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J.K. v. Eden

J.K. v. Eden challenged Arizona's failure to provide mental health services to poor children, resulting in a landmark settlement reforming the state's behavioral healthcare system for children.

"The settlement is groundbreaking," said Ira Burnim, legal director of the Bazelon Center for Mental Health Law, one of the advocacy groups that represents the plaintiffs. "It is the first to overhaul a state mental health system that operates on a managed care basis." The agreement is also unique in its approach to reform, he explained, because it spells out in a legal document a "vision" defining the purpose of children's behavioral health services and a set of 12 principles for improving the quality of those services, to be incorporated in all aspects of the system's operations.

The "Arizona Vision" is a fundamental shift in the way the state treats families and children who seek mental health treatment. It emphasizes respect for and partnership with families and children in the planning, delivery and evaluation of services, and stresses collaboration among the various agencies that serve children, with the goal of enabling children "to achieve success in school, live with their families, avoid delinquency and become stable and productive adults."

The settlement committed the state to a series of concrete steps, including the development of flexible wraparound supports and case management, child and family teams for all children, training and coaching for frontline staff and supervisors, a quality assurance program that measures fidelity to the principles, and specific improvements in the structure of the managed care arrangement. It anticipated implementation over six years, and obliged the state to move "as quickly as is practicable" to make needed changes.

While progress has been made under the settlement agreement, the state did not move as quickly as it committed. In January 2006, the plaintiffs invoked the dispute-resolution provisions of the settlement agreement because of the state’s lack of sufficient progress. In November 2006, state officials agreed to a three-year extension of the terms of the settlement agreement and of federal court supervision.

Since the extension, the state has developed several implementation initiatives, including the Meet Me Where I Am Campaign (focusing on access to flexible wraparound supports and providing to 30% of enrolled children intensive case managers with an average caseload of 15 children) and using the Wraparound Fidelity Index (WFI) as part of the state's quality management system.

History of the J.K. Lawsuit

The J.K. lawsuit was originally filed in federal district court in 1991 by a father who had been unable to obtain services for his son. When the managed care system refused to provide the treatment recommended by professionals, the boy ran away from home, attempted suicide and was ultimately admitted to a psychiatric hospital.

In 1993, the court certified it as a class action on behalf of all Arizona

children seeking Medicaid mental health services and held the state responsible for the actions of the private companies with which it contracted for managed behavioral healthcare. Two years later the court upheld the children's right to due process protections notice and a hearing when behavioral health services are reduced or cut off.

A crisis came in 1997 when ComCare, the managed care contractor in Maricopa County (population 3.8 million), declared bankruptcy and the Department of Health Services, the state's mental health authority, had to take over the county's system. The resulting publicity drew attention to the inadequacy of children's services, and the parties to the lawsuit agreed to commission an evaluation of services provided in Maricopa County, which includes the city of Phoenix.

Both the initial evaluation in 1998 and a follow-up review completed in April 2000 were conducted by a team headed by Dr. Ivor Groves. The team found "a wide gap between the basic standard of care expected ...and the level of performance observed." The team determined that about half of the children in the program had not received required behavioral health services and that the system's performance was poorest for children with the most serious problems. Up to 3,500 of the children have complex needs, the experts reported, because their caretakers have disabilities, they are involved with the child welfare or juvenile justice system, or they have co-occurring disabilities, such as emotional disturbance and mental retardation or addiction. The study called for a "fundamental reassessment" of the children's managed behavioral healthcare program and made recommendations.

The court stayed the litigation in 1998, giving the health department and the lawyers for the children time to develop a negotiated solution. During the same period, the Groves team reviewed programs in the rest of the state.