John B. v. Goetz

  • Your daughter has cerebral palsy and quadriplegia and needs a special wheelchair.  The wheelchair is ordered by her doctor; however, there are numerous delays.  When the wheelchair finally arrives, you immediately realize that it was not built to the correct specifications.  The wheelchair’s lack of proper safety mechanisms causes your daughter to fall out of the chair. The wheelchair must be sent back for modifications.  It takes over two years before your daughter receives the proper wheelchair.
  • You are the parent of a special needs boy with severe emotional and behavioral health needs.  Your son has been treated at a residential treatment facility and his condition has improved.  He no longer needs residential treatment; however, he cannot move home because of the threat he poses to your other children.  Although his doctor has ordered treatment at a therapeutic foster home, TennCare denied this care saying that your son must go into foster care to receive this treatment.  You are faced with the decision of whether to surrender custody of your son to the state or bring your son home and put his siblings at risk of harm.
  • Your teenage daughter has severe diabetes. Your daughter’s doctor recommends an insulin pump to keep her blood sugar regulated. Her HMO denies the pump.

The above cases are from TJC clients who rely upon the John B. class action to ensure that their health needs are met.


John B. v. Goetz is a class action against the state of Tennessee for its failure to abide by the federal law that requires the state to maintain the health of children enrolled in TennCare.  This law is called Early Periodic Screening Diagnostic and Treatment, or EPSDT. Congress passed EPSDT to ensure that all children grow up healthy, strong, and able to reach their full potential.  EPSDT covers all Medicaid children under the age of 21.  Since 1968, every state in the nation has been obligated to meet federal EPSDT standards.

John B. was filed (see complaint) and settled on the same day in 1998. When the State signed the settlement agreement (see consent decree), it agreed to comply with EPSDT. The consent decree allowed the State several years to fulfill its promises to Tennessee’s children.  Initially, the State worked toward compliance; however, as state officials and priorities changed, the State failed to implement the promises it made under the John B. consent decree.  Rather than develop a plan for compliance or work to ensure that the health needs of the most vulnerable Tennesseans are met, the State has spent its energies fighting its obligations to Tennessee’s children.  In fact, since 2001, every fact finder that has analyzed the State’s compliance with its EPSDT obligations has found that the State is not in compliance with the law and is failing its most vulnerable children.

In 2001, the Federal Court found the State had violated every aspect of the federal law and the consent decree. In response, the Court appointed a special master to help the State develop and implement a plan for compliance with the law (See Court’s Dec. 20, 2001 order and findings).  In October 2004, the Court found that the State was still failing children and that the State did not even have a plan for developing a system that would meet children’s medical needs. To date, the State refuses to produce a plan for compliance.

In February 2006, Judge Nixon recused himself from the case in a scathing opinion about the State’s efforts. In early 2006, the State declared itself in compliance. The District Court appointed five court monitors to evaluate whether the State met its obligations to Tennessee’s children.  In January 2007, the monitors released their findings, which showed the State’s ongoing problems and non-compliance with the Consent Decree and EPSDT (see Jan. 26, 2007 executive summary and monitors’ reports on Screening, Diagnosis and Treatment, Outreach, Department of Children’s Services: Part 1 and Part 2, and Coordination).

The State’s failure to meet its obligations under John B. is particularly troubling given the current financial crisis.  Each month, the State pays it HMO contractors in advance.  Under their contracts with the state, the HMOs are obligated to meet the standards of the federal law.  However, because the State has no plan for compliance, TennCare is unable to require its HMOs to deliver medical care to enrollees.  The State pays these HMOs tax revenues for comprehensive care for children which they often do not receive.  If the State were to develop a plan for compliance, TennCare would be able to demand the services purchased with taxpayer dollars.

In 2010, the State again moved to vacate the consent decree.  The Court of Appeals found that the consent decree is valid and refused to vacate the decree; the case was sent back to District Court for further proceedings.  In March 2011, under new direction of Judge Wiseman, a date was set for trial beginning on October 31, 2011 and lasting about six weeks.

Much of 2011 was spent identifying fact witnesses (caretakers, attorneys, advocates, and TennCare enrollees) and expert witnesses (doctors and nurses, juvenile court judge, and former state officials); gathering witness documents and medical records; and taking depositions of the State’s witnesses and defending depositions that the State took of our clients. Our witnesses testified in court about how TennCare had failed children in important ways. Their stories, along with high level medical data analyses by experts and testimony from doctors, nurses, and other medical providers, showed that TennCare still has work to do to meet the vital needs of its enrollees.

We began court proceedings for the John B. trial on October 31, 2011 and concluded on November 30, 2011.  Our Post-Trial Proposed Findings of Fact and Conclusions of Law was submitted to the court on December 20 and can be found here.

The federal trial court in Nashville issued the decision for John B. on February 14, 2012. The federal court ruled that the state is in “substantial compliance” with earlier orders and that the case can now be closed. Click here to read our press release about the decision. The full text of the decision can be found here.

The case went to the Sixth Circuit Court of Appeals for further review. Oral arguments were set for October 4, 2012. On March 14, 2013, the Sixth Circuit Court of Appeals upheld the closing of the John B. case. The ruling closed a 17-year chapter in TJC’s work to improve the care of Tennessee’s children. The court found that the case had served its purpose, and that services for the 750,000 children enrolled in TennCare are now improved to the point where they meet federal requirements.

John B. required tens of thousands of hours, tens of millions of dollars of resources by TJC and our pro bono co-counsel, and the courageous testimony of many parents, foster parents, doctors, nurses, and other experts. Although proud of the progress that has been made, we opposed the closure of the case. Our daily contact with families and professionals who care for TennCare children makes us painfully aware that TennCare continues to shortchange some children, many of whom have great needs. The ruling therefore came as a great disappointment.

The decision leaves undiminished our determination to “keep our eyes on the prize” – the prize of better health and better lives for vulnerable Tennesseans of all ages. The John B. chapter ends, but TJC’s work for justice continues.