGrp>
      <OtherRevenueMiscGrp>
        <Desc>IA HLTH ACO JT VENT K1</Desc>
        <BusinessCd>621990</BusinessCd>
        <TotalRevenueColumnAmt>22599</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>22599</RelatedOrExemptFuncIncomeAmt>
      </OtherRevenueMiscGrp>
      <OtherRevenueMiscGrp>
        <Desc>CRPHO</Desc>
        <BusinessCd>623990</BusinessCd>
        <TotalRevenueColumnAmt>270</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>270</RelatedOrExemptFuncIncomeAmt>
      </OtherRevenueMiscGrp>
      <OtherRevenueTotalAmt>48623</OtherRevenueTotalAmt>
      <TotalRevenueGrp>
        <TotalRevenueColumnAmt>15773205</TotalRevenueColumnAmt>
        <RelatedOrExemptFuncIncomeAmt>12972729</RelatedOrExemptFuncIncomeAmt>
        <UnrelatedBusinessRevenueAmt>0</UnrelatedBusinessRevenueAmt>
        <ExclusionAmt>19251</ExclusionAmt>
      </TotalRevenueGrp>
      <InfoInScheduleOPartIXInd>X</InfoInScheduleOPartIXInd>
      <CompCurrentOfcrDirectorsGrp>
        <TotalAmt>2756395</TotalAmt>
        <ProgramServicesAmt>1934744</ProgramServicesAmt>
        <ManagementAndGeneralAmt>821651</ManagementAndGeneralAmt>
      </CompCurrentOfcrDirectorsGrp>
      <OtherSalariesAndWagesGrp>
        <TotalAmt>6362755</TotalAmt>
        <ProgramServicesAmt>5873554</ProgramServicesAmt>
        <ManagementAndGeneralAmt>421113</ManagementAndGeneralAmt>
        <FundraisingAmt>68088</FundraisingAmt>
      </OtherSalariesAndWagesGrp>
      <PensionPlanContributionsGrp>
        <TotalAmt>312401</TotalAmt>
        <ProgramServicesAmt>240805</ProgramServicesAmt>
        <ManagementAndGeneralAmt>71596</ManagementAndGeneralAmt>
      </PensionPlanContributionsGrp>
      <OtherEmployeeBenefitsGrp>
        <TotalAmt>1227971</TotalAmt>
        <ProgramServicesAmt>1025138</ProgramServicesAmt>
        <ManagementAndGeneralAmt>187165</ManagementAndGeneralAmt>
        <FundraisingAmt>15668</FundraisingAmt>
      </OtherEmployeeBenefitsGrp>
      <PayrollTaxesGrp>
        <TotalAmt>633796</TotalAmt>
        <ProgramServicesAmt>545312</ProgramServicesAmt>
        <ManagementAndGeneralAmt>83275</ManagementAndGeneralAmt>
        <FundraisingAmt>5209</FundraisingAmt>
      </PayrollTaxesGrp>
      <FeesForServicesLegalGrp>
        <TotalAmt>17517</TotalAmt>
        <ProgramServicesAmt>56</ProgramServicesAmt>
        <ManagementAndGeneralAmt>17461</ManagementAndGeneralAmt>
      </FeesForServicesLegalGrp>
      <FeesForServicesAccountingGrp>
        <TotalAmt>167621</TotalAmt>
        <ProgramServicesAmt>23983</ProgramServicesAmt>
        <ManagementAndGeneralAmt>143638</ManagementAndGeneralAmt>
      </FeesForServicesAccountingGrp>
      <FeesForServicesOtherGrp>
        <TotalAmt>1923424</TotalAmt>
        <ProgramServicesAmt>1750015</ProgramServicesAmt>
        <ManagementAndGeneralAmt>173409</ManagementAndGeneralAmt>
      </FeesForServicesOtherGrp>
      <AdvertisingGrp>
        <TotalAmt>71646</TotalAmt>
        <ProgramServicesAmt>1879</ProgramServicesAmt>
        <ManagementAndGeneralAmt>69767</ManagementAndGeneralAmt>
      </AdvertisingGrp>
      <OfficeExpensesGrp>
        <TotalAmt>78939</TotalAmt>
        <ProgramServicesAmt>43491</ProgramServicesAmt>
        <ManagementAndGeneralAmt>27655</ManagementAndGeneralAmt>
        <FundraisingAmt>7793</FundraisingAmt>
      </OfficeExpensesGrp>
      <InformationTechnologyGrp>
        <TotalAmt>194478</TotalAmt>
        <ProgramServicesAmt>41440</ProgramServicesAmt>
        <ManagementAndGeneralAmt>153038</ManagementAndGeneralAmt>
      </InformationTechnologyGrp>
      <OccupancyGrp>
        <TotalAmt>424542</TotalAmt>
        <ProgramServicesAmt>367483</ProgramServicesAmt>
        <ManagementAndGeneralAmt>56900</ManagementAndGeneralAmt>
        <FundraisingAmt>159</FundraisingAmt>
      </OccupancyGrp>
      <TravelGrp>
        <TotalAmt>130332</TotalAmt>
        <ProgramServicesAmt>31295</ProgramServicesAmt>
        <ManagementAndGeneralAmt>99037</ManagementAndGeneralAmt>
      </TravelGrp>
      <ConferencesMeetingsGrp>
        <TotalAmt>16153</TotalAmt>
        <ProgramServicesAmt>10770</ProgramServicesAmt>
        <ManagementAndGeneralAmt>5383</ManagementAndGeneralAmt>
      </ConferencesMeetingsGrp>
      <InterestGrp>
        <TotalAmt>253262</TotalAmt>
        <ProgramServicesAmt>195818</ProgramServicesAmt>
        <ManagementAndGeneralAmt>57444</ManagementAndGeneralAmt>
      </InterestGrp>
      <DepreciationDepletionGrp>
        <TotalAmt>587304</TotalAmt>
        <ProgramServicesAmt>444676</ProgramServicesAmt>
        <ManagementAndGeneralAmt>142628</ManagementAndGeneralAmt>
      </DepreciationDepletionGrp>
      <InsuranceGrp>
        <TotalAmt>67640</TotalAmt>
        <ManagementAndGeneralAmt>67640</ManagementAndGeneralAmt>
      </InsuranceGrp>
      <OtherExpensesGrp>
        <Desc>RECRUITMENT</Desc>
        <TotalAmt>20370</TotalAmt>
        <ProgramServicesAmt>2089</ProgramServicesAmt>
        <ManagementAndGeneralAmt>18281</ManagementAndGeneralAmt>
      </OtherExpensesGrp>
      <OtherExpensesGrp>
        <Desc>SUPPLIES</Desc>
        <TotalAmt>1021409</TotalAmt>
        <ProgramServicesAmt>1020441</ProgramServicesAmt>
        <ManagementAndGeneralAmt>968</ManagementAndGeneralAmt>
      </OtherExpensesGrp>
      <OtherExpensesGrp>
        <Desc>ALL OTHER</Desc>
        <TotalAmt>287086</TotalAmt>
        <ProgramServicesAmt>214116</ProgramServicesAmt>
        <ManagementAndGeneralAmt>72970</ManagementAndGeneralAmt>
      </OtherExpensesGrp>
      <OtherExpensesGrp>
        <Desc>DUESSUBSBOOKSLIC</Desc>
        <TotalAmt>236512</TotalAmt>
        <ProgramServicesAmt>104238</ProgramServicesAmt>
        <ManagementAndGeneralAmt>132274</ManagementAndGeneralAmt>
      </OtherExpensesGrp>
      <TotalFunctionalExpensesGrp>
        <TotalAmt>16791553</TotalAmt>
        <ProgramServicesAmt>13871343</ProgramServicesAmt>
        <ManagementAndGeneralAmt>2823293</ManagementAndGeneralAmt>
        <FundraisingAmt>96917</FundraisingAmt>
      </TotalFunctionalExpensesGrp>
      <JointCostsInd>X</JointCostsInd>
      <CashNonInterestBearingGrp>
        <BOYAmt>3419736</BOYAmt>
        <EOYAmt>2470096</EOYAmt>
      </CashNonInterestBearingGrp>
      <SavingsAndTempCashInvstGrp>
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        <EOYAmt>2359211</EOYAmt>
      </SavingsAndTempCashInvstGrp>
      <PledgesAndGrantsReceivableGrp>
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        <EOYAmt>496527</EOYAmt>
      </PledgesAndGrantsReceivableGrp>
      <AccountsReceivableGrp>
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        <EOYAmt>1517702</EOYAmt>
      </AccountsReceivableGrp>
      <InventoriesForSaleOrUseGrp>
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        <EOYAmt>39459</EOYAmt>
      </InventoriesForSaleOrUseGrp>
      <PrepaidExpensesDefrdChargesGrp>
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        <EOYAmt>123156</EOYAmt>
      </PrepaidExpensesDefrdChargesGrp>
      <LandBldgEquipCostOrOtherBssAmt>10714041</LandBldgEquipCostOrOtherBssAmt>
      <LandBldgEquipAccumDeprecAmt>2261836</LandBldgEquipAccumDeprecAmt>
      <LandBldgEquipBasisNetGrp>
        <BOYAmt>6529040</BOYAmt>
        <EOYAmt>8452205</EOYAmt>
      </LandBldgEquipBasisNetGrp>
      <OtherAssetsTotalGrp>
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        <EOYAmt>1052192</EOYAmt>
      </OtherAssetsTotalGrp>
      <TotalAssetsGrp>
        <BOYAmt>16352240</BOYAmt>
        <EOYAmt>16510548</EOYAmt>
      </TotalAssetsGrp>
      <AccountsPayableAccrExpnssGrp>
        <BOYAmt>2160073</BOYAmt>
        <EOYAmt>1742034</EOYAmt>
      </AccountsPayableAccrExpnssGrp>
      <MortgNotesPyblScrdInvstPropGrp>
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        <EOYAmt>3965351</EOYAmt>
      </MortgNotesPyblScrdInvstPropGrp>
      <TotalLiabilitiesGrp>
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        <EOYAmt>5707385</EOYAmt>
      </TotalLiabilitiesGrp>
      <OrganizationFollowsFASB117Ind>X</OrganizationFollowsFASB117Ind>
      <NoDonorRestrictionNetAssetsGrp>
        <BOYAmt>10240146</BOYAmt>
        <EOYAmt>10579317</EOYAmt>
      </NoDonorRestrictionNetAssetsGrp>
      <DonorRestrictionNetAssetsGrp>
        <BOYAmt>1365644</BOYAmt>
        <EOYAmt>223846</EOYAmt>
      </DonorRestrictionNetAssetsGrp>
      <TotalNetAssetsFundBalanceGrp>
        <BOYAmt>11605790</BOYAmt>
        <EOYAmt>10803163</EOYAmt>
      </TotalNetAssetsFundBalanceGrp>
      <TotLiabNetAssetsFundBalanceGrp>
        <BOYAmt>16352240</BOYAmt>
        <EOYAmt>16510548</EOYAmt>
      </TotLiabNetAssetsFundBalanceGrp>
      <ReconcilationRevenueExpnssAmt>-1018348</ReconcilationRevenueExpnssAmt>
      <NetUnrlzdGainsLossesInvstAmt>215721</NetUnrlzdGainsLossesInvstAmt>
      <OtherChangesInNetAssetsAmt>0</OtherChangesInNetAssetsAmt>
      <MethodOfAccountingAccrualInd>X</MethodOfAccountingAccrualInd>
      <AccountantCompileOrReviewInd>false</AccountantCompileOrReviewInd>
      <FSAuditedInd>true</FSAuditedInd>
      <FSAuditedBasisGrp>
        <SeparateBasisFinclStmtInd>X</SeparateBasisFinclStmtInd>
      </FSAuditedBasisGrp>
      <AuditCommitteeInd>true</AuditCommitteeInd>
      <FederalGrantAuditRequiredInd>true</FederalGrantAuditRequiredInd>
      <FederalGrantAuditPerformedInd>true</FederalGrantAuditPerformedInd>
    </IRS990>
    <IRS990ScheduleA documentId="990A">
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      <GiftsGrantsContrisRcvd509Grp>
        <CurrentTaxYearMinus4YearsAmt>3193571</CurrentTaxYearMinus4YearsAmt>
        <CurrentTaxYearMinus3YearsAmt>4221674</CurrentTaxYearMinus3YearsAmt>
        <CurrentTaxYearMinus2YearsAmt>3878332</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>5500526</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>2800476</CurrentTaxYearAmt>
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      </GiftsGrantsContrisRcvd509Grp>
      <GrossReceiptsAdmissionsGrp>
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        <CurrentTaxYearMinus3YearsAmt>11642822</CurrentTaxYearMinus3YearsAmt>
        <CurrentTaxYearMinus2YearsAmt>12440442</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>12646670</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>12842734</CurrentTaxYearAmt>
        <TotalAmt>60477749</TotalAmt>
      </GrossReceiptsAdmissionsGrp>
      <Total509Grp>
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        <CurrentTaxYearMinus2YearsAmt>16318774</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>18147196</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>15643210</CurrentTaxYearAmt>
        <TotalAmt>80072328</TotalAmt>
      </Total509Grp>
      <PublicSupportTotal509Amt>80072328</PublicSupportTotal509Amt>
      <GrossInvestmentIncome509Grp>
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        <CurrentTaxYearMinus2YearsAmt>6294</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>75589</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>81372</CurrentTaxYearAmt>
        <TotalAmt>202644</TotalAmt>
      </GrossInvestmentIncome509Grp>
      <InvestmentIncomeAndUBTIGrp>
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        <CurrentTaxYearMinus3YearsAmt>8421</CurrentTaxYearMinus3YearsAmt>
        <CurrentTaxYearMinus2YearsAmt>6294</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>75589</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>81372</CurrentTaxYearAmt>
        <TotalAmt>202644</TotalAmt>
      </InvestmentIncomeAndUBTIGrp>
      <OtherIncome509Grp>
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        <CurrentTaxYearMinus2YearsAmt>136678</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>144244</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>48623</CurrentTaxYearAmt>
        <TotalAmt>884409</TotalAmt>
      </OtherIncome509Grp>
      <TotalSupportCalendarYearGrp>
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        <CurrentTaxYearMinus3YearsAmt>16279166</CurrentTaxYearMinus3YearsAmt>
        <CurrentTaxYearMinus2YearsAmt>16461746</CurrentTaxYearMinus2YearsAmt>
        <CurrentTaxYearMinus1YearAmt>18367029</CurrentTaxYearMinus1YearAmt>
        <CurrentTaxYearAmt>15773205</CurrentTaxYearAmt>
        <TotalAmt>81159381</TotalAmt>
      </TotalSupportCalendarYearGrp>
      <PublicSupportCY509Pct>0.98660</PublicSupportCY509Pct>
      <PublicSupportPY509Pct>0.98550</PublicSupportPY509Pct>
      <InvestmentIncomeCYPct>0.00000</InvestmentIncomeCYPct>
      <InvestmentIncomePYPct>0.00000</InvestmentIncomePYPct>
      <ThirtyThrPctSuprtTestsCY509Ind>X</ThirtyThrPctSuprtTestsCY509Ind>
    </IRS990ScheduleA>
    <IRS990ScheduleB documentId="990B">
      <ContributorInformationGrp>
        <ContributorNum>RESTRICTED</ContributorNum>
        <ContributorBusinessName>
          <BusinessNameLine1>RESTRICTED</BusinessNameLine1>
        </ContributorBusinessName>
        <ContributorUSAddress>
          <AddressLine1>RESTRICTED</AddressLine1>
          <AddressLine2>RESTRICTED</AddressLine2>
          <City>RESTRICTED</City>
          <State>RESTRICTED</State>
          <ZIPCode>RESTRICTED</ZIPCode>
        </ContributorUSAddress>
        <TotalContributionsAmt>RESTRICTED</TotalContributionsAmt>
      </ContributorInformationGrp>
    </IRS990ScheduleB>
    <IRS990ScheduleC documentId="990C">
      <VolunteersInd>false</VolunteersInd>
      <PaidStaffOrManagementInd>false</PaidStaffOrManagementInd>
      <MediaAdvertisementsInd>false</MediaAdvertisementsInd>
      <MailingsMembersInd>false</MailingsMembersInd>
      <PublicationsOrBroadcastInd>false</PublicationsOrBroadcastInd>
      <GrantsOtherOrganizationsInd>false</GrantsOtherOrganizationsInd>
      <DirectContactLegislatorsInd>false</DirectContactLegislatorsInd>
      <RalliesDemonstrationsInd>false</RalliesDemonstrationsInd>
      <OtherActivitiesInd>false</OtherActivitiesInd>
      <NotDescribedSection501c3Ind>false</NotDescribedSection501c3Ind>
    </IRS990ScheduleC>
    <IRS990ScheduleD documentId="990D">
      <LandGrp>
        <OtherCostOrOtherBasisAmt>251501</OtherCostOrOtherBasisAmt>
        <BookValueAmt>251501</BookValueAmt>
      </LandGrp>
      <BuildingsGrp>
        <OtherCostOrOtherBasisAmt>8005134</OtherCostOrOtherBasisAmt>
        <DepreciationAmt>1387702</DepreciationAmt>
        <BookValueAmt>6617432</BookValueAmt>
      </BuildingsGrp>
      <EquipmentGrp>
        <OtherCostOrOtherBasisAmt>2404791</OtherCostOrOtherBasisAmt>
        <DepreciationAmt>874134</DepreciationAmt>
        <BookValueAmt>1530657</BookValueAmt>
      </EquipmentGrp>
      <OtherLandBuildingsGrp>
        <OtherCostOrOtherBasisAmt>52615</OtherCostOrOtherBasisAmt>
        <BookValueAmt>52615</BookValueAmt>
      </OtherLandBuildingsGrp>
      <TotalBookValueLandBuildingsAmt>8452205</TotalBookValueLandBuildingsAmt>
      <OtherAssetsOrgGrp>
        <Desc>IOWA HEALTH CNTRS FOR ACC LLC</Desc>
        <BookValueAmt>735264</BookValueAmt>
      </OtherAssetsOrgGrp>
      <OtherAssetsOrgGrp>
        <Desc>INTEREST IN ASSETS HELD BY GREATER</Desc>
      </OtherAssetsOrgGrp>
      <OtherAssetsOrgGrp>
        <Desc>CEDAR RAPIDS COMMUNITY FOUNDATION</Desc>
        <BookValueAmt>33807</BookValueAmt>
      </OtherAssetsOrgGrp>
      <OtherAssetsOrgGrp>
        <Desc>RIGHT TO USE LEASES</Desc>
        <BookValueAmt>283121</BookValueAmt>
      </OtherAssetsOrgGrp>
      <TotalBookValueOtherAssetsAmt>1052192</TotalBookValueOtherAssetsAmt>
      <TotalRevEtcAuditedFinclStmtAmt>15988926</TotalRevEtcAuditedFinclStmtAmt>
      <NetUnrealizedGainsInvstAmt>215721</NetUnrealizedGainsInvstAmt>
      <RevenueNotReportedAmt>215721</RevenueNotReportedAmt>
      <RevenueSubtotalAmt>15773205</RevenueSubtotalAmt>
      <TotalRevenuePerForm990Amt>15773205</TotalRevenuePerForm990Amt>
      <TotExpnsEtcAuditedFinclStmtAmt>16791553</TotExpnsEtcAuditedFinclStmtAmt>
      <ExpensesSubtotalAmt>16791553</ExpensesSubtotalAmt>
      <TotalExpensesPerForm990Amt>16791553</TotalExpensesPerForm990Amt>
    </IRS990ScheduleD>
    <IRS990ScheduleG documentId="990G">
      <FundraisingEventInformationGrp>
        <Event1Nm>BIG GROVE FR</Event1Nm>
        <GrossReceiptsEvent1Amt>29632</GrossReceiptsEvent1Amt>
        <GrossRevenueEvent1Amt>29632</GrossRevenueEvent1Amt>
        <CashPrizesEvent1Amt>82</CashPrizesEvent1Amt>
        <RentFacilityCostsEvent1Amt>1000</RentFacilityCostsEvent1Amt>
        <FoodAndBeverageEvent1Amt>5073</FoodAndBeverageEvent1Amt>
        <EntertainmentEvent1Amt>1300</EntertainmentEvent1Amt>
        <OtherDirectExpensesEvent1Amt>2926</OtherDirectExpensesEvent1Amt>
        <GrossReceiptsTotalAmt>29632</GrossReceiptsTotalAmt>
        <GrossRevenueTotalEventsAmt>29632</GrossRevenueTotalEventsAmt>
        <CashPrizesTotalEventsAmt>82</CashPrizesTotalEventsAmt>
        <RentFcltyCostsTotalEventsAmt>1000</RentFcltyCostsTotalEventsAmt>
        <FoodAndBeverageTotalEventsAmt>5073</FoodAndBeverageTotalEventsAmt>
        <EntertainmentTotalEventsAmt>1300</EntertainmentTotalEventsAmt>
        <OthDirectExpnssTotalEventsAmt>2926</OthDirectExpnssTotalEventsAmt>
        <DirectExpenseSummaryEventsAmt>10381</DirectExpenseSummaryEventsAmt>
        <NetIncomeSummaryAmt>19251</NetIncomeSummaryAmt>
      </FundraisingEventInformationGrp>
    </IRS990ScheduleG>
    <IRS990ScheduleJ documentId="990J">
      <WrittenEmploymentContractInd>X</WrittenEmploymentContractInd>
      <BoardOrCommitteeApprovalInd>X</BoardOrCommitteeApprovalInd>
      <SeverancePaymentInd>false</SeverancePaymentInd>
      <SupplementalNonqualRtrPlanInd>false</SupplementalNonqualRtrPlanInd>
      <EquityBasedCompArrngmInd>false</EquityBasedCompArrngmInd>
      <CompBasedOnRevenueOfFlngOrgInd>false</CompBasedOnRevenueOfFlngOrgInd>
      <CompBsdOnRevRelatedOrgsInd>false</CompBsdOnRevRelatedOrgsInd>
      <CompBsdNetEarnsFlngOrgInd>false</CompBsdNetEarnsFlngOrgInd>
      <CompBsdNetEarnsRltdOrgsInd>false</CompBsdNetEarnsRltdOrgsInd>
      <AnyNonFixedPaymentsInd>false</AnyNonFixedPaymentsInd>
      <InitialContractExceptionInd>false</InitialContractExceptionInd>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>HARIPRIYA SANTHANAM</PersonNm>
        <TitleTxt>PHYSICIAN</TitleTxt>
        <BaseCompensationFilingOrgAmt>162855</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>6514</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>537</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>169906</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>SIDNEY J SMITH</PersonNm>
        <TitleTxt>PHYSICIAN</TitleTxt>
        <BaseCompensationFilingOrgAmt>449341</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>17874</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>9277</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>476492</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>BASSELL EID</PersonNm>
        <TitleTxt>PHYSICIAN</TitleTxt>
        <BaseCompensationFilingOrgAmt>581832</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>22500</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>13669</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>618001</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>ANDREW VAUGHN</PersonNm>
        <TitleTxt>CHIEF MEDICAL OFFICER</TitleTxt>
        <BaseCompensationFilingOrgAmt>145480</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>5819</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>13509</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>164808</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>JOE LOCK</PersonNm>
        <TitleTxt>CEO</TitleTxt>
        <BaseCompensationFilingOrgAmt>203953</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>8158</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>12424</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>224535</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>ANTHONY D EISHMAN</PersonNm>
        <TitleTxt>PHYSICIAN</TitleTxt>
        <BaseCompensationFilingOrgAmt>421584</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>16863</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>1597</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>440044</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>AMY SMOLOUCHA</PersonNm>
        <TitleTxt>PHYSICIAN</TitleTxt>
        <BaseCompensationFilingOrgAmt>319132</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>12765</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>1106</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>333003</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>SCOTT ARERNSDORF</PersonNm>
        <TitleTxt>CHIEF FINANCIAL OFFICER</TitleTxt>
        <BaseCompensationFilingOrgAmt>150820</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>6033</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>7490</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>164343</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>DIANA JONES</PersonNm>
        <TitleTxt>CHIEF DENTAL OFFICER</TitleTxt>
        <BaseCompensationFilingOrgAmt>175918</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>7037</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>10377</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>193332</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
      <RltdOrgOfficerTrstKeyEmplGrp>
        <PersonNm>DAWN BAUGHMAN</PersonNm>
        <TitleTxt>CHIEF CLINICAL OFFICER</TitleTxt>
        <BaseCompensationFilingOrgAmt>145480</BaseCompensationFilingOrgAmt>
        <DeferredCompensationFlngOrgAmt>5819</DeferredCompensationFlngOrgAmt>
        <NontaxableBenefitsFilingOrgAmt>4254</NontaxableBenefitsFilingOrgAmt>
        <TotalCompensationFilingOrgAmt>155553</TotalCompensationFilingOrgAmt>
      </RltdOrgOfficerTrstKeyEmplGrp>
    </IRS990ScheduleJ>
    <IRS990ScheduleO documentId="990O">
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Form 990 governing body review Part VI line 11</FormAndLineReferenceDesc>
        <ExplanationTxt>Form 990 will be presented to board of directors</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Conflict of interest policy compliance Part VI line 12c</FormAndLineReferenceDesc>
        <ExplanationTxt>Board would discuss any conflict of interest</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>CEO executive director top management comp Part VI line 15a</FormAndLineReferenceDesc>
        <ExplanationTxt>Executive committee and finance committee review and make recommendation to board for CEO salary</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Other officer or key employee compensation Part VI line 15b</FormAndLineReferenceDesc>
        <ExplanationTxt>CEO makes recommendation for compensation, executive committee and finance committee review and make recommendation to board for overall organizations wage increases.</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Governing documents etc available to public Part VI line 19</FormAndLineReferenceDesc>
        <ExplanationTxt>The governing documents, conflict of interest policy, and financial statements are not available to the general public. Public officials serve on the board and would share documents with their governmental entities.</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>List of other fees for services expenses Part IX line 11g</FormAndLineReferenceDesc>
        <ExplanationTxt>Program ServicesPatient Claim Processing $643,925 Collection Fees $5,756 Interpretation Services $358,931 Physician Services $78,390 Leadership $42,050 IT $103,224 340B Fees $167,044 Staffing $290,372 Consulting &amp; Other $60,323 Total $1,750,015Management and GeneralAccounting $23,013 Human Resources $13,235 IT Services $39,565 Leadership $42,050 Marketing $39,098 Other $16,448 Total $173,409</ExplanationTxt>
      </SupplementalInformationDetail>
    </IRS990ScheduleO>
  </ReturnData>
</Return>