Tri-Cities Holdings v. Tenn. Health Servs. ( 2018 )


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  •                NOT RECOMMENDED FOR FULL-TEXT PUBLICATION
    File Name: 18a0097n.06
    Nos. 17-5628/6046
    UNITED STATES COURT OF APPEALS
    FOR THE SIXTH CIRCUIT
    TRI-CITIES HOLDINGS LLC et al.,               )
    FILED
    Feb 28, 2018
    )
    Plaintiffs-Appellants,                                          DEBORAH S. HUNT, Clerk
    )
    v.                                            )
    )
    TENNESSEE ADMINISTRATIVE PROCEDURES )                      ON APPEAL FROM THE
    DIVISION     et    al.   (17-5628); TENNESSEE )            UNITED STATES DISTRICT
    HEALTH SERVICES AND DEVELOPMENT )                          COURT FOR THE EASTERN
    AGENCY et al. (17-6046),                      )            DISTRICT OF TENNESSEE
    )
    Defendants-Appellees.                  )
    )                    OPINION
    Before: MOORE, THAPAR, and LARSEN, Circuit Judges.
    KAREN NELSON MOORE, Circuit Judge. This consolidated appeal caps a trilogy of
    federal lawsuits brought by the would-be owner and operator of a methadone1 clinic in Johnson
    City, Tennessee, on behalf of itself and several prospective clients, under the Americans with
    1
    “Methadone is the oldest FDA-approved medication for treating opioid dependence.”
    Barbara Andraka-Christou, What Is “Treatment” for Opioid Addiction in Problem-Solving
    Courts?, 13 STAN. J. C.R. & C.L. 189, 221 (2017). The synthetic drug—a substitute for more
    baneful opioids—“works by activating opioid receptors in the brain” so as to “prevent[]
    cravings,” ward off withdrawal symptoms, and “prevent[] a sense of euphoria or a ‘high’ if a
    person abuses heroin or painkillers while undergoing methadone treatment.” 
    Id. At the
    same
    time, “[m]ethadone can be dangerous if diverted and improperly used,” 
    id., and a
    2012 report
    found that methadone was “involved in one third of [opioid-pain-reliever]-related overdose
    deaths,” despite comprising less than two percent of opioid-pain-reliever prescriptions, CENTERS
    FOR DISEASE CONTROL & PREVENTION, Vital Signs: Risk for Overdose from Methadone Used for
    Pain Relief—United States, 1999–2010, 61 MORBIDITY & MORTALITY WEEKLY REP. 493, 493–
    94 (2012) [hereinafter “Risk for Overdose”]. Both methadone users and clinics set up to serve
    them have standing to bring suits like this one. See MX Grp., Inc. v. City of Covington, 
    293 F.3d 326
    , 335–36 (6th Cir. 2002).
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Disabilities Act (“ADA”), 42 U.S.C. § 12101 et seq., and the Rehabilitation Act of 1973 (“RA”),
    29 U.S.C. § 794. The primary Plaintiff-Appellant is Tri-Cities Holdings (“TCH”), a Georgia
    corporation, and the other Plaintiffs-Appellants have been anonymized as John and Jane Does.2
    The Defendants-Appellees are Tennessee state and local government actors who, in one way or
    another, stood in the way of TCH’s efforts to open the proposed clinic. For the reasons that
    follow, we AFFIRM the district court’s grant of summary judgment to all defendants.
    I. BACKGROUND
    A. State and Local Laws Governing the Establishment of Methadone Clinics
    Perhaps unsurprisingly, Tennessee regulates the establishment of medical-services
    providers. An entity seeking to set up “any type of health care institution” must first obtain a
    “certificate of need” (“CON”) from the state’s Health Services and Development Agency
    (“HSDA”) through a vote of its eleven-member board (all of whom are defendants-appellees
    here). See Tenn. Code Ann. §§ 68-11-1604, -1607(a). Before it goes to the HSDA, however, a
    CON application is reviewed by one of three state departments, who both check the application’s
    claims and evaluate the application under three statutorily inscribed criteria: need, economic
    feasibility, and contribution “to the orderly development of adequate and effective health care
    facilities or services.” See § 68-11-1609(b); TCH III R. 15-1 (Review of CON Application at
    2
    For simplicity, we refer to Plaintiffs-Appellants collectively as “TCH,” distinguishing
    only where relevant.
    2
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    2) (Page ID #131).3 In the case of a methadone clinic, the evaluator is the state’s Department of
    Mental Health and Substance Abuse Services (“DMHSAS”) (another defendant-appellee here).
    All CON applicants are required to give some general notice of their intentions: they
    must file a “letter of intent” and then publish that letter “in a newspaper of general circulation in
    the proposed service area of the project.” 
    Id. § 68-11-1607(c)(1).
    But there is an additional
    notice requirement that applied specifically to would-be methadone clinics at the time of TCH’s
    CON application and that now applies to any “nonresidential substitution-based treatment center
    for opiate addiction.” 
    Id. § 68-11-1607(c)(9)(A);
    2015 Tenn. Pub. Acts, ch. 505.4 This extra
    provision requires that any such applicant also mail notice to a handful of local elected officials,
    including the relevant municipality’s mayor. Tenn. Code Ann. § 68-11-1607(c)(9)(A).
    A CON applicant may request that the HSDA hold a public hearing prior to its vote.
    Tenn. Code Ann. § 68-11-1608(b). “[A] local governing body” may, upon request, “participate
    in” that hearing “and express support or opposition,” although such “testimony . . . shall be
    informational and advisory” only. 
    Id. § 68-11-1624.5
    If a CON application is denied, the
    applicant may appeal to a state administrative law judge (“ALJ”). 
    Id. § 68-11-1610.
    3
    Because this consolidated case includes two district court records, we use “TCH II” or
    TCH III” before each record citation unless context makes clear which one is being referenced.
    4
    The methadone-specific version of this provision was codified at Tenn. Code Ann. § 68-
    11-1607(c)(3). There is no suggestion that the Tennessee legislature’s slight broadening of the
    provision, which may reflect the ascendancy of newer forms of treatment, affects this case.
    5
    At the time of TCH’s CON application, Tenn. Code Ann. § 68-11-1624 applied only to
    “a hearing conducted by the agency for a nonresidential substitution-based treatment center for
    opiate addiction,” but it now applies to any CON application hearing. 2015 Tenn. Pub. Acts, ch.
    505.
    3
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Johnson City also regulates the establishment of methadone clinics within city limits,
    which may be located only in areas zoned “MS-1.” TCH II R. 41-5 (Johnson City Zoning
    Requirements at 96–97) (Page ID #864–65). The ordinance in operation when TCH sought a
    CON also required that such clinics, among other requirements, (1) have first obtained a CON;
    (2) “not be located within two hundred (200) feet of a school, day-care facility, or park”;
    (3) operate only between 7:00 AM and 8:00 PM; and (4) “be located on” and provide “primary
    access . . . from an arterial street.” TCH II R. 44-1 (Old Ordinance) (Page ID #1821–22).6
    B. Tri-Cities I, TCH’s CON Application, and Tri-Cities II
    TCH’s first federal lawsuit, Tri-Cities Holdings LLC et al. v. Johnson City et al. (“Tri-
    Cities I”), No. 2:13-cv-108, challenged Johnson City’s zoning ordinances and argued that
    various city defendants (all of whom are also defendants-appellees here7) had violated the ADA
    and RA by refusing to issue necessary permits to TCH. TCH II R. 19-3 (Tri-Cities I Compl.)
    (Page ID #468–70). The district court dismissed that suit on June 12, 2013, on ripeness grounds.
    TCH II R. 19-1 (Tri-Cities I Dist. Ct. Op. & Order at 8–10) (Page ID #465). The district court
    reasoned that, in light of the absence of a CON, it was “virtually impossible . . . to determine any
    likelihood that the harm alleged by plaintiffs will ever come to pass,” and moreover there was
    “minimal hardship on the parties” to delay adjudication until TCH obtained a CON. 
    Id. at 8–9
    6
    In 2015, Johnson City revised its ordinance, apparently eliminating the regulations on
    hours of operation and distance from other types of properties while retaining its requirement
    that a CON be obtained and presented. TCH II R. 214-7 (New Ordinance) (Page ID #6039–41).
    7
    For simplicity, we refer to these defendants-appellees collectively as “Johnson City.”
    4
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    (Page ID #463–64). The district court accordingly entered a judgment of dismissal without
    prejudice. TCH II R. 19-2 (Tri-Cities I J.) (Page ID #467). TCH did not appeal.
    TCH filed a second federal lawsuit, Tri-Cities Holdings LLC et al. v. Tenn. Health Servs.
    & Dev. Agency et al. (“Tri-Cities II”), No. 3:13-cv-669,8 which is one of the two cases in this
    consolidated appeal (No. 17-6046), after the HSDA denied TCH’s CON application by a vote of
    3–6–1 after a lengthy public hearing on June 26, 2013, TCH III R. 31-3 (Tr. of CON Application
    Hr’g at 3, 197) (Page ID #1021, 1215). In addition to HSDA board members and staff, the
    attendees included a range of community members, including local political leaders, as well as a
    minister, several doctors, at least one educator, and a nurse. See 
    id. at 5
    (Page ID #1023). The
    hearing began with HSDA General Counsel Jim Christoffersen advising participants not to base
    their decisions on any Johnson City zoning issues in light of the unresolved litigation and then
    reading aloud a letter from TCH’s attorney, James Dunlap, asking that, were the application to be
    denied, “the applicant be provided all reasonable accommodations or modifications to any and
    all applicable rules and requirements necessary to enable its application to be approved, as
    required by the ADA and the RA.”9 
    Id. at 9
    (Page ID #1027).
    8
    This suit, filed in the Middle District of Tennessee, was ultimately transferred to the
    Eastern District of Tennessee as Tri-Cities Holdings LLC v. Tenn. Health Servs. & Dev. Agency,
    No. 2:13-cv-305.
    9
    This was one of many functionally identical requests that Dunlap made to the various
    state and local entities involved in this case for “reasonable accommodations or modifications”
    to state and local policies in order to allow TCH to open its clinic. See, e.g., TCH III R. 31-3 (Tr.
    of CON Application Hr’g at 197) (Page ID #1215); TCH III R. 15-5 (Dunlap Letter to HSDA at
    1–3) (Page ID #484–86); TCH III R. 15-6 (Dunlap Letter to ALJ Summers at 1) (Page ID #504).
    5
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Some of the hearing’s discussion focused on DMHSAS’s eighteen-page report, which the
    department had submitted about two weeks prior. TCH III R. 15-1 (Review of CON Application
    at 1) (Page ID #130). DHMSAS had concluded that it could not “support approval of the
    application because” two of the three statutory criteria—need, economic feasibility, and
    contribution to the orderly development of healthcare—“ha[d] not been met.” 
    Id. at 4
    (Page ID
    #133). While observing that economic feasibility, “ha[d] possibly been established,” 
    id. at 6
    (Page ID #135), the report stated that need for this particular type of facility “ha[d] not been
    clearly established,” 
    id. at 5
    (Page ID #134), and that “[t]he project [would] not contribute to the
    orderly development of healthcare,” 
    id. at 6
    (Page ID #135).
    Those who spoke in favor of TCH’s application at the hearing, meanwhile, tended to
    emphasize the hardship of requiring people seeking methadone treatments to travel dozens of
    miles away. See TCH III R. 31-3 (Tr. of CON Application Hr’g at 26–27, 34–35, 39) (Page ID
    #1044–45, 1052–53, 1057). Others who were skeptical or opposed questioned the efficacy and
    safety of methadone when compared against other substitution-based treatments—chiefly a
    newer synthetic drug called buprenorphine10—that were already readily available, see 
    id. at 43–
    10
    Emergent since its approval by the FDA in 2002, buprenorphine (often known by the
    brand name Suboxone) likewise “prevents . . . withdrawals,” “cravings,” and “a ‘high’ from any
    additional opioid used.” 
    Andraka-Christou, supra, at 224
    . “The opioid ingredient in
    buprenorphine,” however, “is significantly less potent than in methadone, so buprenorphine is
    significantly less likely to be abused and rarely causes an overdose.” 
    Id. Accordingly, buprenorphine
    has been characterized by at least some researchers and doctors as a “much safer
    option,” with “significant harm reduction qualities” and very limited risk of overdose. See Alan
    Gordon & Alexandra A. Gordon, Does It Fit?—A Look at Addiction, Buprenorphine, and the
    Legislation Trying to Make It Work, 12 J. HEALTH & BIOMEDICAL L. 1, 10–11 & nn. 50, 54
    (2016) (describing comparative safety of buprenorphine and citing sources).
    6
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    49, 51, 54–56, 59–60, 73–75, 141, 147–48, 168–69, 180–81) (Page ID #1061–67, 1069, 1072–
    74, 1077–78, 1091–93, 1159, 1165–66, 1186–87, 1198–99), and the quality of the facility that
    TCH’s 50% owner and chief executive, Steven Kester, could be expected to establish, see 
    id. at 5
    0–52, 60–70, 79–80, 105–08, 119–23, 130–31, 137–39, 151–53, 166–67, 169–71 (Page ID
    #1068–70, 1078–88, 1097–98, 1123–26, 1137–41, 1148–49, 1155–57, 1169–71, 1184–85, 1187–
    89). Two parents, for example, discussed their son’s death from a methadone overdose in North
    Carolina. 
    Id. at 75
    (Page ID #1093). “[A] board-certified internal medicine physician,” medical-
    school professor, and associate chief of staff at local VA hospital, 
    id. at 6
    0–62 (Page ID #1078–
    80), meanwhile, castigated Kester’s track record and summed up his objections bluntly:
    “Mr. Kester is asking the State to provide a certificate for him to open a pill mill that will hurt far
    more people than it helps,” 
    id. at 70
    (Page ID #1088).
    More spoke against the proposal than spoke for it. Those speaking against the proposal
    included a person named Jerry Taylor, speaking “on behalf of Johnson City,” 
    id. at 42
    (Page ID
    #1060), as well as Johnson City’s mayor, who was also a practicing oral surgeon, 
    id. at 5
    3, 56
    (Page ID #1070, 1073). None of the speakers said anything derogatory about people struggling
    with addiction problems or denied the need for effective treatment of opioid addiction.
    On July 8, 2013, approximately two weeks after the HSDA board voted to deny TCH’s
    application, TCH filed Tri-Cities II. In addition to raising again its zoning claims against
    Johnson City from Tri-Cities I, TCH this time also sued the HSDA, challenging both the statute
    governing the CON process and the HSDA’s denial of TCH’s CON application, which TCH
    7
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    alleged constituted both intentional discrimination and a failure to make a reasonable
    modification.11 TCH II R. 1 (Compl.) (Page ID #3–4, 59–71).
    C. TCH’s Administrative Appeal and Tri-Cities III
    Later that July, TCH appealed the HSDA’s denial of its CON application through the
    state’s administrative process. See TCH III R. 15-12 (Order Revoking Permission at 1) (Page ID
    #548). TCH argued that its pending federal lawsuit, however, had the potential to render the
    state administrative process unnecessary, and so Dunlap asked ALJ Kim Summers (another
    defendant-appellee here), for a stay, which ALJ Summers granted. 
    Id. at 2
    (Page ID #549). ALJ
    Summers scheduled conference calls for the parties to check in, and Dunlap requested another
    stay in September, which ALJ Summers again granted. 
    Id. On January
    8, with another conference call looming, ALJ Summers emailed the parties
    and asked if there were “any new developments to report.” TCH III R. 69-6 (Email Chain) (Page
    ID #2154). Dunlap responded: “No new developments. Motion for Summary Judgement [sic]
    and Motions to Dismiss are pending. I would suggest another 60 day stay in our matter.” 
    Id. The problem,
    as others saw it, was that there was something to report: just a few weeks
    before, the magistrate judge to whom Tri-Cities II had been assigned had issued a scathing order,
    chastising TCH for “a transparent attempt to explain away rather obvious judge-shopping” and
    an argument that trod “perilously close to being offensive,” TCH III R. 31-5, Ex. F (Magistrate’s
    Order at 2–4) (Page ID #1293–95), while suggesting that the district court would very likely
    11
    TCH also raised state-law claims, TCH II R. 1 (Compl.) (Page ID #67–70), which are
    not at issue on appeal.
    8
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    deem Tri-Cities II subject to the same ripeness problems that had felled Tri-Cities I, 
    id. at 5
    –6
    (Page ID #1296–97). The HSDA’s general counsel, Christoffersen, soon emailed ALJ Summers
    to dispute Dunlap’s account, TCH III R. 69-6 (Email Chain) (Page ID #2154), and subsequently
    filed a motion to set a hearing in the administrative appeal, attaching the magistrate judge’s
    order, see TCH III R. 31-5 (Motion to Set Hr’g) (Page ID #1226–28, 1292–97).
    A few days later, Dunlap filed an objection to the HSDA’s motion. TCH III R. 15-10
    (Objection to Motion to Set Hr’g at 1, 21) (Page ID #521, 541). In its opening section, he wrote:
    In filing its Motion to Set Hearing, HSDA is attempting to make this
    tribunal the “fixer” by illegally providing HSDA cover in what amounts to its
    blatant violations of the [ADA]. HSDA is facing a virtually certain loss in federal
    court . . . for its blatant violations of the ADA . . . . HSDA also faces a pending
    investigation, and a seemingly imminent enforcement action against it, by the
    United States Department of Justice. Petitioner suggests that HSDA would love
    nothing more than to have this tribunal “enter the fight,” create a diversion, and
    take the heat off HSDA and somehow “fix” HSDA’s unfixable position. . . .
    In addition, if this tribunal does “take HSDA’s bait” and takes any action
    to decide this appeal before a federal court or DOJ has spoken on this case,
    including scheduling a hearing, Petitioner respectfully indicates that it will have
    no choice but to join Your Honor, in an official capacity, and this tribunal, as
    defendants in the pending federal court action.
    Finally, Petitioner respectfully submits that, under the ADA, Your Honor
    and this tribunal are required to offer Petitioner a reasonable modification to allow
    the CON to be issued. Petition [sic] respectfully submits that Your Honor’s and
    this tribunal’s continuing failure to do this creates a cause of action that Petitioner
    may bring against Your Honor, and the tribunal itself, and may well move DOJ to
    include Your Honor and this tribunal as respondents in an ADA enforcement
    action.
    
    Id. at 3–4
    (Page ID #523–24).
    On March 14, 2014, ALJ Summers revoked Dunlap’s permission to appear pro hac vice.
    TCH III R. 15-12 (Order Revoking Permission at 1, 4) (Page ID #548, 551). In her order, ALJ
    9
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Summers detailed Dunlap’s conduct and concluded that his “coercion and misrepresentations are
    a flagrant attempt to improperly influence a judge in violation of Rules 3.3 [candor],
    3.5 [improper influence], and 8.4 [misconduct] of the Tennessee Rules of Professional Conduct,
    as well as Tenn. Code Ann. § 39-14-112 [extortion].” 
    Id. at 10
    (Page ID #557).
    That revocation prompted TCH’s third federal lawsuit, Tri-Cities Holdings LLC v. Tenn.
    Admin. Procedures Div. et al. (“Tri-Cities III”), No. 2:14-cv-233, which is the other case in this
    consolidated appeal (No. 17-5628). In Tri-Cities III, TCH named as defendants ALJ Summers,
    DMHSAS, and a range of related state actors and entities (all of whom are defendants-appellees
    here).    TCH alleged that all involved had violated the ADA and RA by failing to make
    reasonable modifications, and it alleged further that ALJ Summers and related state entities had
    violated those statutes by retaliating against Dunlap in revoking his pro hac vice admission.12
    TCH III R. 1 (Compl.) (Page ID #1, 4, 40–57). The district court stayed that case on October 28
    while TCH pressed various appeals. TCH III R. 50 (Dist. Ct. Order) (Page ID #1399–1400).
    D. TCH’s Appeals and Summary Judgment in the District Court
    None of TCH’s appeals was fruitful. The Tennessee Chancery Court affirmed ALJ
    Summers’s revocation of Dunlap’s admission. TCH III R. 51 (Chancery Ct. Op. at 1, 27) (Page
    ID #1401, 1427). The Tennessee Court of Appeals affirmed the Chancery Court’s ruling, Tri-
    Cities Holdings LLC v. Tenn. Health Servs. & Dev. Agency, No. M2015-00058-COA-R3-CV,
    12
    TCH also raised federal and state due-process claims that it later dismissed. TCH III R.
    87 (Notice of Dismissal at 1–2) (Page ID #2462–63). Those claims are thus not at issue here.
    10
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    
    2016 WL 721067
    (Tenn. Ct. App. Feb. 22, 2016), and the Tennessee Supreme Court denied
    TCH permission to appeal that affirmance, TCH III R. 58 (Order at 1) (Page ID #1592).
    Our court, meanwhile, ruled that we lacked jurisdiction to review the denial of TCH’s
    motion for partial summary judgment in Tri-Cities II. Tri-Cities Holdings LLC v. Tenn. Health
    Servs. & Dev. Agency, 598 F. App’x 404, 408 (6th Cir. 2015). We also affirmed denial of
    TCH’s motion for a preliminary injunction in that case, noting that the district court had deemed
    TCH’s claims unripe and concluding that TCH had “not shown any error in that conclusion.” 
    Id. Ultimately, on
    August 15, 2016, TCH moved to dismiss its administrative appeal
    “because it was unable to obtain an extension of its lease option” for its proposed methadone-
    clinic site and could not find any “other financially viable locations for a clinic.” TCH III R. 72-
    2 (Pet.’s Mot. to Dismiss Appeal at 1) (Page ID #2282). Around the same time, the HSDA
    granted a CON for “a joint venture owned equally by Mountain States Health Alliance and East
    Tennessee State University Research Foundation” to establish a methadone clinic in the Johnson
    City area. TCH II R. 214-9 (Tr. of MSHA CON Application Hr’g at 8, 82) (Page ID #6057,
    6131). The parties agree that this new clinic opened in September 2017. TCH II Appellants’ Br.
    at 5 n.4; TCH II Johnson City Appellees’ Br. at 49.
    In October 2016, TCH appeared before the district court in Tri-Cities II, at which point
    the district court addressed a motion by TCH to file a third amended complaint and a motion
    from a third Jane Doe plaintiff to intervene. R. 251 (Hr’g Tr. at 3, 12) (Page ID #6965, 6974).
    The district court ultimately denied both motions, and it also lifted stays that been granted in
    both Tri-Cities II and Tri-Cities III. R. 205 (Dist. Ct. Order) (Page ID #5447); TCH III R. 62
    11
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    (Dist. Ct. Order) (Page ID #1607). The parties then moved for summary judgment in both cases,
    and the district court granted summary judgment for all defendants in each. TCH III R. 86 (Dist.
    Ct. Op. & Order) (Page ID #2433–34); TCH II R. 246 (Dist Ct. Op. & Order at 1–3) (Page ID
    #6878–80). These now-consolidated appeals followed.
    II. DISCUSSION
    On appeal, TCH argues that the following claims of intentional discrimination13 under the
    ADA and RA ought to have survived summary judgment: (1) that Johnson City imposed a
    facially invalid ordinance and sought to exclude methadone clinics, including TCH’s proposed
    clinic, prior to the CON hearing; (2) that Johnson City discriminated against TCH by attempting
    to prevent it from securing a CON; (3) that the HSDA discriminated against TCH in denying it a
    CON; (4) that the Tennessee statute requiring methadone clinics to provide special notice to local
    officeholders is facially discriminatory; (5) that all defendants failed to provide TCH with a
    reasonable modification of existing policies; and (6) that ALJ Summers and the related
    Tennessee defendants retaliated against TCH for engaging in protected activity by revoking
    Dunlap’s pro hac vice admission. TCH also argues (7) that the district court erred in denying its
    motion to file a third amended complaint and Jane Doe #3’s motion to intervene. For the reasons
    that follow, we AFFIRM the district court on all grounds.
    13
    TCH also adverts in its briefing to “disparate impact of discrimination.” TCH II
    Appellants’ Br. at 18. But it did not make this argument below, and we therefore “decline[] to
    consider on appeal arguments that were not presented to the district court.” Fawkes v.
    JPMorgan Chase Bank, N.A., 645 F. App’x 453, 454 (6th Cir. 2016) (citation omitted).
    12
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    A. Standard of Review
    “We review de novo a district court’s grant of summary judgment.” Williams v. AT&T
    Mobility Servs. LLC, 
    847 F.3d 384
    , 391 (6th Cir. 2017). Summary judgment is to be granted “if
    the movant shows that there is no genuine dispute as to any material fact and the movant is
    entitled to judgment as a matter of law.” FED. R. CIV. P. 56(a). “A genuine dispute of material
    fact exists ‘if the evidence is such that a reasonable jury could return a verdict for the nonmoving
    party.’” 
    Williams, 847 F.3d at 391
    (quoting Anderson v. Liberty Lobby, Inc., 
    477 U.S. 242
    , 248
    (1986)). “In reviewing the district court’s decision to grant summary judgment, we must view
    all evidence in the light most favorable to the nonmoving party.” Kleiber v. Honda of Am. Mfg.,
    Inc., 
    485 F.3d 862
    , 868 (6th Cir. 2007) (citing Matsushita Elec. Indus. Co. v. Zenith Radio Corp.,
    
    475 U.S. 574
    , 587 (1986)).
    B. The ADA and the RA
    “Title II of the ADA mandates that, ‘no qualified individual with a disability shall, by
    reason of such disability, be excluded from participation in or be denied the benefits of the
    services, programs, or activities of a public entity, or be subjected to discrimination by any such
    entity.’” Johnson v. City of Saline, 
    151 F.3d 564
    , 569 (6th Cir. 1998) (quoting 42 U.S.C.
    § 12132).   “Section 504 of the Rehabilitation Act provides that ‘[n]o otherwise qualified
    individual with a disability . . . shall, solely by reason of her or his disability, be excluded from
    the participation in, be denied the benefits of, or be subjected to discrimination under any
    program or activity receiving Federal financial assistance.’” McPherson v. Michigan High Sch.
    Athletic Ass’n, 
    119 F.3d 453
    , 459 (6th Cir. 1997) (en banc) (quoting 29 U.S.C. § 794(a)). “[T]he
    13
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    two statutes are quite similar in purpose and scope,” such that “[t]he analysis of claims under the
    [ADA] roughly parallels those brought under the [RA].” 
    Id. at 4
    59–60 (citation omitted).
    Where, as here, the “differences in the two statutes are not implicated . . . in the issues presented
    in [a] case”—or, indeed, raised by the parties at all—“we need not address them.” See 
    id. at 460.
    Under the ADA, the term “public entity” is a broad one: it encompasses “any State or
    local government,” as well as “any department, agency, special purpose district, or other
    instrumentality of a State or States or local government.”          42 U.S.C. § 12131(1)(A)–(B).
    Discrimination by a public entity against a qualified individual “must relate to services,
    programs, or activities,” a definition that we have understood to “encompass[] virtually
    everything that a public entity does,” 
    Johnson, 151 F.3d at 569
    , while noting that it is
    nevertheless “subject . . . to the bounds of reasonableness,” 
    id. at 5
    71.        Under regulations
    promulgated by the Attorney General pursuant to Congress’s instructions, see Olmstead v. L.C.
    ex rel. Zimring, 
    527 U.S. 581
    , 591 (1999); see also 42 U.S.C. § 12134(a), public entities must
    also “make reasonable modifications in policies, practices, or procedures when the modifications
    are necessary to avoid discrimination on the basis of disability, unless the public entity can
    demonstrate that making the modifications would fundamentally alter the nature of the service,
    program, or activity,” 28 C.F.R. § 35.130(b)(7)(i).
    Claims of intentional discrimination under the ADA follow “the familiar burden-shifting
    analysis established by [McDonnell Douglas Corp. v. Green, 
    411 U.S. 792
    (1973)].” Anderson
    v. City of Blue Ash, 
    798 F.3d 338
    , 356 (6th Cir. 2015) (punctuation omitted) (quoting Turner v.
    City of Englewood, 195 F. App’x 346, 353 (6th Cir. 2006)). As we have explained:
    14
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    To establish a prima facie case of intentional discrimination under Title II
    of the ADA, a plaintiff must show that: (1) she has a disability; (2) she is
    otherwise qualified; and (3) she was being excluded from participation in, denied
    the benefits of, or subjected to discrimination under the program because of her
    disability. In other words, the plaintiff must show that the defendant took action
    because of the plaintiff’s disability, i.e., the plaintiff must present evidence that
    animus against the protected group was a significant factor in the position taken
    by the municipal decision-makers themselves or by those to whom the decision-
    makers were knowingly responsive. Further, the plaintiff must show that the
    discrimination was intentionally directed toward him or her in particular.
    
    Id. at 357
    (footnote, citations, and quotation marks omitted). “Once a plaintiff establishes a
    prima facie case of discrimination, the defendant ‘must then offer a legitimate, nondiscriminatory
    reason for its’ challenged action.” 
    Id. (quoting Sjostrand
    v. Ohio State Univ., 
    750 F.3d 596
    , 599
    (6th Cir. 2014)). If the defendant produces such an explanation, the plaintiff “must then present
    evidence allowing a jury to find that the [defendant’s] explanation is a pretext for unlawful
    discrimination.” 
    Id. (quoting Sjostrand
    , 750 F.3d at 599).
    C. Issue 1: Issue Preclusion and the Tri-Cities I Claims
    The first cluster of claims on which TCH appeals matches its claims from Tri-Cities I:
    essentially, that Johnson City’s zoning regulations in effect at the time of its CON application
    were facially discriminatory and reflected a broader effort by Johnson City to exclude TCH (and
    other, similar facilities) from its city limits. See TCH II Appellants’ Br. at 2–3, 6–7, 20–22.
    Johnson City argues (as the district court held) that the legal question of whether these claims are
    ripe for adjudication is subject to issue preclusion based on Tri-Cities I. See TCH II Johnson
    City Appellees’ Br. at 11–12; TCH II R. 246 (Dist. Ct. Op. & Order at 1-15) (Page ID #6878–
    92). Inexplicably, TCH barely mentions the district court’s issue-preclusion ruling and offers
    15
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    essentially no legal argument as to why issue preclusion does not apply. See TCH II Appellants’
    Br. at 22–23 (providing eight conclusory lines of text and citing one opinion as authority).
    As we have repeatedly made clear, “addressing an issue on appeal ‘requires developed argument;
    a party is required to do more than advert to an issue in a perfunctory manner.’” Puckett v.
    Lexington-Fayette Urban Cty. Gov’t, 
    833 F.3d 590
    , 611 (6th Cir. 2016) (quoting Bolden v. City
    of Euclid, 595 F. App’x 464, 468 (6th Cir. 2014)); see also, e.g., Gerboc v. ContextLogic, Inc.,
    
    867 F.3d 675
    , 681–82 (6th Cir. 2017).          TCH’s argument is indeed so perfunctory and
    undeveloped as to be forfeited.
    Regardless, however, Johnson City has the better of the dispute. As we have explained:
    Issue preclusion, often referred to as collateral estoppel, “precludes relitigation of
    issues of fact or law actually litigated and decided in a prior action between the
    same parties and necessary to the judgment, even if decided as part of a different
    claim or cause of action.” Four requirements must be met before issue preclusion
    applies: “(1) the precise issue must have been raised and actually litigated in the
    prior proceedings; (2) the determination of the issue must have been necessary to
    the outcome of the prior proceedings; (3) the prior proceedings must have resulted
    in a final judgment on the merits; and (4) the party against whom estoppel is
    sought must have had a full and fair opportunity to litigate the issue in the prior
    proceeding.”
    Georgia-Pac. Consumer Prod. LP v. Four-U-Packaging, Inc., 
    701 F.3d 1093
    , 1098 (6th Cir.
    2012) (citations omitted). Here, the question of whether TCH’s claims against Johnson City’s
    zoning regulations and allegedly exclusionary posture toward methadone clinics were ripe was
    clearly litigated during Tri-Cities I, and the resolution of that question was necessary to (indeed,
    determined) the outcome of that case. See TCH II R. 19-1 (Tri-Cities I Dist. Ct. Op. & Order)
    (Page ID #456–65). Those proceedings resulted in a final judgment dismissing the action on the
    16
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    merits, TCH II R. 19-2 (Tri-Cities I J.) (Page ID #467), which TCH could have appealed but did
    not. See Robert N. Clemens Tr. v. Morgan Stanley DW, Inc., 
    485 F.3d 840
    , 845–46 (6th Cir.
    2007) (explaining that dismissal of an action constitutes a final and appealable order, in contrast
    to dismissal only of a complaint, which would present only an opportunity to amend and refile).
    And TCH had “a full and fair opportunity to litigate the issue,” Georgia-Pac. Consumer 
    Prod., 701 F.3d at 1098
    , in Tri-Cities I. Issue preclusion applies.
    D. Issue 2: Johnson City’s Effect on the CON Process
    TCH also argues that the district court erred in granting summary judgment on TCH’s
    claims that Johnson City violated the ADA and RA by seeking to prevent TCH from obtaining a
    CON, both at the CON hearing itself and by withholding zoning approval. See, e.g., TCH II
    Appellants’ Br. at 2, 9, 11–12, 17–18. Though logically distinct from those governed by the
    district court’s prior ripeness determination in Tri-Cities I, and thus not subject to issue
    preclusion, TCH has arguably forfeited these arguments by failing to raise them in its
    complaints. But even assuming for the sake of argument that TCH properly presented its
    arguments to the district court through its pleadings at the summary-judgment stage, see Vencor,
    Inc. v. Standard Life & Acc. Ins. Co., 
    317 F.3d 629
    , 641 n.11 (6th Cir. 2003); TCH II, R. 213
    (Pls.’ Mem. in Support of Motion for Summary J. at 8–11) (Page ID #5518–21), summary
    judgment was proper on the merits. That is because, to succeed in its intentional discrimination
    claims, TCH must first (among other requirements) “present evidence that animus against the
    protected group was a significant factor in the position taken by the municipal decision-makers
    17
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    themselves or by those to whom the decision-makers were knowingly responsive.” 
    Anderson, 798 F.3d at 357
    (quoting Turner, 195 F. App’x at 353). It has not met this bar.
    For one, Johnson City had a right under state law to participate in the CON hearing. See
    Tenn. Code Ann. § 68-11-1624 (making clear that “a local governing body” may “participate in”
    a CON hearing “and express support or opposition to the granting of a certificate of need to the
    applicant”). The ADA, of course, trumps state law, see U.S. CONST. art. VI, cl. 2, and whether
    such a rule itself violates the ADA is a separate question implicated below.            But TCH’s
    suggestion that Johnson City manifested animus by showing up to offer its opinion is clearly
    vitiated by the fact that Johnson City was invited by statute to do exactly that.
    TCH also maintains that Johnson City’s expression of these views violated the
    “integration mandate” of Olmstead v. L.C. ex rel. Zimring, 
    527 U.S. 581
    (1999). TCH II
    Appellants’ Br. at 11. But this authority does little to support TCH’s case. After all, Olmstead
    does not require that a locality support every single application for necessary permits by a
    corporation seeking to serve disabled persons. Rather, it simply holds that “placement of persons
    with mental disabilities in community settings rather than in institutions” is required under the
    ADA “when the State’s treatment professionals have determined that community placement is
    appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the
    affected individual, and the placement can be reasonably accommodated, taking into account the
    resources available to the State and the needs of others with mental disabilities.” 
    Olmstead, 527 U.S. at 587
    . TCH has not put forward nearly enough evidence to create a genuine issue of
    material fact as to whether Johnson City has run afoul of that more nuanced rule.
    18
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Meanwhile, TCH’s argument that “state entities enjoy no Free Speech Clause Rights,”
    see TCH II Appellants’ Br. at 18, is at best highly misleading, as even the portion of a Supreme
    Court opinion that TCH cites makes clear. See Columbia Broad. Sys., Inc. v. Democratic Nat’l
    Comm., 
    412 U.S. 94
    , 139 & n.7 (1973) (Stewart, J., concurring); see also Walker v. Sons of
    Confederate Veterans, Inc., 
    135 S. Ct. 2239
    , 2246 (2015) (“[A]s a general matter, when the
    government speaks it is entitled to promote a program, to espouse a policy, or to take a
    position.”); Pleasant Grove City v. Summum, 
    555 U.S. 460
    , 467 (2009) (“A government entity
    has the right to ‘speak for itself.’” (citation omitted)). Johnson City does not have a right to
    discriminate, to be sure, but it did have a right to express its nondiscriminatory views.
    Nor does Johnson City’s zoning ordinance appear to have been intended to affect (nor
    does it appear to have affected) TCH’s CON application itself. As noted above, Christoffersen
    urged HSDA board members not to take zoning into account in determining their votes, TCH III
    R. 31-3 (Tr. of CON Application Hr’g at 8) (Page ID #1026), and there is no evidence in the
    record to the contrary. Similarly, TCH’s claim that “TDMHSAS issued a negative report that
    TCH had only ‘possibly established economic feasibility,’ in part because Johnson City had
    refused TCH zoning approval based on its discriminatory zoning ordinance,” TCH II Appellants’
    Br. at 9 (quoting TCH II R. 214-4 (Review of CON Application at 5–7) (Page ID #6012–14)), is
    at best highly confused.     First of all, “economic feasibility” was TCH’s best score in the
    DMHSAS report: DMHSAS rated that factor “possibly . . . established,” whereas it found both
    need and “contribut[ion] to the orderly development of healthcare” lacking. See TCH II R. 214-4
    (Review of CON Application at 5–7) (Page ID #6012–14). So it is odd for TCH to suggest that
    19
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    any harm to its economic-feasibility rating made a difference, when two other factors that it
    neglects to mention revealed bigger red flags. But even more importantly, the reason that
    DMHSAS found TCH’s economic feasibility only possibly established was not because of
    zoning, but rather because TCH’s application was missing “requested documentation.” 
    Id. at 5
    (Page ID #6012). And while the DMHSAS report does mention the zoning issue under “orderly
    development of healthcare,” all that it observes there is that TCH has not yet “provide[d] a
    current letter from the City of Johnson City that the proposed site meets zoning requirements”
    and that “the Applicant has requested zoning variances.” 
    Id. at 7
    (Page ID #6014). While doing
    so, the report also notes a bevy of other problems, including TCH’s lack of “existing agreements
    and affiliations,” its lack of “letters of support” from “local universities and professional
    societies,” the lack of information about whether it can meet its proposed “staffing
    requirements,” and the lack of clarity from its responses as to “whether [TCH] is fully aware of
    and understands the complexity of all federal, Tennessee, and local laws, regulations, rules, and
    ordinances” involved in its undertaking. 
    Id. at 6–7
    (Page ID #6013–14). In short, the report
    does not help TCH’s case.
    Perhaps most importantly, the record of the CON hearing itself does not disclose the
    “wide-spread community animus,” TCH III Appellants’ Br. at 12, against opioid-addicted
    persons that TCH claims. Such cases certainly do exist: in MX Group, Inc. v. City of Covington,
    
    293 F.3d 326
    (6th Cir. 2002), for example, we affirmed a judgment for a methadone clinic after
    it had its zoning permit revoked following substantial and suspicious public opposition—
    including an assistant police chief testifying, without supporting evidence, about supposed crime
    20
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    risks associated with methadone clinics, 
    id. at 329–30—and
    where, after that, the city passed a
    zoning amendment that “completely foreclosed” the clinic’s “opportunity to locate in the city,”
    
    id. at 331.
    But that is not this case. Instead, as is already clear, the record here is devoid of
    animus against people struggling with addiction, and instead principally reflects two kinds of
    permissible skepticism unrelated to disability: first, skepticism that methadone is better than
    buprenorphine (which was already plentifully available), and second, skepticism about Kester
    and the type of operation that he was likely to lead.14 We express no view on whether either vein
    of skepticism was ultimately correct; what matters is that there is no evidence that either was
    motivated by (or, for that matter, used to conceal) animus against the protected group.15
    TCH seeks to avoid this conclusion by picking out two quotes from the hearing that,
    divorced from context, understandably give pause. The first quote is an HSDA board member’s
    having characterized Johnson City’s response as “staunch opposition in this particular area to
    this kind of treatment.” See TCH III R. 31-3 (Tr. of CON Application Hr’g at 186) (Page ID
    #1204). But closer inspection belies the significance that TCH ascribes to this quote. For one,
    the quote clearly refers to an apparent preference for a different kind of treatment—
    buprenorphine—which, as already discussed, is hardly a smoking gun for animus.               And
    14
    Kester himself seems to have recognized this trend in the testimony. See TCH III R.
    31-3 (Tr. of CON Application Hr’g at 174) (Page ID #174) (stating that he had refrained from
    defending himself against charges of “being a terrible, rotten person and a terrible, rotten
    operator”).
    15
    The former strain of skepticism, we note, is at least empirically justifiable. See
    
    Andraka-Christou, supra, at 221
    , 224; Gordon & 
    Gordon, supra, at 10
    –11 & nn. 50, 54; Risk for
    
    Overdose, supra, at 493
    –94. And the latter is at least consistent with the fact that there now is,
    as TCH acknowledges, a methadone clinic in the Johnson City area. See TCH II R. 214-9 (Tr. of
    MSHA CON Application Hr’g at 82) (Page ID #6131); TCH II Appellants’ Br. at 5 n.4.
    21
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    moreover, TCH’s quotation omits the end of the sentence, which, reproduced in full, reads:
    “I see it really as a staunch opposition in this particular area to this kind of treatment, and also,
    obviously, opposition to the provider themselves.” 
    Id. at 186
    (Page ID #1204). As likewise
    discussed, the record amply supports the accuracy of this second clause.
    The other snippet that TCH carves out is even more misleading. “At the CON hearing,”
    TCH states in its brief, “a Johnson City Press news story was read aloud quoting a Johnson City
    Commissioner, saying ‘We want the applicant to get the message methadone clinics are not
    welcome in Johnson City.’” TCH II Appellants’ Br. at 10; TCH III Appellants’ Br. at 12. If this
    were in fact telling evidence, there might well be a genuine dispute of material fact. But, for one,
    the full quote makes clear that the news story in question was more than a decade old and
    unrelated to the CON application at issue. See TCH III R. 31-3 (Tr. of CON Application Hr’g at
    84–85) (Page ID #1102–03). Second, the attendee who chose to read this outdated and largely
    irrelevant quote into the record was not a city participant or disinterested onlooker, but rather
    Kester himself. 
    Id. A plaintiff
    (or, in this case, its agent and partial owner) cannot avert
    summary judgment by “manufactur[ing] a genuine issue of material fact” in this way. See
    Brenneman v. MedCentral Health Sys., 
    366 F.3d 412
    , 420 (6th Cir. 2004). This claim fails.
    E. Issue 3: The HSDA’s Denial of a CON
    In light of the foregoing, the question of whether the HSDA violated the ADA in denying
    TCH’s CON application can be dealt with more briefly. The public benefit that TCH sought
    here was a CON. In making available a public benefit, like a CON, state actors are not required
    to ensure that each applicant accrues purely “equal results from the provision of the benefit.”
    22
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    See Jones v. City of Monroe, 
    341 F.3d 474
    , 479 (6th Cir. 2003); see also Alexander v. Choate,
    
    469 U.S. 287
    , 302–03 (1985). Rather, as noted above, it is TCH’s burden to “present evidence
    that animus against the protected group was a significant factor in the” board’s decision to
    withhold a CON. See 
    Anderson, 798 F.3d at 357
    (quoting Turner, 195 F. App’x at 353).
    As the preceding discussion helps make clear, TCH has failed to present such evidence.
    None of the participants in the CON meeting, let alone any of the HSDA board members,
    expressed animus against disabled persons or the entities that serve them. Rather, as already
    discussed, the participants primarily expressed skepticism about methadone as a treatment as
    compared against other types of already-available treatments (chiefly buprenorphine), and
    skepticism about Kester and his business model. Nor does the DMHSAS report on which the
    board relied reveal any discriminatory animus, but rather a sober, lengthy analysis of the
    relevant, statutorily prescribed factors. See Tenn. Code Ann. §§ 68-11-1608(a), -1609(b), -1614;
    TCH III R. 15-1 (Review of CON Application) (Page ID #130–47).
    TCH’s allegations of discriminatory intent on HSDA’s part are also difficult to square
    with Kester’s own declaration that other, similar clinics had received CONs and were “operating
    in other parts of Tennessee,” TCH II R. 46 (Kester Decl. at 3 ¶ 16) (Page ID #3010), as well as
    with the HSDA’s having granted a CON for a methadone clinic in the Johnson City area
    specifically, TCH II R. 214-9 (Tr. of MSHA CON Application Hr’g at 8, 82) (Page ID #6057,
    6131). All of which makes sense, given that the HSDA is a statewide board, quite possibly
    created to avoid the not-in-my-backyard-type dangers that more local review could conceivably
    invite.
    23
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    Even if TCH could make out a prima facie case, it would fail at step three of the
    McDonnell Douglas framework for the reasons just discussed. The reasons provided by the
    DMHSAS and the HSDA members plainly qualify as “legitimate” and “nondiscriminatory,” and
    TCH has wholly failed to “present evidence allowing a jury to find that the [defendants’]
    explanation is a pretext for unlawful discrimination.” See 
    Anderson, 798 F.3d at 357
    (quoting
    
    Sjostrand, 750 F.3d at 599
    ). Summary judgment was correct here too.
    F. Issue 4: The Tennessee Notice Rule
    TCH also appeals the district court’s grant of summary judgment against its claims that
    Tenn. Code Ann. § 68-11-1607(c)(9)(A)—the “Notice Rule” formerly codified at § 68-11-
    1607(c)(3)—violates the ADA and RA. See TCH II Appellants’ Br. at 14–15. TCH argues that
    this requirement burdens “applicants serving the disabled” (here, people addicted to opioids) and
    “operates to galvanize local opposition to treatment for the disabled.” 
    Id. at 6.
    The HSDA
    argues instead that, as the district court held, the statute does “not impose any burden . . . [that]
    would, in any way, disadvantage TCH in receiving a CON,” TCH II HSDA Appellees’ Br. at 17
    (quoting R. 246 (Dist. Ct. Op. & Order at 23) (Page ID #6900)), and that nothing in the “current”
    or “historical record” shows that the notice requirement generates the kind of vociferous
    opposition that TCH asserts, TCH II HSDA Appellees’ Br. at 18–19.
    Though it is a close case, we think that summary judgment was proper. To establish a
    prima facie case, TCH must present evidence that disabled persons were “excluded from
    participation in, denied the benefits of, or subjected to discrimination” by the statute. See
    
    Anderson, 798 F.3d at 357
    . The scope of these protections is broad, but it is also “subject . . . to
    24
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    the bounds of reasonableness.” 
    Johnson, 151 F.3d at 571
    . We have accordingly ruled in the past
    that a plaintiff lacked grounds for a claim under the ADA where any harm asserted was truly de
    minimis. See Robinson v. Corr. Corp. of Am., 14 F. App’x 382, 383 (6th Cir. 2001).
    This is a low bar, but it is one that TCH has failed to meet given the evidence that it has
    offered here. The notice requirement does not add cognizably to the burdens that all CON
    applicants face, given that nothing but bare notice is required, see Tenn. Code Ann. §68-11-
    1607(9)(A), and all applicants must file “letter[s] of intent” and then publish these letters “in a
    newspaper of general circulation in the proposed service area of the project” anyway, 
    id. § 68-
    11-1607(c)(1). Any additional burden, in other words, appears to be so vanishingly small that
    we cannot say that there was, in fact, any kind of exclusion, deprivation, or discrimination.
    In so deciding, we pause to note how limited our ruling here is. After all, classifications
    that appear to treat people with disabilities differently raise serious concerns under the ADA and
    RA. See 42 U.S.C. § 12132; Sch. Bd. of Nassau Cty. v. Arline, 
    480 U.S. 273
    , 287 (1987) (noting
    the RA’s “goal of protecting handicapped individuals from deprivations based on prejudice,
    stereotypes, or unfounded fear”). Were the differences here more extreme, summary judgment
    could well be inappropriate. Cf. New Directions Treatment Servs. v. City of Reading, 
    490 F.3d 293
    , 304–05 (3d Cir. 2007) (ruling that zoning law seriously restricting placement of methadone
    clinics violates ADA); MX 
    Grp., 293 F.3d at 345
    (agreeing that a “blanket prohibition of all
    methadone clinics from [an] entire city is discriminatory on its face”); Potomac Grp. Home
    Corp. v. Montgomery Cty., 
    823 F. Supp. 1285
    , 1296 (D. Md. 1993) (deeming facially invalid,
    under the Fair Housing Amendments Act, a notice requirement directing any “prospective
    25
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    provider of group home services to the elderly” both to “notify neighbors and civic
    organizations” about future disabled residents and to “invite [those] neighbors to comment”).
    Moreover, our ruling is especially narrow because TCH has failed to present any
    evidence that the notice provision at issue did or generally does operate to generate opprobrium.
    While it is conceivable that such a provision could operate to generate discriminatory opposition,
    the record here is devoid of any such evidence. And uncontroverted evidence in the record
    actually indicates that TCH’s assertions are “not supported by the historical record,” which
    instead “reveals instances in which public officials neither supported nor opposed such
    applications,” and “at least two . . . applications [that] were supported by elected public officials
    to whom the applicants were required to provide notice.” R. 90 (Hill Decl. at 3 ¶ 7) (Page ID
    #3407). On the record that TCH developed here, with all justifiable inferences made in TCH’s
    favor, we affirm the district court’s grant of summary judgment.
    G. Issue 5: Failure to Make a Reasonable Modification
    TCH also appeals the district court’s rejection of TCH’s argument that it was denied
    reasonable modifications of existing policies that would have enabled its CON application to be
    granted. See TCH II Appellants’ Br. at 25–27; TCH III Appellants’ Br. at 16. It levels this
    argument in essentially every possible direction: at Johnson City for not modifying its zoning
    regulations; at the HSDA for not modifying its application of the CON criteria; at DMHSAS for
    not modifying its interpretation of the CON criteria; and even at ALJ Summers (and related state
    defendants) for not modifying her adjudication of TCH’s claims. TCH also argues that these
    26
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    various defendants impermissibly failed to provide an explanation of why such a modification
    was not required. See TCH II Appellants’ Br. at 27; TCH III Appellants’ Br. at 17–22.
    The Johnson City branch of this multidirectional claim can be dealt with quickly, in that
    it is not analytically distinct from the issues already deemed unripe (and then not appealed) in
    Tri-Cities I. See TCH II R. 19-1 (Tri-Cities I Dist. Ct. Op. & Order) (Page ID #456–65).
    Because that prior determination has issue preclusive effect, this branch of TCH’s claim fails.
    TCH’s claims against DMHSAS and ALJ Summers can also be dealt with fairly quickly.
    As noted above, discrimination by a public entity against a qualified individual “must relate to
    services, programs, or activities.” 
    Johnson, 151 F.3d at 569
    . While we have understood that
    “phrase” to “encompass[] virtually everything that a public entity does,” 
    id., it does
    not cover
    everything that is in any way related to a given government function, because the requirement
    itself is “subject . . . to the bounds of reasonableness.” See 
    id. at 5
    71. Thus, the scope of a
    benefit cannot be so “amorphous” as to sweep in protection against all possible outcomes, see
    
    Choate, 469 U.S. at 303
    , or liability for all possible government actors, cf. Bowers v. Nat’l
    Collegiate Athletic Ass’n, 
    9 F. Supp. 2d 460
    , 485 (D.N.J. 1998) (noting that “it would be odd to
    saddle someone with liability for a certain discriminatory condition . . . when it is not that person
    who manages, controls, or regulates . . . that particular condition” and questioning “what relief
    could [even] be obtained from someone who has no power to effect a remedy for the violation”).
    Here, DMHSAS and ALJ Summers are not responsible for granting or denying CON
    applications. Rather, they are responsible, respectively, for preparing a report for the HSDA that
    checks a CON application’s claims and evaluates that application in light of statutorily
    27
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    determined factors, see Tenn. Code Ann. §§ 68-11-1608(a), -1609(b), -1614; TCH III R. 15-1
    (Review of CON Application) (Page ID #130–47), and for adjudicating contested CON
    application decisions, see Tenn. Code Ann. § 68-11-1610.           While these defendants were
    certainly required to discharge those responsibilities in a nondiscriminatory fashion, they were
    not in charge of the CON application program itself. As a matter of law, therefore, they were not
    responsible for providing a reasonable modification to that program.16
    That leaves the HSDA itself, which is responsible for granting or denying CON
    applications. As noted above, public entities must “make reasonable modifications in policies,
    practices, or procedures when the modifications are necessary to avoid discrimination on the
    basis of disability, unless the public entity can demonstrate that making the modifications would
    fundamentally alter the nature of the service, program, or activity.” 28 C.F.R. § 35.130(b)(7)(i);
    see also, e.g., 
    Jones, 341 F.3d at 480
    . “The public entity bears the burden of proving that the
    accommodation would fundamentally alter the program.”17 
    Jones, 341 F.3d at 480
    .
    “In cases involving waiver of applicable rules and regulations, the overall focus should be
    on ‘whether waiver of the rule in the particular case would be so at odds with the purposes
    16
    ALJ Summers is also, as the state defendants note, TCH III Appellees’ Br. at 20 n.12,
    absolved of any damages for another reason: judicial immunity. See Mireles v. Waco, 
    502 U.S. 9
    , 11–12 (1991); Dixon v. Clem, 
    492 F.3d 665
    , 674 (6th Cir. 2007).
    17
    TCH’s argument that the state defendants have run afoul of this rule by failing to offer
    “specific facts showing any costs of a modification or their rules,” TCH II Appellants’ Br. at 28,
    misunderstands what we have required of defendants. It is true, to be sure, that a district court
    errs if, at a pre-discovery stage, it “merely accept[s] [a] defendant’s affirmative defense without
    requiring facts and evidence to support it.” Hindel v. Husted, 
    875 F.3d 344
    , 347–48 (6th Cir.
    2017). But here at summary judgment we have a more-than-ample record to which to refer,
    particularly given that the question of whether the HSDA should be required to adjust the CON
    criteria is more abstract than a “typically fact-based” case. See 
    id. at 347.
    28
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    behind the rule that it would be a fundamental and unreasonable change.’” 
    Id. (quoting Dadian
    v. Village of Wilmette, 
    269 F.3d 831
    , 838–39 (7th Cir. 2001)). Accordingly, in a case in which a
    city had provided free “all-day and one-hour parking in specific locations” to encourage
    “downtown shopping and other downtown business activities,” 
    id. at 477–78,
    we ruled that a
    resident with a disability was not denied a reasonable modification when the city declined to
    allow her to park all day at one of the one-hour spots near her office, 
    id. 480. That
    was because,
    we explained, “[b]y its very nature, the benefit of one-hour free public parking cannot be altered
    to permit disabled individuals to park all day without jeopardizing the availability of spaces to
    other disabled and nondisabled individuals,” which would in turn vitiate “the rule itself.” 
    Id. This logic
    applies with stronger force here. As directed by the Tennessee legislature, the
    HSDA is responsible for applying neutral criteria to determine whether a given applicant is
    qualified to operate its proposed facility. See Tenn. Code Ann. § 68-11-1609. By their very
    nature, neither these criteria nor their application can be altered to provide a waiver to TCH
    without jeopardizing Tennessee’s interest in ensuring that healthcare institutions meet the non-
    discriminatory qualifications that its legislators and regulators have set. To require the HSDA or
    the state itself to give up its interest in ensuring that those qualifications are met by each aspiring
    provider would surely impose a fundamental alteration. See 
    Jones, 341 F.3d at 480
    .
    Moreover, waiver is especially likely to impose a fundamental alteration when the
    question of whether to grant such a waiver would require complex, “case-by-case assessments.”
    See 
    McPherson, 119 F.3d at 462
    ; see also Sandison v. Michigan High Sch. Athletic Ass’n,
    
    64 F.3d 1026
    , 1035 (6th Cir. 1995). Thus, where nineteen-year-old students with learning
    29
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    disabilities sought waiver of the state high school athletic association’s age requirement,
    
    Sandison, 64 F.3d at 1028
    , we reasoned that waiver of the age requirement would
    “fundamentally alter[]” that rule by vitiating its ability to ensure fair competition, 
    id. at 1035.
    Referencing the possibility that there would be no fundamental alteration because the plaintiffs
    were not “were not ‘star’ players,” 
    id. at 1029,
    we reasoned that it would be “an undue burden”
    to ask an athletic association to assess whether a particular candidate’s “average athletic skills
    . . . would . . . fundamentally alter the program,” given the number of complex variables
    involved. 
    Id. at 10
    35. “It is unreasonable,” we explained, “to call upon coaches and physicians
    to make these near-impossible determinations.” Id.; see also 
    McPherson, 119 F.3d at 462
    .
    Again, the logic of those precedents applies with stronger force here. The HSDA is not
    only responsible for deciding whether TCH qualifies for a CON, but also for deciding whether a
    host of applicants across the State of Tennessee qualify for CONs. Even if TCH, as it has
    steadfastly maintained, is worthy of a CON in some abstract sense that could be honored by
    adjusting the CON criteria, TCH offers no answer to how the HSDA ought to determine which
    CON applicants deserve to have the CON criteria adjusted in their favor and which do not. “It is
    unreasonable to call upon [the HSDA] to make these near-impossible determinations.”
    
    Sandison, 64 F.3d at 1035
    . We affirm summary judgment on this set of issues as well.
    30
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    H. Issue 6: Retaliation for Engaging in Protected Activity
    TCH presses one more charge under the ADA and RA on appeal: that ALJ Summers
    retaliated in violation of these statutes18 by revoking Dunlap’s pro hac vice admission. TCH III
    Appellants’ Br. at 26–29. The state defendants argue that the district court was correct to grant
    summary judgment to them for two independently sufficient reasons: first, because the issue of
    what caused the revocation is subject to preclusion based on TCH’s prior litigation in state court,
    and second, because TCH cannot establish sufficient proof that TCH’s engaging in protected
    activity motivated ALJ Summers’s adverse action. TCH III Appellees’ Br. at 24–29.
    We need not decide whether issue preclusion resolves this claim in its entirety; even if it
    does not, TCH has failed to provide sufficient proof of retaliatory motive. “Retaliation claims
    are also analyzed under the McDonnell Douglas framework where, as here, there is no direct
    evidence of retaliation.” Williams v. AT&T Mobility Servs. LLC, 
    847 F.3d 384
    , 396 (6th Cir.
    2017). As we have explained in an analogous context:
    The initial burden falls on Plaintiffs to present a prima facie case of retaliation.
    That requires them to establish that: (1) they engaged in activity protected under
    Section 504 and the ADA; (2) [the defendants] knew of this protected activity; (3)
    [the defendants] then took adverse action against Plaintiffs; and (4) there was a
    causal connection between the protected activity and the adverse action. “The
    burden of establishing a prima facie case in a retaliation action is not onerous, but
    one easily met.”
    A.C. ex rel. J.C. v. Shelby Cty. Bd. of Educ., 
    711 F.3d 687
    , 697 (6th Cir. 2013) (quoting Nguyen
    v. City of Cleveland, 
    229 F.3d 559
    , 563 (6th Cir. 2000)) (citations omitted). “If the plaintiff does
    18
    As with TCH’s preceding claims, in the absence of any argument against so doing and
    in keeping with precedent, we analyze TCH’s retaliation claims under the ADA and RA in
    tandem. See A.C. ex rel. J.C. v. Shelby Cty. Bd. of Educ., 
    711 F.3d 687
    , 696–97 (6th Cir. 2013).
    31
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    so, then the burden shifts to the employer to articulate a legitimate, nondiscriminatory reason for
    the adverse . . . action. The plaintiff must then show that the reason given . . . was actually a
    pretext designed to mask retaliation.”     
    Williams, 847 F.3d at 396
    (citation omitted).       “To
    establish pretext, a plaintiff must demonstrate ‘both that the [defendant’s] proffered reason was
    not the real reason for its action, and that the [defendant’s] real reason was unlawful.’” 
    Id. (quoting EEOC
    v. Ford Motor Co., 
    782 F.3d 753
    , 767 (6th Cir. 2015) (en banc)).
    Regardless of whether TCH could make out a prima facie case, TCH cannot satisfy step
    three of this analysis. At step two, the state defendants can clearly put forward a legitimate,
    nondiscriminatory reason for Dunlap’s expulsion: Dunlap’s unprofessional behavior. That, after
    all, was ALJ Summers’s stated reason for revoking Dunlap’s pro hac vice admission—that his
    “coercion and misrepresentations” violated three Tennessee Rules of Professional Conduct as
    well as, in her view, the Tennessee extortion statute. See TCH III R. 15-12 (Order Revoking
    Permission to Appear Pro Hac Vice at 10) (Page ID #557). And the Tennessee Court of Appeals
    ratified her conclusion regarding the three Tennessee Rules (while expressing no opinion on the
    extortion statute), deeming ALJ Summers’s decision “reasonable” and “consistent with a proper
    application of the controlling legal principles.” Tri-Cities Holdings, LLC v. Tenn. Health Servs.
    & Dev. Agency, No. M2015-00058-COA-R3-CV, 
    2016 WL 721067
    , at *10 (Tenn. Ct. App. Feb.
    22, 2016) (citation omitted), appeal denied (June 23, 2016). There is no cause to doubt this
    conclusion in light of the record, and, in any event, the Tennessee Court of Appeals’s ruling that
    ALJ Summers’s conclusions were reasonable does have issue-preclusive effect. See Georgia-
    Pac. Consumer 
    Prod., 701 F.3d at 1098
    .               So TCH must show that this legitimate,
    32
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    nondiscriminatory reason “was not the real reason for [ALJ Summers’s] action, and that [her]
    real reason was” Dunlap’s pressing ADA and RA claims. See Ford Motor 
    Co., 782 F.3d at 767
    .
    Though plaintiffs can rely on “temporal proximity” to meet their “causal burden” at the
    prima facie stage, see, e.g., A.C. ex rel. 
    J.C., 711 F.3d at 699
    , “temporal proximity cannot be the
    sole basis for finding pretext,” Ford Motor 
    Co., 782 F.3d at 767
    (quoting Donald v. Sybra, Inc.,
    
    667 F.3d 757
    , 763 (6th Cir. 2012)). In other words, TCH must point to at least some other
    evidence that Dunlap’s violations of the Tennessee Rules of Professional Conduct were “not the
    real reason that” ALJ Summers revoked his pro hac vice admission, “and that unlawful
    retaliation” for Dunlap’s pressing ADA claims “in fact was.” See 
    id. TCH has
    failed to do so. TCH rests its case essentially on one piece of ALJ Summers’s
    justification: that Dunlap’s behavior amounted to extortion in violation of Tenn. Code Ann.
    § 39-14-112. See TCH III Appellants’ Br. at 26. This statement by ALJ Summers indeed
    appears to have been overreaction, as the Tennessee appellate court’s decision seems to suggest
    by negative inference. But the question here is not whether one of ALJ Summers’s justifications
    was an overreaction, but rather whether ALJ Summers’s explanation as a whole was mere
    pretext to conceal a retaliatory motive. See, e.g., Bryson v. Regis Corp., 
    498 F.3d 561
    , 572 (6th
    Cir. 2007).   Because TCH has failed to provide any other evidence that ALJ Summers’s
    revocation of Dunlap’s admission had anything to do with retaliatory animus, summary
    judgment was proper.
    33
    No. 17-5628/6046 Tri-Cities Holdings LLC et al. v. Tenn. Admin. Procedures Div. et al.
    I. Issue 7: TCH’s Motion to File a Third Amended Complaint and Jane Doe #3’s Motion
    to Intervene
    That leaves one final set of procedural questions: was the district court wrong to deny
    TCH’s motion to file a third amended complaint and Jane Doe #3’s motion to intervene? In one
    conclusory paragraph, TCH says yes, citing only Federal Rule of Civil Procedure 15(a)(2).
    “This perfunctory attempt at argument waives this claim.” 
    Gerboc, 867 F.3d at 681
    –82.
    III. CONCLUSION
    The opioid-addiction crisis in the United States is serious, as are the mandates of the
    ADA and RA. Fortunately, despite TCH’s claims to the contrary, the record in this case does not
    indicate a lack of seriousness on the various defendants’ part with regard to either, particularly in
    light of Johnson City’s revisions to its zoning code and the recent opening of a methadone clinic
    in the area. Instead, the record reveals permissible skepticism with regard to TCH’s proposed
    methods and with regard to TCH’s leadership. We AFFIRM the district court’s grant of
    summary judgment to all defendants.
    34