John B. v. Mark Emkes, 710 F.3d 394

Tennessee's TennCare program operated under a federal consent decree for 15 years with a sunset contingent on 80% adjusted periodic screening and ongoing compliance.
District court conducted an 18-day evidentiary hearing and a detailed review of TennCare’s compliance with the decree and federal Medicaid law.
Court found TennCare markedly improved its outreach, screening (physical, vision, hearing, dental), and diagnostic/treatment services, largely without private-rights enforcement issues.
Court relied on monitoring tools—NCQA accreditation, HEDIS metrics, CAHPS scores, and an External Quality Review Organization (Qsource)—to assess performance.
Court also examined the decree’s paragraphs for enforceability under §1983, vacating those based on provisions not privately enforceable, while leaving others intact.
After extensive findings, the district court vacated the decree in full as TennCare met the sunset and federal-law compliance requirements.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether the district court properly vacated paragraphs under Rule 60(b)(5).	Plaintiffs contend law-of-the-case and basis issues require reversal.	TennCare argues paragraphs rested on non-privately enforceable provisions and could be vacated.	Yes; court did not abuse discretion vacating those paragraphs.
Whether paragraph 84's basis was correctly determined.	Argue Adoption Act basis; §1396a(a)(43) overlap renders improper.	District court correctly tied paragraph 84 to Adoption Act, not to §1396a(a)(43).	Yes; district court did not abuse its interpretation.
Whether paragraphs 78–83 on agency coordination were properly vacated.	Regulation §441.61(c) and its relation to privately enforceable provisions were misread.	Implementing regulation not privately enforceable; vacatur proper.	Yes; district court did not abuse discretion.
Whether the sunset-clause analysis correctly concluded current substantial compliance.	Argue continued enforcement necessary due to potential ongoing violations.	Court found durable, ongoing compliance and no ongoing violation requiring supervision.	Yes; decree vacated under the sunset clause.
Whether TennCare’s minor error in calculating the denominator was harmless.	Denominator error inflates compliance metrics, undermining sunset validity.	Error is technical; does not affect substantial rights or overall compliance.	Yes; error deemed harmless.

Westside Mothers v. Olszewski, 454 F.3d 532 (6th Cir. 2006) (certain parts of Medicaid Act not privately enforceable under §1983)
Rufo v. Inmates of Suffolk Cnty. Jail, 502 U.S. 367 (U.S. 1992) (change in law may justify vacating consent decree)
Doe v. Briley, 562 F.3d 777 (6th Cir. 2009) (private enforceability of statutory rights in consent decrees)
John B. v. Goetz, 626 F.3d 356 (6th Cir. 2010) (statutory basis of decree; guidance on vacatur and enforceability)
Horne v. Flores, 557 U.S. 433 (U.S. 2009) (durable remedy; termination in institutional reform requires ongoing compliance)
Gonzales v. Galvin, 151 F.3d 526 (6th Cir. 1998) (termination of consent decree; interplay with Horne controlling)
Dowell v. Oklahoma City Public Schools, 498 U.S. 237 (U.S. 1991) (durable remedy framework for institutional reform)
Sault Ste. Marie Tribe of Chippewa Indians v. Granholm, 475 F.3d 805 (6th Cir. 2007) (contract-like interpretation of consent decrees; de novo review of decree terms)
Memisovski ex rel. Memisovski v. Maram, 2004 WL 1878332 (N.D. Ill. 2004) (district court counting method; not controlling here)