United States Court of Appeals

For the First Circuit

No. 15–1745

RIO GRANDE COMMUNITY HEALTH CENTER, INC., ET AL.,

Plaintiffs, Appellees,

v.

HON. ANA RÍUS ARMENDÁRIZ,

SECRETARY OF THE DEPARTMENT OF HEALTH OF THE COMMONWEALTH OF 

PUERTO RICO,

Defendant, Appellant.

ON APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

[Hon. Gustavo A. Gelpí, Jr., U.S. District Judge] 

Before

Lynch, Kayatta, and Thompson,

Circuit Judges.

Margarita Mercado-Echegary, Solicitor General, and Susana I. 

Peñagarícano-Brown, Assistant Solicitor General, on brief for 

appellant.

James L. Feldesman, Robert A. Graham, Nicole M. Bacon, and 

Feldesman Tucker Leifer Fidell LLP, on brief for appellee. 

July 7, 2015
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PER CURIAM. After a decade of litigation over the 

Commonwealth of Puerto Rico's failure to make "wraparound"

payments under federal Medicaid law, 42 U.S.C. § 1396a(bb), the 

district court entered an order compelling the payment of amounts 

due plaintiffs according to a lawful, prospective injunction.1 

When the defendant failed to make those payments in accord with 

the terms of the order, and after exhausting efforts to secure 

defendant's voluntary compliance, the district court entered 

additional orders, one directed to the Commonwealth-owned 

Government Development Bank of the Commonwealth of Puerto Rico

(attaching funds held on behalf of the Commonwealth's Treasury 

Department), and a second directed to the president of that bank 

(ordering her to issue a check for the amount due plaintiffs). 

The defendant has appealed those orders. In connection with that 

appeal, she asks that we stay the district court orders that are 

the subject of the appeal. We initially issued a brief, temporary 

stay so that we could consider the merits of the stay motion. For 

 

1 This protracted litigation has reached the First Circuit 

six prior times. See Consejo de Salud v. Gonzalez-Feliciano, 695 

F.3d 83 (1st Cir. 2012); Concilio de Salud Integral de Loíza, Inc.

v. Pérez-Perdomo, 625 F.3d 15 (1st Cir. 2010); Concilio de Salud 

Integral de Loiza, Inc. v. Pérez-Perdomo, 551 F.3d 10 (1st Cir.

2008); Dr. José S. Belaval, Inc. v. Pérez-Perdomo, 488 F.3d 11 

(1st Cir. 2007); Dr. José S. Belaval, Inc. v. Pérez-Perdomo, 465 

F.3d 33 (1st Cir. 2006); Rio Grande Cmty. Health Ctr., Inc. v. 

Rullan, 397 F.3d 56 (1st Cir. 2005). 
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the following reasons, we now dissolve that temporary stay and 

deny the motion to stay.

The defendant must make the following four showings to secure 

a stay: "(1) a strong showing that [it] is likely to succeed on 

the merits, (2) a showing that unless a stay is granted [it] will 

suffer irreparable injury, (3) a showing that no substantial harm 

will come to the other interested parties, and (4) a showing that 

a stay will do no harm to the public interest." Ainsworth 

Aristocrat Intern. Pty. v. Tourism Co., 818 F.2d 1034, 1039 (1st 

Cir. 1987). 

In an effort to make these required showings, the 

defendant argues that the orders violate the Eleventh Amendment. 

We have already rejected such an argument, albeit in dictum, in 

this very litigation. See Concilio de Salud Integral de Loiza, 

Inc. v. Perez-Perdomo, 625 F.3d 15, 19–20 & n.4 (1st Cir. 2010) 

("[O]nly if the state were disobeying a forward-looking court order

to make such payments could a violation of that order be redressed 

by a federal court remedial directive to make payments to comply 

with the preexisting order.") (emphasis in original) (citing Frew 

ex rel. Frew v. Hawkins, 540 U.S. 431, 440 (2004); Hutto v. Finney, 

437 U.S. 678, 690–91 (1978)); Concilio de Salud Integral de Loiza, 

Inc. v. Perez-Perdomo, 551 F.3d 10, 18 n.8 (1st Cir. 2008) ("Any 

claims for past non-compliance with the district court's 

preliminary injunction, though claims for monies due, are also not 
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barred by the Eleventh Amendment."). While we reserve final 

decision until we rule on the appeal, we easily find now that the 

defendant is not likely to change our preliminary view. As the 

Supreme Court observed in Hutto, "the principles of federalism 

that inform Eleventh Amendment doctrine surely do not require 

federal courts to enforce their decrees only by sending high state 

officials to jail. The less intrusive power to impose a fine is 

properly treated as ancillary to the federal court's power to 

impose injunctive relief." 437 U.S. at 691. These orders on 

appeal would seem to represent actions more modest and less 

intrusive in their effect than the fines and imprisonment expressly 

blessed in Hutto.

The defendant also argues that Commonwealth law does not 

allow attachment of Commonwealth funds, and that the district court 

under Federal Rule of Civil Procedure 69 can only attach funds to 

execute on a monetary judgment in the manner allowed for by 

Commonwealth law. Whether this is so we need not decide. Rather, 

we need only observe that it is not likely that the court's 

inherent powers in aid of enforcing its orders for prospective 

payments are limited in this manner by Rule 69. See, e.g., Spain

v. Mountanos, 690 F.2d 742, 744–45 (9th Cir. 1982) (noting the 

district court's "plenary power to enforce its commands").

We also acknowledge the extreme financial distress in 

which the Commonwealth finds itself. That distress, however, at 
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least without action by Congress, would not seem to justify a 

failure to comply with a lawful order, especially where the 

district court has been so patient in enforcing its order.2

For the aforementioned reasons, we dissolve the temporary 

stay of the district court's orders that we entered on June 23, 

2015, and we deny defendant's motion to stay those orders pending 

the resolution of any appeal from the orders.

So ordered. 

 

2 Regarding the Commonwealth's claim of irreparable harm, to 

the extent the Commonwealth accessed estimated matching funds from 

the federal government for the relevant quarter pursuant to 42 

U.S.C. § 1396b(d) and 45 C.F.R. § 201.5(c), being compelled to put 

those funds to their intended use -- Medicaid expenses -- can 

hardly be classified as causing irreparable harm.