Full opinion text
ORDER JUSTICE, Senior District Judge. Defendants’ Rule 60(b) Motion for Relief From Judgment (Docket No. 406) has been presented for adjudication. Background and Procedural History Filed on September 1, 1993, this civil action concerns the alleged failure of the State of Texas to implement a Medicaid program that assures that indigent • children and youth receive timely, comprehensive health care. The action was brought by a class of more than one and one-half million indigent children in Texas who are entitled to health benefits through the Early Periodic Screening, Diagnosis and Treatment (“EPSDT”) program. See Docket No.. 1, 93; see also 42 U.S.C. §§ 1396a(a)(43), 1396d(r). In Texas, the program is referred to as “Texas Health Steps,” which is administered jointly by the federal government and the Texas. Health and Human Services Commission. EPSDT is intended to be “the nation’s largest preventive health program for children.” H.R. 3299, 101st Cong. § 4213 (1989). It is “among the most important programs that the Texas Department of Health runs.” Docket No. 133 at 8 (internal quotes omitted). The purpose of the EPSDT program is to ensure that poor children receive comprehensive health care at an early age, in order that they will develop fewer health problems as they grow older. EPSDT is designed to provide health education, preventive care, and effective follow-up care for conditions identified during check-ups. Preventive health care identifies health problems that may respond to early treatment but, if left untreated, may instead lead to serious health conditions. For example, a heart murmur detected during an EPSDT screening, if untreated, could lead to heart failure. Severe anemia, if untreated, could result in behavioral problems and reduced mental capacity. Other important components of the EPSDT program' include immunizations, parental education, assistance with scheduling appointments, transportation assistance, and coordination of EPSDT and other programs serving Medicaid-eligible children. After two years of extensive negotiation following the filing of this case, the parties proposed the Consent Decree to the Court in July of 1995. During a fairness hearing held in December of that year, the parties urged the Court to approve the proposed decree. The Court approved the Consent Decree as fair,, reasonable, and adequate on February 16, 1996. Docket No. 135. Per the agreement of the parties, the Consent Decree expressly retains the Court’s jurisdiction to rectify violations of its terms, and provides a mechanism to invoke this jurisdiction. On November 10, 1998, Plaintiffs filed their first Motion- to Enforce Consent Decree. Docket No. 208. After nearly a year and a half of discovery and jurisdictional challenges, the Court held a hearing in March of 2000 on Plaintiffs’ motion (the “2000 Hearing”). Evidence was presented on multiple issues, including, inter alia: (1) proper implementation of the outreach program and delivery of required outreach reports; (2) operation of the State’s managed care system; (3) Defendants’ operation of toll-free numbers; and (4) provision of case management to all class members who need it, statewide. In a lengthy memorandum opinion and order, the Court found that the State had failed to comply with numerous provisions of the Consent Decree and that the Consent Decree is enforceable. See Frew v. Gilbert, 109 F.Supp.2d 579 (E.D.Tex.2000) (the “2000 Opinion”). In an attempt to judiciously consider the recommendations of state officials, the Court requested that the parties submit proposed corrective action plans, rather than the Court’s unilaterally entering a comprehensive order of enforcement. Before submitting the proposed corrective action plans, however, Defendants brought two interlocutory appeals; and the Fifth Circuit stayed the Court’s order requesting proposed corrective action plans during the pendency of the appeals. See Frazar v. Gilbert, 300 F.3d 530 (5th Cir.2002). One of the appeals involved Defendants’ argument that a federal court’s jurisdiction over a state official is limited by the Eleventh Amendment to requiring compliance with federal law. Defendants argued that the Consent Decree may not be enforced against them, to the extent that it goes beyond the scope of simple compliance with federal law. The Court rejected this argument, but the Court was overruled by the Fifth Circuit on appeal. Frazar, 300 F.3d at 530. The Fifth Circuit held that the Eleventh Amendment prevented enforcement of the Consent Decree, unless the violation of the Consent Decree was also a statutory violation of the Medicaid Act that imposed a clear and binding obligation on the State. Id. at. 543. The Supreme Court, however, unanimously reversed the Fifth Circuit, holding that the Consent Decree, is enforceable, in its entirety, under Ex Parte Young. Frew v. Hawkins, 540 U.S. 431, 124 S.Ct. 899, 157 L.Ed.2d 855 (2004). The Supreme Court noted that, “[t]he decree states that it creates ‘a mandatory, enforceable obligation,’ ” in the process of holding that “[o]nce entered, a consent decree may be enforced.” Id. at 438, 440, 124 S.Ct. 899 (quoting Consent Decree ¶ 302). On remand, the Fifth Circuit held that, absent the jurisdictional issues related to the Eleventh Amendment, it lacked interlocutory jurisdiction over the appeal. Frazar v. Hawkins, 376 F.3d 444 (5th Cir.2004). The Supreme Court, while clarifying that the Consent Decree is valid and enforceable in its entirety, also explained that “the law’s primary response to [the fear that enforcement of consent decrees can undermine the sovereign interests and accountability of state governments] has its source not in the Eleventh Amendment but in the court’s equitable powers and the direction given by the Federal Rules of Civil Procedure.” Frew, 540 U.S. at 441, 124 S.Ct. 899. It provided Defendants with a- potential avenue for relief, Fed. R. Civ. P. 60(b)(5) (hereinafter “Rule 60(b)(5)”), and directed the Court and the parties to two cases as examples of the application of Rule 60(b)(5) to consent decrees in the context of institutional reform litigation. It also explained that a “federal court must exercise its equitable powers to ensure that when the objects of the decree have been attained, responsibility for discharging the State’s obligations is returned promptly to the State and its officials.” Id. at 442, 124 S.Ct. 899. Defendants thus filed the instant Rule 60(b)(5) Motion for Relief from Judgment (“Defendants’ Rule 60(b) Motion”) on November 4, 2004. Docket No. 406. The Hearing and Memorandum Opinion The Court held a hearing from June 6-15, 2005 (the “June Hearing”), on Defendants’ Rule 60(b) Motion. Following the hearing, Plaintiffs and Defendants submitted briefs on the legal and factual issues involved in the instant motion. This memorandum opinion details the Court’s findings of fact and conclusions of law based on the evidence presented at, the June Hearing. Part One of the opinion discusses consent decrees and Rule 60(b)(5) motions generally, for the purpose of establishing the proper legal framework for the Court’s: analysis. Part Two details findings of fact and conclusions of law regarding Defendants’ demand to dissolve the Consent Decree in its entirety. Part Three outlines findings of fact and conclusions of law regarding Defendants’ alternative demand for relief. Part Four addresses whether Defendants’ demanded relief satisfies the tailoring requirement set forth in Rufo v. Inmates of Suffolk County Jail, 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867 (1992). Finally, Part Five contains the. Court’s analysis of whether Defendants have made reasonable efforts to comply with the Consent Decree, as required by Cooper v. Noble, 33 F.3d 540 (5th Cir.1994). PART ONE: THE NATURE OF CONSENT DECREES AND RULE 60(b)(5) A. The Nature Of A Consent Decree The Court begins its analysis by describing the general nature of a consent decree, to provide context for the Court’s analysis as to whether the Consent Decree should be dissolved in its entirety, as Defendants primarily demand. The Supreme Court has described a consent decree as “an agreement between the parties to a case after careful negotiation has produced agreement on [its] precise terms.” Local Number 93, Int’l Ass’n of Firefighters v. City of Cleveland, 478 U.S. 501, 522, 106 S.Ct. 3063, 92 L.Ed.2d 405 (1986) (internal quotations omitted) (quoted in Alberti v. Klevenhagen, 46 F.3d 1347, 1364 (5th Cir.1995)). Moreover, the Fifth Circuit has noted that “once the district court enters the settlement as a judicial consent decree ending the lawsuit, the settlement takes on the nature of a judgment.” Ho v. Martin Marietta Corp., 845 F.2d 545, 548 (5th Cir.1988). It is “an agreement that the parties desire and expect will be reflected in, and be enforceable as, a judicial decree that is subject to the rules generally applicable to other judgments and decrees.” Rufo, 502 U.S. at 378, 112 S.Ct. 748. A consent decree is not court-imposed; rather, it is a voluntary agreement between the parties involved in litigation that is then evaluated for fairness, and potentially accepted by the Court and entered as a judgment. In the instant case, as with all consent decrees, the Court was not a party to the Consent Decree negotiations and did not have a hand in crafting the obligations contained therein. In Frew v. Hawkins, 540 U.S. 431, 124 S.Ct. 899, 157 L.Ed.2d 855 (2004), the Supreme Court found, in the instant action, that although the Consent Decree implements the Medicaid statute “in a highly detailed way, requiring the state officials to take some steps that the statute does not specifically require ... [t]he same could be said ... of any effort to implement the general EPSDT statute in a particular way.” Id. at 439, 124 S.Ct. 899. Defendants thus voluntarily chose the result of its negotiations with Plaintiffs, the Consent Decree, to be its judicially enforceable method of implementing the general federal EPSDT statute. B. Rule 60(b)(5) 1. Rule 60(b)(5) Generally Rule 60(b)(5) provides, in relevant part, On motion and upon such terms as are just, the court may reheve a party ... from a final judgment, order, or proceeding for the following reasons ... (5) the judgment has been satisfied, released, or discharged ... or it is no longer equitable that the judgment should have prospective application. As the Supreme Court wrote in the instant case, “[tjhe Rule [60(b)(5) ] encompasses the traditional power of a court of equity to modify its decree in light of changed circumstances.” Frew, 540 U.S. at 441, 124 S.Ct. 899. Under Rule 60(b)(5), the Court may relieve Defendants from the Consent' Decree if the judgment has been satisfied, released, or discharged. Defendants do not argue that the Consent Decree has been satisfied, released, or discharged; instead, they argue that Defendants are in compliance with' federal Medicaid law, thus rendering the Consent Decree unnecessary and its enforcement inequitable. In other words, Defendants argue that the ends of the Consent Decreé havé been met, not that the obligations within the Consent Decree have been satisfied, released, or discharged. Defendants thus proceed with this motion under the second portion of Rule 60(b)(5), insisting that “it is no longer equitable that the judgment should have prospective application.” Rule 60(b)(5) is a form of equitable relief. See Frew, 540 U.S. at 441, 124 S.Ct. 899; Waste Mgmt. of Ohio, Inc. v. City of Dayton, 132 F.3d 1142, 1145 (6th Cir.1997) (“Equitable considerations are clearly factors a district court can address when they are related to a court’s.power and duty to modify, interpret, and oversee a consent decree.”). “Equity” is defined as “[t]he recourse to principles of justice to correct or supplement the law-as applied to particular circumstances,” or more generally, “[t]he body of principles constituting what is fair and right.” Black’s Law Dictionary (8th ed.2004). Remedies grounded in equity, therefore, take into account all factors that contribute to a just, fair, and right outcome. In order to determine whether to order equitable relief, the Court examines the entire record-the facts and procedural history of the case, in addition to the actions of the parties throughout the progression of the case. 2. Legal Standard for Rule 60(b)(5) Relief In Frew, 540 U.S. at 441, 124 S.Ct. 899, the Supreme Court cites two cases as examples of the application of Rule 60(b) to consent decrees in the context of institutional reform litigation: Rufo, 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867 and Philadelphia Welfare Rights Org. v. Shapp, 602 F.2d 1114 (3rd Cir.1979). An overview of these two Rule 60(b) application cases provides a necessary introduction to the legal framework for the Court’s analysis. In Rufo, the Supreme Court adopted a flexible standard for determining whether to modify an institutional reform consent decrees and announced a. two-part test regarding their modification. 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867. Rufo involved a consent decree entered ás a result of litigation regarding álleged unconstitutional conditions at Suffolk County Jail. A change in factual circumstance-an upsurge in the population of pretrial detainees-led the petitioners to file a Rule 60(b) motion for modification of a decree provision prescribing single-bunking. The district court denied petitioners’ Rule 60(b) motion, which was affirmed by the United States Court of Appeals for the First Circuit, although the Supreme Court found that the district court applied the wrong consent decree modification standard in its analysis. Id. In announcing the flexible modification standard applicable in the instant case, the Supreme Court explained a two-part test: (1) the party seeking modification of the consent decree must establish that a significant change in facts or law warrants revision of the decree, and (2) the court should determine whether the proposed modification is suitably tailored to the changed circumstances. See id. at 392, 112 S.Ct. 748. A flexible standard is desirable, the Rufo Court reasoned, because (1) the extended life of consent decrees increases the likelihood that significant changes will occur and (2) it serves the public’s interest in the sound and efficient operations of its institutions. Id. at 380-81, 112 S.Ct. 748. The Rufo Court also clarified that, within the “flexible standard” analysis, [T]he moving party bears the burden of establishing that a significant change in circumstances warrants modification of a consent decree. No deference is involved in this threshold inquiry. However, once a court has determined that a modification is warranted, we think that principles of federalism and simple common sense require the court to give significant weight to the views of the local government officials who must implement any modification. Id. at 392 n. 14, 112 S.Ct. 748. Rufo provides a non-exhaustive list of three significant changes in factual conditions sufficient to support modification: (1) if the changed conditions “make compliance with the decree substantially more onerous;” (2) if the decree “proves to be unworkable because of unforeseen obstacles;” or (3) if “enforcement of the decree without the modification would be detrimental to the public interest.” Rufo, 502 U.S. at 384, 112 S.Ct. 748; see Thompson v. United States HUD, 404 F.3d 821, 827 (4th Cir.2005). If the Court determines that Defendants have met their “burden of establishing either a change in fact or in law warranting modification of a consent decree, the district court should determine whether the proposed modification is suitably tailored to the changed circumstance.” Id. at 391, 112 S.Ct. 748. The Rufo Court also warned that, although “a district court should exercise flexibility in considering requests for modification of an institutional reform consent decree, it does not follow that a modification will be warranted in all circumstances.” 502 U.S. at 383, 112 S.Ct. 748. In Shapp, 602 F.2d 1114, a pre-Rufo case, the district court ordered modification of an institutional reform consent decree in light of changed circumstances that were beyond the defendants’ control and were not contemplated by the court or the parties when the decree was entered. The consent decree at issue in Shapp was entered as a result of litigation over Pennsylvania’s EPSDT program, and the defendants were seeking to modify or vacate the decree based on (1) the exemplary performance of Pennsylvania’s program, and (2) inability to comply, after a good faith effort, with certain terms of the decree. The district court modified the decree in three respects after finding that the defendants had made a good faith effort at compliance, but circumstances beyond the defendants’ control and not contemplated by the court or parties “put achievement of the [provisions’ requirements] beyond reach.” Id. at 1120-21. The court denied the defendants’ motion to vacate the decree. Id. Together, Rufo and Shapp: (1) instruct the Court to apply a flexible standard that contemplates federalism concerns with respect to modification of a consent decree based on changed circumstances under Rule 60(b)(5) and (2) illustrate that not all changed circumstances should be considered in the analysis. Instead, an example of a relevant significant change in circumstances is one that is unanticipated and beyond the defendants’ control. After the Supreme Court announced Rufo’s flexible standard, the Fifth Circuit clarified the Rule 60(b) standard for modification of a consent decree in the context of institutional reform litigation, based on changed factual circumstances, in Cooper v. Noble. 33 F.3d 540, 544 (5th Cir.1994). The Cooper Court upheld a United States Magistrate Judge’s denial of the defendants’ Rule 60(b) motion in a pre-Prison Litigation Reform Act ease applying the Rufo Rule 60(b) standard. The court explained: When significant changes in factual conditions make a consent judgment unworkable, make compliance substantially more onerous, or make enforcement detrimental to the public interest, a court has the discretion to modify the judgment. However, the Supreme Court [in Rufo ] never suggested that changed factual circumstances in and of themselves were sufficient grounds for relief from a judgment. In fact, the Court insisted that the petitioning party must “make a. reasonable .effort to comply with the decree.” Thus, even if we take as true all the alleged changes in factual conditions, the county officials are far from meeting their burden under Rufo. The county officials must also: (1) show that those changes affect compliance with, or the workability or enforcement of, the final judgment, and (2) show that those changes occurred despite the county officials’ reasonable efforts to comply with the judgment. Cooper, 33 F.3d at 544 (quoting Rufo, 502 U.S. at 385, 112 S.Ct. 748) (citations omitted). A change in factual circumstances, without more, is thus insufficient to warrant modification of a consent decree in the Fifth Circuit; the moving party must additionally show how the change in factual circumstances warrants modification of the consent decree by “showing] that those changes affect compliance with, or the workability or enforcement of, the final judgment.” Cooper, 33 F.3d at 544; cf. Rufo, 502 U.S. at 384, 112 S.Ct. 748. Stated more simply, the Fifth Circuit clarified that consent decree modification under Rule 60(b) requires satisfaction of the Rufo test, in addition to a showing that the moving party made reasonable efforts to comply with the judgment, similar to Shapp. 3. The Parties Misunderstand the Applicable Rule 60(b)(5) Standard The Court now addresses the parties’ arguments with respect to the Rule 60(b)(5) legal standard that the Court should employ. The Court finds that both parties are mistaken as to the applicable standard; instead of applying the standards the parties proffer, the Court will apply the flexible standard as set forth in Rufo, 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867, Shapp, 602 F.2d 1114, Cooper, 33 F.3d 540, and their progeny, as detailed in Parts 1(B)(2) and 1(B)(4). Defendants’ Arguments The crux of Defendants’ argument in support of their Rule 60(b) motion is that they are currently in compliance with federal Medicaid law, which they assert' is sufficient to warrant dissolution of the Consent Decree either in its entirety, or for the areas of Texas under managed care, under Rule 60(b)(5). Tr. Vol. VIII, pp. 77, 84-85, 111 (closing argument of Defendants’ counsel); Defendant’s Post-Hearing Brief at 3. Because they are currently in compliance with federal law, Defendants argue, the objects of the Consent Decree have been attained, and “it is no longer equitable that the judgment should have prospective application.” Id. at 2, 5 (citing Rule 60(b)(5)). Defendants argue that “[w]hen it was entered, and throughout the ten years and more of its application, the Consent Decree could have only one legitimate object-to ensure that Texas complied with federal law regarding the administration of its EPSDT program.” Id. Alternatively, Defendants argue that they have established compliance with federal law in- all “Urban Areas” of the State; thus, the objects of the Consent Decree have been attained, and it should have no prospective application, with respect to these areas. In sum, as articulately summarized at ’the June Hearing and outlined in Defendants’ Post-Hearing Brief, Defendants demand only two alternative forms of relief, each based solely on compliance with federal law: (1) dissolution of the Consent Decree in its entirety, or (2) dissolution of the Consent Decree in its entirety for all Urban Areas of Texas. Defendants’ Post-Hearing Brief at 1-4, 75-79; Tr. Vol. VIII, p. 88 (closing argument of Defendants’ counsel). Notably, neither in their original Rule 60(b) Motion, at the June Hearing, nor in their Post-Hearing Brief do Defendants cite an applicable Rule 60(b) standard for modification or dissolution of consent decrees. Instead, they simply recite the plain language of Rule 60(b)(5); they do not discuss either of the two cases cited by the Supreme Court in its discussion of Rule 60(b)(5) in Frew, 540 U.S. 431, 124 S.Ct. 899, 157 L.Ed.2d 855, nor do they discuss any other cases applying Rule 60(b)(5) or addressing the burden placed on a party .moving for modification or dissolution of a consent decree under Rule 60(b)(5). Additionally, Defendants do not argue that they are in substantial compliance with the Consent Decree; rather, they argue that they are in compliance with federal law and that such compliance, regardless of compliance with the Consent Decree, is sufficient to warrant dissolution under Rule 60(b)(5). See Defendants’ Post-Hearing Brief at 78-79; Tr. Vol. VIII, pp. 76-88 (closing argument of Defendants’ counsel). Plaintiffs’ Arguments Plaintiffs contend that Defendants are not entitled to Rule 60(b)(5) relief, because: (1) compliance with federal law is insufficient, by itself, to warrant dissolution of the Consent Decree; (2) Defendants are not in compliance with federal law; (3) Defendants have never attempted to comply, in good faith, with certain provisions of the Consent Decree; and (4) the objects of the Consent Decree have not been attained. See Plaintiffs’ Post-Hearing Brief at 3-10; Tr. Vol. VIII, pp. 89-90, 99 (closing argument of Plaintiffs’ counsel). In support of their response to Defendants’ request for dissolution of the Consent Decree in its entirety, Plaintiffs cite a legal standard set forth in Missouri v. Jenkins, 515 U.S. 70, 115 S.Ct. 2038, 132 L.Ed.2d 63 (1995). Plaintiffs argue that Defendants cannot satisfy their burden for dissolution under Rule 60(b), in that they have not shown a good faith commitment to the whole of the Consent Decree’s provisions, as they intentionally violated or ignored, inter alia, ¶¶ 17, 35, 37, 171 and 223 thereof. Plaintiffs’ Post-Hearing Brief at 5; Plaintiffs’ Motion for Sanctions (Docket No. 429). In support of their response to Defendants’ request for modification of the Consent Decree to exclude the Urban Areas of the State, Plaintiffs argue that Defendants have not met Rufo’s requirements for modification under Rule 60(b)(5). Id. at 6-7. Plaintiffs thus distinguish between the Rule 60(b)(5) standard for modification of institutional reform consent decrees and the standard for dissolution. Defendants’ managed care companies, argue Plaintiffs, remain in disarray, their outreach efforts have no effect or even make things worse, and their overall outcomes are poor. Id. a. The Rufo Flexible Standard Applies to Both Modification and Dissolution of Consent Decrees While Defendants do not cite a legal standard for Rule 60(b) beyond the text of the rule itself, Plaintiffs distinguish between the standard for consent decree modification and the standard for consent decree dissolution. See Plaintiffs’ Post-Hearing Brief at 3-7. The applicable legal standard in the Fifth Circuit for both types of relief, however, is that announced in Rufo and applied in Cooper. First, the Supreme Court does not draw a distinction between the two types of relief in Rufo or in Frew, nor does the Fifth Circuit draw a distinction in Cooper. Indeed, the defendants in Rufo moved to vacate the decree as well as to modify it and, on remand, the district court applied a single flexible standard for determining whether either type of relief was warranted under Rule 60(b). See Rufo, 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867; Inmates of Suffolk County Jail v. Rufo, 148 F.R.D. 14 (D.Mass.1993). The defendants in Cooper also demanded relief from the whole of the consent judgment via a' Rule 60(b) motion, and the Magistrate Judge applied Rufo’s flexible standard in the process of denying their motion. Cooper, 33 F.3d at 540. Second, multiple courts have addressed and dismissed similar arguments with respect to a differing standard for consent decree modification versus that for consent decree dissolution under Rule 60(b)(5). For example, the defendants in Alexander v. Britt, 89 F.3d 194 (4th Cir.1996), argued that the standard set forth in Board of Education of Oklahoma City Public Schools v. Dowell, 498 U.S. 237, 111 S.Ct. 630, 112 L.Ed.2d 715 (1991), applies to Rule 60(b) motions for dissolution, as opposed to modification, of a consent decree. Rufo, the defendants argued, applies only to Rule 60(b) motions to modify a consent decree. The Alexander Court harmonized the Rufo and Dowell standards, by explaining that the two formulations of the Rule 60(b) standard, announced by the Supreme Court in two consecutive terms, simply illustrate the flexibility of the standard and the need to tailor the inquiry to the specific context of the case. 89 F.3d at 197. The Alexander Court thus found that a court should employ a single, flexible standard for either modification or dissolution of a consent decree under Rule 60(b). Id.; see Rufo, 502 U.S. at 380, 112 S.Ct. 748 (“The same theme [the need for flexibility in administering consent decrees] was repeated in our decision last Term in [Dowell].”); see also Nat’l Labor Relations Board v. Harris Teeter Supermarkets, 215 F.3d 32, 36 (D.C.Cir.2000) (“Do-well and Rufo must be read together ....”). Finally, employing a unified flexible standard for consent decree modification and dissolution under Rule 60(b) is simply logical. Because both types of relief are forms of equitable relief, and both may be demanded under Rule 60(b), a single standard that takes into account equitable considerations pertaining to the unique circumstances of each case (as the Rufo standard does) is the most efficient standard under which to determine whether significant changed factual circumstances exist that warrant any change in, or relief from, obligations contained within a consent decree. Furthermore, the Missouri v. Jenkins standard is inapplicable to the instant case. 515 U.S. 70, 115 S.Ct. 2038, 132 L.Ed.2d 63 (1995). In Jenkins, Missouri demanded that it be relieved of the district court order that required the State to fund remedial quality education programs in the context of school desegregation litigation. In its analysis, the Jenkins Court discussed “the showing that must be made by a school district operating under a desegregation order for complete or partial relief from that order,” a test it had previously articulated in Freeman v. Pitts, 503 U.S. 467, 112 S.Ct. 1430, 118 L.Ed.2d 108 (1992). Id. at 88-89, 115 S.Ct. 2038. However, Jenkins did not involve modification or dissolution of a consent decree, nor was the defendants’ motion for relief from the judgment’s obligations made under Rule 60(b). The Court thus declines to apply the Jenkins standard, as urged by Plaintiffs, as it does not apply to either the Rule 60(b)(5) motion before the Court or to the type of judgment from which Defendants demand relief. b. Defendants Misstate the Objects of the Consent Decree Defendants’ main argument in support of their demand for dissolution of the Consent Decree in its entirety is that the objects of the Consent Decree have been attained. As the Supreme Court admonished, “when the objects of the decree have been attained, the responsibility for discharging the State’s obligations [must be] returned promptly to the State and its officials.” Frew, 540 U.S. at 442, 124 S.Ct. 899. Defendants thus argue that the only legitimate object of the Consent Decree, to ensure that Texas complied with federal law regarding the administration of its EPSDT program, has been attained, and it is thus “no longer equitable that the judgment should have prospective application.” Frew, 540 U.S. at 442, 124 S.Ct. 899; Defendants’ Post-Hearing Brief at 3; Rule 60(b)(5). Defendants’ argument, therefore, can be interpreted as two discrete assertions: (1) the sole object of the Consent Decree is to ensure compliance with federal law, and (2) Defendants are currently in compliance with federal law. Because the Court finds that compliance with federal law is not the sole object of the Consent Decree, the second assertion need not be addressed. Plaintiffs respond to Defendants’ argument by citing Rufo’s admonishment that a court should not rewrite the decree to reduce it to the constitutional minima. Rufo, 502 U.S. at 391, 112 S.Ct. 748. In Rufo, the Supreme Court stated: A proposed modification should not strive to rewrite a consent decree so that it conforms to the constitutional floor. Once a court has determined that changed circumstances warrant a modification in a consent decree, the focus should be on whether the proposed modification is tailored to resolve the problems created by the change in circumstances. A court should do no more, for a consent decree is a final judgment that may be reopened only to the extent that equity requires. The court should not “turn aside to inquire whether some of [the provisions of the decree] upon separate as distinguished from joint action could have been opposed with success if the defendants had offered opposition.” Id. at 391-92, 112 S.Ct. 748 (quoting United States v. Swift & Co., 286 U.S. 106, 116—17, 52 S.Ct. 460, 76 L.Ed. 999 (1932)). Plaintiffs thus argue that Defendants’ assertion that the sole object of the Consent Decree is to ensure compliance with federal law implicitly requires the Court to rewrite the Consent Decree to conform to the constitutional floor, in clear violation of Rufo. The Court finds Plaintiffs’ argument to be meritorious. In rejecting Defendants’ argument, it is sufficient to find that compliance with federal law is not the sole object of the Consent Decree. First, ¶ 6 of the Consent Decree states: To address the parties’ concerns, to enhance recipients’ access to health care, and to foster the improved use of health care services by Texas EPSDT recipients, the parties agree and the Court orders Defendants to implement the following changes and procedure for the Texas EPSDT program. The Consent Decree itself does not refer to mere compliance with federal law as its object; rather, it speaks to the broader goals of enhancing recipients’ access to health care and improving the use of health care services by Texas EPSDT recipients. The Consent Decree’s stated purpose is, moreover, not limited by importing any reference to federal Medicaid law in ¶ 6. Finally, the Consent Decree implements the Medicaid statute “in a highly detailed way, requiring the state officials to take some steps that the statute does not specifically require.” Frew, at 540 U.S. at 439, 124 S.Ct. 899. To interpret the sole object of the Consent Decree to ensure compliance with something less than that which is stated in the Consent Decree itself would be akin to rewriting the Consent Decree to conform to the constitutional floor. Such action is clearly prohibited by the Supreme Court’s holding in Rufo. See 502 U.S. at 391-92, 112 S.Ct. 748. Second, as the Fifth Circuit has noted, “[t]he very nature of a consent agreement is such that parties will agree to act in ways they do not believe the Constitution requires in order to save themselves the time, expense, and inevitable risk of litigation.” Cooper, 33 F.3d at 545. If the sole object of the Consent Decree is compliance with the minimum requirements of federal law, as Defendants argue, and Defendants were thus entitled to dissolution of the Consent Decree under Rule 60(b)(5), without reference to the naturally enhanced obligations of the Consent Decree, Plaintiffs would not receive the benefits for which they bargained; and Defendants would never be required to comply with the obligations which they undertook in exchange for saving the time, expense, and inevitable risk of litigation. Taking into account the Consent Decree’s statement as to its purpose, Cooper ’s explication of the nature of a consent decree, and Rufo’s admonishment to avoid rewriting a consent decree to merely conform to the constitutional floor, the Court disallows Defendants’ argument that the sole object of the Consent Decree is to ensure that Texas complies with federal law regarding the administration of its EPSDT program. Because it is unnecessary to delineate the objects of the Decree beyond discarding Defendants’ arguments, the Court abstains from doing so. c. Compliance With Federal Law, Alone, is Insufficient to Warrant Rule 60(b)(5) Relief Given , the Court’s rejection of Defendants’ argument that compliance with federal law is the sole object of the Consent Decree, the alternative interpretation of Defendants’ argument will be addressed, ie., that -.compliance with federal.law, by itself, is sufficient to warrant relief under Rule 60(b)(5). For this assertion to be accurate, compliance with federal law must be sufficient, by itself, to prove significant changed circumstances warranting dissolution of the Consent Decree, and dissolution of the Consent Decree must be suitably tailored to this changed circumstance. See Rufo, 502 U.S. at 384-91, 112 S.Ct. 748. The Court finds that this is not the case. While compliance with federal law may be one factor in assessing changed factual circumstances, it is neither the focus of the Court’s inquiry nor dispositive of the merits of Defendants’ Rule 60(b) Motion. Defendants cite no authority for the assertion that compliance with federal law is sufficient, alone, to warrant relief under Rule 60(b), nor has the Court discovered any inquiry into compliance with federal law in the context of a Rule 60(b) motion for relief from a consent decree. Instead, courts addressing modification or dissolution of a consent decree since 1992 are bound by Rufo’s flexible standard and its requirements to prove both that significant changed, factual circumstances warrant modification of the consent decree and that the demanded relief is suitably tailored- to the changed circumstances. Rufo, 502 U.S. at 384-91, 112 S.Ct. 748; see Frew, 540 U.S. at 441, 124 S.Ct. 899. Defendants’ contention that compliance with federal law, without more, is sufficient to warrant relief under Rule 60(b) improperly circumvents both prongs of the Rufo test. Furthermore, the Supreme Court noted Defendants’ argument that “[a] State in full compliance with federal law could remain subject to federal court oversight through a course of judicial proceedings brought to enforce the consent decree.” Frew, 540 U.S. at 438, 124 S.Ct. 899." The Supreme Court, cognizant of Defendants’ concern that it could be bound by the Consent Decree despite compliance with federal law, unanimously held that the Consent Decree is enforceable in its entirety unless and until a federal court grants a Rule 60(b)(5) motion. Frew, 540 U.S. at 431, 124 S.Ct. 899. It did not mention federal law compliance as a factor in the Rule 60(b)(5) analysis; rather, it directed the Court to Rufo and Shapp as examples of the proper application of Rule 60(b)(5) to modification of institutional reform consent decrees, neither of which discusses the merits of the claims on which a consent decree is based. Dissolution based on mere compliance with the minimum requirements of federal law is, additionally, inequitable, because it would permit perpetual re-litigation of the merits of Plaintiffs’ claims. In choosing to voluntarily enter into the Consent Decree, Defendants waived the opportunity to litigate the merits of the claims in Plaintiffs’ Third Amended Complaint in exchange for negotiating the terms of the Consent Decree and avoiding the time, expense, and inevitable risk of litigation. See Cooper, 33 F.3d at 545. Through their argument that compliance with federal law necessarily warrants relief under Rule 60(b)(5), however, Defendants are seemingly attempting to re-litigate the claims underlying the Consent Decree. If the basis for a meritorious Rule 60(b) motion is that the claims underlying the consent decree are not meritorious, then parties to consent decrees would be permitted to file periodic Rule 60(b) motions asserting compliance with federal law and, in effect, continually re-litigate the underlying claims until a court determines the defendants are in compliance with federal law and the decree is dissolved. The party filing the Rule 60(b) motion would potentially be able to eliminate consent decree obligations, even if there, is no attempted compliance with its legally enforceable terms, no showing that conformity to federal law makes compliance with the consent decree substantially more onerous or unworkable, and no showing that the requested relief is sufficiently tailored to the changed factual circumstances. See Rufo, 502 U.S. at 384-91, 112 S.Ct. 748; Cooper, 33 F.3d at 545. It follows that the parties opposing dissolution would not enjoy the benefits for which they bargained or the judicially enforceable obligations upon which they relied in entering into the consent decree; and the parties seeking dissolution would paradoxically be entitled to equitable relief despite their inequitable behavior. A Rule 60(b) motion is not a vehicle by which Defendants may disregard the voluntary obligations contained in the Consent Decree, allow time to pass, and then litigate the underlying claims in hopes of never actually complying with the its terms. Based on the absence of authority for Defendants’ argument, contradiction with the Rufo Rule 60(b) consent decree modification standard and the inequities involved in simply ruling on the merits of the claims which were the basis for negotiation and entry of the Consent Decree, the Court rejects Defendants’ argument that compliance with federal law, by itself, is sufficient to warrant Rule 60(b)(5) relief. Because Defendants’ asserted Rule 60(b) standard is found to be wanting, the Court abstains from determining whether Defendants are currently in compliance with federal Medicaid law. Additionally, it is noted that Plaintiffs adamantly object to the assertion that Defendants are currently in compliance with federal Medicaid law. See Plaintiffs’ Post-Hearing Brief at 162-181; Tr. Vol. VIII, pp. 89-90, 99 (closing argument of Plaintiffs’ counsel). Specifically, Plaintiffs argue, inter alia, that: (1) Defendants’ protocols are not designed to effectively inform class members about EPSDT, in violation of 42 U.S.C. § 1396a(a)(43)(A) and 42 C.F.R. § 441.56(a)(1); (2) Medical checkups are incomplete, in violation of 42 U.S.C. § 1396a(a)(43)(B); (3) “requests” for medical checkups go unmet; and (4) Defendants do not “arrange” follow-up treatment that class members need, in violation of 42 U.S.C. § 1396a(a)(43)(C). Id. As the parties have either failed to cite the proper standard for Rule 60(b) relief, or have cited to a standard inapplicable to the instant case, the Court will hereafter interpret the parties’ arguments to comply with the appropriate standard as set forth in Frew, Rufo, Shapp and Cooper. By following relevant precedent, taking general equitable considerations into account and “ensuring] that when the objects of the decree have been attained, -responsibility for discharging the State’s obligations is returned promptly to the State and its officials,” Frew, 540 U.S. at 442, 124 S.Ct. 899, the Court will determine whether, and to what extent, Rule 60(b)(5) relief is warranted in the instant case. 4. Overview of Cases Applying Rule 60(b) to Consent Decrees In this section, the Court analyzes cases determining whether significant changes in circumstances warranting revision of a consent decree under Rule 60(b) exist, in order to inform the Court’s determination of whether Defendants have met their burden in the instant case. Cases applying Rufo’s tailoring requirement are discussed in Part IV, infra. a. Cases Finding A Significant Change in Factual Circumstances Generally, in the analysis of whether to modify a consent decree, courts first consider whether there is a relevant significant change in factual circumstances that fits within one of Rufo’s three categories: (1) if the changed conditions “make compliance with the decree substantially more onerous;” (2) if the decree “proves to be unworkable because of unforeseen obstacles;” or (3) if “enforcement of the decree without the modification would be detrimental to the public interest.” Rufo, 502 U.S. at 384, 112 S.Ct. 748. Indeed, this is the Fifth Circuit’s approach. Cooper, 33 F.3d at 544. While Rufo does not necessarily preclude the possibility that other changed factual circumstances may warrant modification of a consent decree, post-Rufo courts typically analyze changed factual circumstances within Rufo’s three-category structure. After the Supreme Court’s Rufo decision, 502 U.S. 367, 112 S.Ct. 748, 116 L.Ed.2d 867, the case was remanded to the United States District Court for the District of Massachusetts for reconsideration under the appropriate, flexible standard. On remand, the district court denied the defendants’ motion to vacate the consent decree and two motions to modify the consent decree; the First Circuit then affirmed the denials. Inmates of Suffolk County Jail v. Rufo, 148 F.R.D. 14 (D.Mass.1993); Inmates of the Suffolk County Jail v. Rufo, 12 F.3d 286 (1st Cir.1993). The .district court found a significant changed circumstance-an upsurge in pretrial detainee population-but then found that the defendants’ proposed modifications “fail the test that this court ‘should consider whether the proposed modification is suitably tailored to the changed circumstance^].’ ” Rufo, 148 F.R.D. at 16-17 (quoting Rufo, 502 U.S. at 383, 112 S.Ct. 748). The district court found that the upsurge in pretrial detainee population was “higher than actually anticipated or reasonably foreseeable” and thus satisfied Rufo’s requirement that a significant change in factual circumstances existed that made compliance with the decree substantially more onerous. Rufo, 148 F.R.D. at 20; Rufo, 502 U.S. at 384, 112 S.Ct. 748. Reynolds v. McInnes, 338 F.3d 1221 (11th Cir.2003), involved a consent decree resulting from an action alleging racial discrimination in employment practices by Alabama state agencies. The district court found that the defendants had made reasonable, good faith efforts at complying with the consent decree, although the efforts had been unsuccessful with respect to one article contained in the consent decree. Reiterating that the standard for modification of consent decrees is a flexible one, the Reynolds Court found that “the fact that a provision of a consent decree has proven to be unworkable is itself a significant change in circumstances.” 338 F.3d at 1228-29. Thus, the court rejected the plaintiffs’ argument that, without evidence of the specific circumstances that gave rise to the provision, there can be no determination that those circumstances have changed. The plain fact that the defendants, after good faith efforts, were unable to comply with a consent decree provision was sufficient to satisfy the Rufo flexible standard. The court, in response to this significant changed circumstance, modified 1 of the 21 articles contained in the consent decree. In the same vein, Shapp, a pre-Rufo case, involved a consent agreement under which the defendants were responsible for 180,000 screenings per year. In support of their Rule 60(b) motion, the defendants presented evidence that the total population eligible for EPSDT screening was between 230,000 and 250,000 persons, “a figure which, due to declining welfare rolls, was significantly lower than had been expected at the time of the consent decree.” Shapp, 602 F.2d at 1118. Given the relatively low number of eligibles, they argued, in addition to a 35-45% screening no-show rate, achievement of the screening goals was virtually impossible. Additionally, the defendants argued that it was impossible to comply with the consent decree provision requiring them to provide treatment for discovered abnormalities within 60 days of the EPSDT examination in which they were discovered. The district 'court found that, despite good faith efforts, both the screening goals and 60-day treatment rule were impossible to perform. Id. at 1120. Accordingly, the district court eliminated the screening goals arid qualified the 60-day treatment provision, and both modifications were affirmed by the Third Circuit. Id. Though Shapp was decided approximately 13 years before Rufo, the Supreme Court cited it as an example of Rule 60(b) application to a consent decree relating to a State’s EPSDT program, and it is instructive with respect to illustrating an example of changed factual circumstances warranting revision of a consent decree under Rule 60(b). In Thompson v. United States HUD, 404 F.3d 821 (4th Cir.2005), the Fourth Circuit, applying Rufo, found that the magnitude of a party’s failure to comply with the terms of the consent decree was a significant change in circumstances warranting modification of the decree. Cf Pigford v. Veneman, 292 F.3d 918 (D.C.Cir.2002) (finding that class counsel’s inability and/or unwillingness to meet consent decree deadlines constituted a significant changed circumstance under Rufo). The Thompson Court found that the defendants were “woefully behind schedule with regard to many provisions of the Consent Decree,” 404 F.3d at 825, but focused on one failure as support for the modification of the decree. The consent decree at issue in Thompson required the defendants to make available 911 hard units of housing (as opposed to rent vouchers)-by a specified date; on that specified date, the defendants had supplied only 8 of the required units. The court thus decided to extend jurisdiction over the defendants, modifying the consent decree’s provision that the district court would exercise jurisdiction for only a limited period of time that was near expiration. The Thompson Court found that the plaintiffs had not anticipated the exceptional magnitude of non-compliance and that the modification ensured that the decree could be efficiently enforced. b. Cases Finding No Significant Change in Factual Circumstances Warranting Revision of a Consent Decree In Cooper, 33 F.3d 540, inmates brought a class action against county officials for alleged unconstitutional conditions at a jail. Ten years after the consent judgment was entered, the county officials filed a Rule 60(b) motion requesting complete relief from the judgment, asserting, inter alia, significant changes in factual circumstances. The county officials argued that dramatic and unforeseen changes had occurred in the prison system since the final judgment wás entered. They contended that jail conditions and procedures had been radically altered by the construction of a new jail, and the resulting conditions and procedures were either in conformity with, or improvements upon, the stipulations contained in the final judgment. The district court found, and the Fifth Circuit affirmed, that the county officials neither (1) adequately explained how the factual changes affected the workability of the final judgment, compliance with the judgment, or enforcement of the judgment, nor (2) showed that those changes occurred despite their reasonable efforts to comply with the judgment. On these bases, the court denied the defendants’ Rule 60(b) request for dissolution of the consent judgment. Alexander, 89 F.3d 194, involved a class action against state officials responsible for the administration of North Carolina’s Aid to Families with Dependent Children and Medical Assistance (Medicaid) programs. The parties entered into a consent decree under which the administrators agreed to meet the deadlines that federal regulations mandate for processing applications; the consent decree also provided that the court would retain jurisdiction over its subject matter for six years. The defendants moved, pursuant to Rule 60(b), to dissolve the consent decree after less than- two years, arguing that they had complied with the decree for a reasonable period of time sufficient to establish that the decree had served its purpose. In denying the defendants’ motion for dissolution, the court found that “[w]ithout proof of a reasonable period of compliance, regardless of a party’s subjective good faith or good intentions, equitable considerations weigh strongly against terminating a consent order.” Id. at 202. The court found that the defendants had not complied with the decree for a reasonable period of time; indeed, the defendants had never complied fully with the consent decree. The court noted that “[ojnly compliance for substantially longer periods has been regarded as significant evidence of good faith compliance.” Id. at 201. The Alexander Court thus found that the defendants’ two-year period of alleged compliance was insufficient to constitute significant changed factual circumstances warranting revision of the consent decree under Rufo and Rule 60(b). PART TWO: DISSOLUTION OF THE CONSENT DECREE IN ITS ENTIRETY In determining whether to award to Defendants their primary demanded relief, dissolution of the Consent Decree in its entirety, the Court considers evidence of all aspects of the Texas Health Steps program. Accordingly, the findings of fact in both Part II (Dissolution of the Consent Decree in its Entirety) and Part III (Dissolution as to all Urban Areas of Texas) are taken into account in the Court’s reaching its conclusions of law with respect to dissolution of the Consent Decree in its entirety. Evidence relating to the Texas Health Steps program’s overall performance, exclusive of evidence relating to Defendants’ STAR MCOs, includes: (1) statistics and anecdotal evidence relating to class members’ receiving medical checkups and dental services; (2) outreach and informing efforts; and (3) case management services. A. Medical Checkups And Provision Of Dental Services The Court, first, addresses Defendants’ provision of medical checkups and dental services, as both parties emphasized these EPSDT services in the presentation of their evidence regarding the overall performance of Texas Health Steps. The Court finds, as the parties argue, that the number of class members receiving medical checkups and the number of class members receiving dental services are the most reliable indicia of the overall performance of Texas Health Steps and, as such, constitute the primary bases for the Court’s conclusions of law with respect to the Texas Health Steps program as a whole. This evaluation metric is consistent with the Consent Decree, as ¶ 2 states that “Check Ups are the cornerstone” of Texas Health Steps. In the analysis that follows, the Court finds that Defendants have failed to prove that significant changed factual circumstances exist that warrant modification of the Consent Decree with respect to either class members’ receipt of medical checkups or Defendants’ provision of dental services. Accordingly, the Court finds that Defendants have failed to meet their burden under Rufo to prove significant changed factual circumstances with respect to medical checkups and provision of dental services warranting dissolution of the Consent Decree. See 502 U.S. at 392,112 S.Ct. 748. 1. The CMS-416 as a Measure of the Overall Performance of Texas Health Steps As a general indicator of the overall performance of Texas Health Steps, both parties presented evidence relating to medical checkups and dental service utilization, as reported to the federal government on the “CMS-416.” Defendants report, inter alia, medical checkup and dental service' statistics annually to the Centers for Medicare and Medicaid Services (“CMS”), the federal agency responsible for oversight of the Medicaid program, in a “CMS-416” report. The Court thus, initially, considers medical checkup and dental service statistics, as reported on the CMS-416, to. determine whether significant. changed factual circumstances exist that warrant dissolution of the Consent Decree. While the Court finds that medical checkups and dental service. provision are the most comprehensive statistics evidencing the overall performance of Texas Health Steps, it does not necessarily follow that these statistics, as reported on the CMS-416, accurately reflect the overall performance of Texas Health Steps. Federal law mandates specific reporting requirements for EPSDT services. Specifically, 42 U.S.C. § 1396a(a)(43)(D) requires that a state Medicaid plan provide for: (emphasis added). The CMS-416 is the federal form that States are required to submit pursuant to 42 U.S.C. 1396a(a)(43)(D), which includes, inter alia, a “participation ratio” and a “screening ratio” regarding medical checkups, as well as a figure reporting the total number of eligibles receiving dental services. Tr. Vol. Ill, p. 161 (testimony of Dr. Bult-man ); D. Ex. 94. reporting to the Secretary []in a uniform form and manner established by the Secretary, by age group and by basis of eligibility for medical assistance ... information relating to early and periodic screening, diagnostic, and treatment services provided' under the plan during each fiscal year ... (i) the number of children provided child health screening services, (ii) the number of children referred for corrective treatment ... (iii) the number of children receiving dental services, and (iv) the State’s results in attaining the participation goals set for the State under section 1905(r). Defendants maintain that, although the CMS-416 participation ratio potentially understates the performance of the Texas Health Steps program, “[t]he participation rate and the screening rate [as reported on the CMS-416] are the best-and the only fair-measures of the Texas Health Steps program’s performance.” Defendants’ Post-Hearing Brief at 21; Tr. Vol. IV, p. 16 (testimony of Dr. Bultman). Plaintiffs, however, maintain that the CMS-416 participation ratio overstates the number of eligible children who actually receive medical checkups and is thus not a reliable indicator of the Texas Health Steps program’s overall performance. Plaintiffs’ Post-Hearing Brief at 44; Tr. Vol. VIII, p. 91 (closing argument of Plaintiffs’ counsel). Furthermore, Plaintiffs argue, any increase in the CMS-416 participation ratio is insufficient to warrant relief under Rule 60(b). See Tr. Vol. VIII, pp. 89-90, 99 (closing argument of Plaintiffs’ counsel). With respect to dental services, Defendants argue that Texas’ dental program is exemplary when compared to other States’ and that Texas’ dental participation ratio has significantly increased since entry of the Consent Decree. Plaintiffs respond that the number of class members receiving no preventive dental care is rapidly increasing, thus Defendants’ dental program’s performance has not significantly improved. 2. Medical Checkups a. How the CMS-416 Participation Ratio is Calculated The CMS-416 participation ratio is the fraction resulting from the number of class members who receive at least one initial or periodic screening over the number of class members “who should receive at least one periodic screening.” D. Ex. 141 at 2 (testimony of Cynthia Ruff); D. Ex. 97 at 3. The number of class members who should have received a checkup during the year, the denominator in the equation, is not the total number of class members; instead, it is adjusted to account for both the average period of Medicaid eligibility during the year and the number of recommended screens per age group. D. Ex. 97 at 3. For example, the average period of eligibility in 2003 and 2004 was .74 years, or slightly less than nine months, so the total number of class members is- multiplied by .74 in the process of determining the denominator for the ratio; D. Ex. 94; D. Ex. 96 at 1. The exact formula that Defendants use in this calculation has recently changed twice-in 1999 and 2001-the implications of which are discussed in Part II(A)(2)(e)(ii), infra. b. The Participation Ratio, as Reported in the CMS-416, is Inflated It is initially noted that the Court has already visited the merits of the participation ratio as reported in the HCFA/CMS form 416. See Frew, 109 F.Supp.2d at 602-613. In 2000, the Court found that “the reported participation ratios are inflated indicators of the actual participation rates among the plaintiff class.” Id. at 602. The Court reasoned that, because the participation ratio is adjusted for the average length of time that class members receive Medicaid during the reporting period; the reported participation ratios did not accurately reflect actual participation rates. Id. For the reasons discussed in the 2000 opinion, in addition to the reasons detailed below, the Court maintains that the CMS-416 participation ratio is an inflated indicator of actual participation rates among the plaintiff class and does not accurately reflect the Texas Health Steps program’s overall performance. Because Defendants re-urge the argument that CMS-416 participation ratios accurately reflect actual participation rates among the class, which the Court rejected in 2000, the Court will again discuss the shortcomings of the participation ratio as reported on the CMS-416. Defendants’ argument in support of using the CMS-416 participation ratio as the primary evaluation metric for Texas Health Steps is three-fold: (1) Defendants should not be held accountable for class members with short periods of Medicaid enrollment; (2) participation rate calculations beyond the requirements of the CMS-416,- such as those required by Consent Decree ¶ 284, misrepresent the Texas Health Steps program’s performance; and (3) even though CMS-416 participation ratios potentially understate Texas Health Steps’ performance, because of its exclusion of class members with some form of medical insurance in addition to Medicaid, they still evidence significant improvement in the program. Defendants’ Post-Hearing Brief at 18-20; Tr. Vol. VIII, pp. 79-82 (closing argum