          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
             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).


                                          - 2 -
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.


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