## Facts

- Medicare covers certain home health aide services for eligible homebound beneficiaries, but those services are furnished through home health agencies (HHAs).
- HHAs may choose whether to participate in Medicare; participating HHAs must comply with Medicare’s conditions of participation, including requirements not to discriminate against beneficiaries with chronic illnesses or disabilities.
- The Department of Health and Human Services (HHS), acting through the Secretary, administers Medicare and is responsible for ensuring participating HHAs comply with program requirements.
- Catherine Johnson and Cara Bunnell were Medicare beneficiaries with multiple sclerosis who required home health aide services to live at home.
- Johnson and Bunnell alleged they had difficulty securing adequate HHA services because HHAs would not accept them as patients or would not keep them as patients long-term.
- They alleged that when an HHA did accept them, it sometimes did so only temporarily, did not provide all services they believed were covered by Medicare, or demanded that they pay amounts beyond Medicare reimbursement.
- The beneficiaries attributed these difficulties to HHAs allegedly disregarding Medicare participation obligations, including nondiscrimination requirements.
- Johnson, Bunnell, and other beneficiaries filed a putative class action against the Secretary of HHS seeking declaratory and injunctive relief.
- The requested relief sought to compel HHS to enforce Medicare requirements against HHAs so that more agencies would accept and appropriately serve chronically ill beneficiaries.
- The district court dismissed for lack of Article III standing, concluding the beneficiaries had not shown that an order directing HHS to act would likely remedy their inability to obtain services from independent, private HHAs.
- The beneficiaries appealed.

## Issues

1. Whether Medicare beneficiaries who struggle to obtain services from private home health agencies have Article III standing to seek an injunction ordering HHS to increase enforcement of Medicare participation and nondiscrimination requirements.
2. Whether the beneficiaries plausibly alleged redressability and traceability when the injury depends on independent decisions by HHAs about whether to accept and serve particular patients.

## Decision

- The D.C. Circuit affirmed the dismissal for lack of Article III standing.
- The court treated the beneficiaries’ alleged inability to obtain adequate home health services as a concrete injury but held the complaint did not show the injury was likely to be remedied by the requested injunction.
- The court concluded redressability was missing because the relief sought would operate through third-party HHAs, which retain discretion over whether to accept patients and what services to provide in practice.
- Because standing was not established, the court did not reach the merits of the beneficiaries’ statutory or regulatory claims.

## Legal Principles

- Article III standing requires (1) injury in fact, (2) a causal connection (fair traceability) between the injury and the defendant’s conduct, and (3) a likelihood that the requested relief will redress the injury.
- When the plaintiff’s injury depends on the conduct of independent third parties not before the court, standing requires more than speculation that a government directive will change those third parties’ behavior in a way that fixes the plaintiff’s injury.
- A request for injunctive relief compelling an agency to police private actors fails redressability where the court cannot say it is likely that increased enforcement would cause those private actors to provide the requested services to the plaintiffs.

## Conclusion

Johnson v. Becerra held that Medicare beneficiaries who alleged they could not obtain adequate home health aide services from private HHAs lacked Article III standing to seek an injunction ordering HHS to increase enforcement of Medicare participation and nondiscrimination requirements, because the asserted causal chain depended on how independent HHAs would respond and the requested relief was not shown likely to result in the beneficiaries receiving the services they sought.


Johnson v. Becerra, 111 F.4th 1237 (2024)