CARLA FREW; CHARLOTTE GARVIN, as next friend of her minor children Johnny Martinez, Brooklyn Garvin and BreAnna Garvin; CLASS MEMBERS; NICOLE CARROLL, Class Representative, Plaintiffs - Appellants
KYLE JANEK, Commissioner of the Texas Health and Human Services Commission in his official capacity; KAY GHAHREMANI, State Medicaid Director of the Texas Health and Human Services Commission in her official capacity, Defendants - Appellees
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Appeal from the United States District Court for the Eastern District of Texas.
For CARLA FREW, CHARLOTTE GARVIN, as next friend of her minor children Johnny Martinez, Brooklyn Garvin and BreAnna Garvin, CLASS MEMBERS, NICOLE CARROLL, Class Representative, NICOLE CARROLL, Class Representative, Plaintiffs - Appellants: Timothy Borne Garrigan, Stuckey, Garrigan & Castetter Law Offices, Nacogdoches, TX; Jane K. Swanson, Law Offices of Jane K. Swanson, Austin, TX.
For KYLE JANEK, Commissioner of the Texas Health and Human Services Commission in his official capacity, Defendant - Appellee: J. Campbell Barker, Deputy Solicitor General, Office of the Attorney General, Office of the Solicitor General, Austin, TX; James Byron Eccles, Esq., Deputy Assistant Attorney General, Office of the Attorney General, General Litigation Division, Austin, TX.
For KAY GHAHREMANI, State Medicaid Director of the Texas Health and Human Services Commission in her official capacity, Defendant - Appellee: Scott A. Keller, Solicitor, Office of the Solicitor General, Austin, TX; J. Campbell Barker, Deputy Solicitor General, Office of the Attorney General, Office of the Solicitor General, Austin, TX; James Byron Eccles, Esq., Deputy Assistant Attorney General, Office of the Attorney General, General Litigation Division, Austin, TX.
Before JOLLY, WIENER, and CLEMENT, Circuit Judges.
WIENER, Circuit Judge:
This appeal arises from the district court's termination of several provisions of a consent decree and the dissolution of a related corrective action order pursuant to the first clause of Federal Rule of Civil Procedure 60(b)(5)--that the judgment has been " satisfied, released, or discharged." Plaintiffs represent a class of Texas children eligible for Medicaid's Early and Periodic Screening, Diagnosis, and Treatment program (" EPSDT" or " the Program" ). They concluded a consent decree (the " Decree" ) with various Texas state officials (" Defendants" ) in 1996 to make improvements to Texas's implementation of the Program. In 2007, the parties agreed on a corrective action order to resolve Plaintiffs' concerns with one part of the Decree. Defendants, believing their obligations to be satisfied, have now moved to dissolve that order and the associated Decree provisions under Rule 60(b)(5). The district court granted their motion. We affirm.
I. Facts and Proceedings
A. Past Proceedings
This action began in 1993 when Plaintiffs, representatives of a class of over 1.5 million Texas children eligible for EPSDT, sued Defendants under 42 U.S.C. § 1983 for violations of federal Medicaid law in the state's implementation of the Program. As noted, the parties concluded a consent decree in 1996 in which Defendants promised to implement a number of changes, among which was a training program for participating health care providers. A few years later, after little progress had been made, the district court found Defendants in violation of the Decree (" Frew I " ). We reversed, solely on Defendants' challenge to the Decree's validity under the Eleventh Amendment (" Frew II " ). The Supreme Court then reversed Frew II (" Frew III " ).
In Frew III, the Court noted that Defendants' legitimate concerns over the Decree's potential to " undermine the sovereign interests and accountability of state governments" were not properly addressed to the Eleventh Amendment but to the district court's power, under Rule 60(b)(5), to grant relief " if 'it is no longer equitable that the judgment should have prospective application.'"  The Court reiterated the " flexible standard" for modification of institutional-reform consent decrees found in Rufo v. Inmates of Suffolk County Jail  and urged district courts to return the " responsibility for discharging the State's obligations" promptly to state officials once " the objects of the decree have been attained." 
On remand, we returned the case to the district court (" Frew IV " ). Defendants moved to dissolve the Decree under
Rule 60(b)(5)'s third clause, claiming that its continued enforcement would be inequitable. The district court, applying Rufo and Frew III, denied their motion, and we affirmed (" Frew V " ).
Back in the district court, the parties agreed on eleven corrective action orders, each aimed at bringing Defendants into compliance with a specific portion of the Decree. CAO 637-8, the order at issue in this appeal, implemented ¶ ¶ 124--30 of the Decree, which concerned deficiencies in Medicaid-participating pharmacies' understanding of EPSDT. All eleven orders were entered into the record in 2007.
B. Consent Decree ¶ ¶ 124--30 and CAO 637-8
1. Consent Decree ¶ ¶ 124--30
The 78-page Decree is organized into 308 paragraphs, of which only 7 are involved in this appeal. Paragraphs 124--30 form one subsection of a larger section that calls for a variety of training initiatives for healthcare providers. Of these 7 paragraphs, 2 mandate that Defendants perform specific actions:
129. By January 31, 1996, Defendants will implement an initiative to effectively inform pharmacists about EPSDT, and in particular about EPSDT's coverage of items found in pharmacies. The effort will include presentations at meetings of the Texas Pharmaceutical Association and other appropriate organizations, if possible, articles in the TPA newsletter, if possible, and at least one mail out to all pharmacists who participate in the Medicaid program. The mail out will be designed to attract pharmacists' attention, explain ...