Prospective Relief Allowed, Property Interest Denied: Fifth Circuit Applies Ex parte Young to Ongoing Medical‑License Restrictions and NPDB Reporting, but Rejects Due‑Process Claim to an Unobtained Unrestricted License

Introduction

This Fifth Circuit decision, Hernandez Caruso v. Texas Medical Board, addresses the intersection of sovereign immunity, medical licensing discretion, and federal constitutional claims brought by a pro se physician seeking to remove restrictions from her Texas medical license and to expunge related public postings and National Practitioner Data Bank (NPDB) reports. The case arises from the Texas Medical Board’s (TMB) decision to grant Dr. Sonia Hernandez Caruso only a restricted license—prohibiting ophthalmological surgical procedures—after years of licensing proceedings and administrative review.

The core issues were:

• Whether sovereign immunity barred the suit (especially as to damages and injunctive relief);
• Whether Ex parte Young permitted prospective injunctive relief against state officials for ongoing postings and licensing restrictions;
• Whether the complaint stated viable federal claims for procedural due process, equal protection, and other theories; and
• Whether the district court properly declined supplemental jurisdiction over state-law claims.

The court affirmed dismissal. It clarified that while Ex parte Young allows prospective challenges to ongoing licensing restrictions and reporting, the plaintiff failed to state plausible federal claims—most significantly because there is no cognizable due‑process property interest in an unrestricted medical license the applicant never previously held.

Summary of the Judgment

The Fifth Circuit (per curiam; unpublished) affirmed the district court’s Rule 12(b)(1) and 12(b)(6) dismissal of Dr. Caruso’s federal claims and the refusal to exercise supplemental jurisdiction over her state-law claims. The panel held:

• Sovereign immunity bars damages claims against the Texas Medical Board (a state agency) and officials in their official capacities. It does not bar Dr. Caruso’s claims for prospective injunctive relief under Ex parte Young because the alleged harms (license restrictions and public/NPDB postings) are ongoing.
• Despite clearing the sovereign-immunity hurdle for prospective relief, the complaint failed to state a claim:
  • Due process (Fifth Amendment): Inapplicable to state actors.
  • Due process (Fourteenth Amendment): No property interest in a full, unrestricted license because she never held one; even assuming a property interest, she received adequate notice and hearing.
  • Equal protection: Inadequately pled; no factual allegations that identified comparators were similarly situated “in all relevant respects.”
  • Eighth Amendment: Inapplicable outside criminal punishment following conviction.
  • Other statutes invoked (e.g., 18 U.S.C. § 242; Title VII; 42 U.S.C. § 1981; HCQIA; 42 C.F.R. Part 1003) either provide no private right of action or are otherwise inapplicable to medical licensing disputes with state agencies.
• With all federal claims dismissed, the court affirmed the district court’s decision to decline supplemental jurisdiction over state-law claims.

Factual and Procedural Background (Condensed)

Dr. Caruso, an ophthalmologist trained in New York, first applied for a Texas medical license in 2011. The TMB denied that application in 2012, referencing competence and prior disciplinary action by a health care entity. An ALJ in 2015 found her ineligible for an unrestricted license—among other reasons, she had not performed surgery since 2011 and needed more training. After a second application in 2018, the TMB again moved toward denial. Following a 2020 administrative hearing, in March 2022 the TMB granted a license—but restricted all ophthalmological surgery until she demonstrated competence via additional surgical training (including at least completion of an ACGME-approved ophthalmology surgical training program) and satisfied the Board that she could independently perform surgical procedures.

The TMB updated her physician profile to reflect “Disciplinary Restrictions” and reported to the NPDB as required. In 2024, Dr. Caruso filed this pro se federal suit asserting constitutional and statutory claims, seeking both damages and an injunction lifting restrictions and removing the public and NPDB postings. The district court dismissed; the Fifth Circuit affirmed.

Detailed Analysis

1) Statutory and Regulatory Framework

• Texas Medical Board Authority: The TMB has statutory authority to regulate medicine and to issue full or restricted licenses, prescribe qualifications, and deny licensure for specific reasons. See Tex. Occ. Code §§ 152.001, 155.002, 155.006–.007.
• Disciplinary Character of Restrictions: Under Texas law, issuing a restricted license or denying a full license is a “Method[] of Discipline.” Tex. Occ. Code § 164.001(b)(3).
• NPDB Reporting: Federal and Texas law require reporting of disciplinary actions to the NPDB. See 42 U.S.C. § 11101(2); Tex. Occ. Code § 164.060(b)(4).

2) Precedents Cited and Their Influence

• City of Austin v. Paxton, 943 F.3d 993 (5th Cir. 2019): Confirms sovereign immunity for states, agencies, and officials acting in official capacities; frames the immunity analysis.
• Will v. Michigan Dep’t of State Police, 491 U.S. 58 (1989): States and state officials in their official capacities are not “persons” under § 1983 for damages; supports dismissal of damages claims.
• Ex parte Young, 209 U.S. 123 (1908): Permits suits for prospective injunctive relief against state officials alleged to be violating federal law; central to allowing the court to consider prospective relief claims despite sovereign immunity.
• Verizon Maryland, Inc. v. Public Service Commission, 535 U.S. 635 (2002): Courts conduct a “straightforward inquiry” under Ex parte Young to determine whether the complaint alleges an ongoing violation and seeks prospective relief; the panel relied on this to treat TMB postings and license restrictions as ongoing.
• Planned Parenthood Gulf Coast, Inc. v. Phillips, 24 F.4th 442 (5th Cir. 2022): Reinforces that Ex parte Young applies where prospective relief is sought for ongoing harm; informs the court’s treatment of the continuing license status and postings.
• Book People, Inc. v. Wong, 91 F.4th 318 (5th Cir. 2024): Clarifies that state officials must have “some connection” with enforcement for Ex parte Young; TMB officials had the necessary connection to licensing and reporting.
• Green Valley Special Utility Dist. v. City of Schertz, 969 F.3d 460 (5th Cir. 2020): Past actions that continue to cause present harm can support prospective relief; used to rebut the argument that relief sought was retrospective.
• Ashcroft v. Iqbal, 556 U.S. 662 (2009), and Bell Atlantic Corp. v. Twombly, 550 U.S. 544 (2007): Pleading standards; the complaint must state a plausible claim for relief; undergirded 12(b)(6) dismissals.
• Jones v. City of Jackson, 203 F.3d 875 (5th Cir. 2000): Fifth Amendment due process applies to federal actors only; defeated Dr. Caruso’s Fifth Amendment theory.
• Board of Regents v. Roth, 408 U.S. 564 (1972): Defines protected property interests as those grounded in independent sources of law and more than unilateral expectations; informed the property‑interest analysis.
• Ramirez v. Ahn, 843 F.2d 864 (5th Cir. 1988): A previously acquired benefit (e.g., an existing license) can create a protectable property interest in continued enjoyment; critical to rejecting a property interest in an unrestricted license never held.
• Texas Entertainment Association, Inc. v. Hegar, 10 F.4th 495 (5th Cir. 2021); Wheeler v. Miller, 168 F.3d 241 (5th Cir. 1999); Nordlinger v. Hahn, 505 U.S. 1 (1992): Equal protection comparators must be similarly situated “in all relevant respects”; supported dismissal of the equal protection claim.
• Palermo v. Rorex, 806 F.2d 1266 (5th Cir. 1987); Ingraham v. Wright, 430 U.S. 651 (1977): Eighth Amendment applies to criminal punishment post‑conviction; extinguishes the Eighth Amendment claim.
• Jett v. Dallas Independent School District, 491 U.S. 701 (1989): § 1983 is the exclusive federal damages remedy for § 1981 rights against state actors; negates standalone § 1981 damages claim.
• Danos v. Jones, 652 F.3d 577 (5th Cir. 2011): Texas ultra vires exception requires more than conclusory allegations; used to reject the ultra vires argument.
• Brookshire Bros. Holding, Inc. v. Dayco Products, Inc., 554 F.3d 595 (5th Cir. 2009): General rule to decline supplemental jurisdiction when all federal claims are dismissed before trial.

3) Legal Reasoning

• Sovereign Immunity and Ex parte Young:
  • The TMB and its officials (in their official capacities) are protected from damages claims by sovereign immunity and by the rule that they are not “persons” for § 1983 damages liability.
  • However, Dr. Caruso’s request to remove ongoing license restrictions and ongoing postings (including NPDB reporting) was prospective in nature. The court held that Ex parte Young applied because:
    • Officials had “some connection” to enforcement of the licensing and reporting regime.
    • The alleged harms (current license status; continuing public/NPDB listings) are ongoing; relief would operate prospectively.
  • Important clarification: The court stressed that the 12(b)(1) sovereign‑immunity inquiry does not evaluate the merits; satisfying Ex parte Young only opens the door to a merits analysis under Rule 12(b)(6).
• Due Process (Fifth and Fourteenth Amendments):
  • Fifth Amendment: Fails outright because it constrains federal actors, and the TMB is a state entity.
  • Fourteenth Amendment property interest: Texas law deems practicing medicine a privilege, not a natural right, but due process can still attach to previously acquired benefits (e.g., an existing license). Dr. Caruso never possessed a full, unrestricted Texas license; her first Texas license (2022) was restricted. She therefore lacked a property interest in an unrestricted license she had never obtained. On that basis, the due‑process claim failed.
  • Alternative holding: Even assuming a cognizable property interest, the process she received—notice, an administrative hearing before an ALJ, an opportunity for post‑hearing submissions, and a reasoned final order—satisfied procedural due process.
• Equal Protection:
  • Dr. Caruso alleged that three male physicians received full, unrestricted licenses despite lacking retina/surgery training while she did not.
  • The court required facts showing these comparators were similarly situated “in all relevant respects,” such as whether they had comparable disciplinary histories or prior denials. The complaint contained no such specifics; the claim was dismissed.
• Eighth Amendment:
  • Inapplicable outside criminal punishment following conviction; claim dismissed.
• Other Federal Theories:
  • 18 U.S.C. § 242 (criminal civil‑rights statute): No private right of action.
  • Title VII (42 U.S.C. § 2000e): Employment discrimination statute, not applicable to a licensing dispute with a state board.
  • 42 U.S.C. § 1981: As to state actors, the exclusive damages remedy is § 1983; the § 1981 claim cannot stand alone.
  • 42 C.F.R. Part 1003: Civil monetary penalties under HHS OIG regulations; irrelevant to these facts.
  • HCQIA (42 U.S.C. §§ 11111–12): Provides immunity and reporting framework but no private right of action to compel or undo NPDB entries. The complaint identified no viable HCQIA claim.
• Ultra Vires:
  • Under Texas law, the ultra vires exception to sovereign immunity requires more than a conclusory assertion that officials acted beyond their authority. The complaint offered only a single, conclusory sentence; dismissal was proper.
• Supplemental Jurisdiction:
  • With all federal claims dismissed at the pleadings stage, the district court adhered to the general rule of declining supplemental jurisdiction over state-law claims; the Fifth Circuit affirmed.
• Qualified Immunity:
  • The district court did not reach qualified immunity, and the Fifth Circuit declined to consider it in the first instance.

4) Impact and Implications

• Ex parte Young remains a viable pathway for professionals to seek prospective injunctive relief against ongoing licensing restrictions and continuing public/NPDB postings. The court’s treatment of the license status and postings as ongoing harms will be frequently cited in future licensing disputes across professional boards.
• But pleading standards are exacting:
  • Due Process: Plaintiffs challenging restrictions on a license they already possess must articulate a cognizable property (or liberty) interest. This decision underscores that there is no property interest in an unobtained unrestricted license. Where the target is the removal of restrictions, plaintiffs should plead a theory tied to their existing license interests or a liberty interest (e.g., stigma-plus), along with concrete process deficiencies.
  • Equal Protection: Detailed comparator pleading is crucial. Plaintiffs must allege how chosen comparators mirror them in all relevant respects, including disciplinary history and procedural posture.
• Medical boards retain broad discretion to impose and maintain restrictions grounded in competence and public protection, particularly where applicants have time gaps in surgical practice or prior adverse findings. So long as notice and hearing are provided, constitutional due process challenges will be difficult to sustain.
• NPDB reporting and public disclosures are tightly linked to state disciplinary actions. While plaintiffs may style relief as prospective under Ex parte Young, they must still state a substantive federal claim; HCQIA does not supply a private right to alter NPDB entries.
• Strategic litigation takeaway: Where federal claims are thin, state-law theories (defamation, business disparagement, ultra vires under Texas law) may be more promising—but only in the proper forum and after clearing sovereign immunity hurdles particular to state law. Federal courts commonly decline supplemental jurisdiction once federal claims fall out early.

Complex Concepts Simplified

• Sovereign Immunity: States and their agencies are generally immune from private suits for money in federal court. You can still sue state officials for an order to stop an ongoing violation of federal law (prospective relief) under Ex parte Young.
• Ex parte Young: A legal doctrine allowing suits against state officials (not the state itself) for court orders that stop ongoing violations. Key: the harm must be continuing, and the relief must look forward (e.g., remove a current restriction or posting), not just declare past actions unlawful.
• Property Interest (Due Process): Due process protects certain established interests, not hopes or expectations. If you never held an unrestricted license, you typically lack a property interest in obtaining one. You may have process rights in keeping a license you already have, but not necessarily in upgrading or expanding it.
• Liberty Interest / Stigma‑Plus (not adjudicated here): Government defamation alone usually isn’t enough for a constitutional claim; there must be reputational harm plus a change in legal status or right (for example, revoking a license). Plaintiffs who rely on reputational injury must connect it to a concrete change in legal status to state a federal due process claim.
• Similarly Situated (Equal Protection): To claim unequal treatment, you must identify others who are aligned with you in all relevant ways (e.g., same licensure history, similar conduct), and show they were treated better.
• Rule 12(b)(1) vs. Rule 12(b)(6): 12(b)(1) tests the court’s power to hear the case (jurisdiction, including sovereign immunity). 12(b)(6) asks whether the complaint plausibly alleges facts that, if true, would entitle the plaintiff to relief under the law.
• Unpublished Opinion: Not designated for publication under Fifth Circuit rules; it may have limited precedential weight but is still persuasive and instructive.

Conclusion

Hernandez Caruso v. Texas Medical Board underscores two critical points in professional‑licensing litigation. First, Ex parte Young remains a robust avenue for seeking prospective injunctive relief where a professional’s current license status and public/NPDB disclosures impose ongoing effects; the Fifth Circuit explicitly recognizes such harms as prospective in nature. Second, plaintiffs must still plausibly plead a violation of federal law. There is no due‑process property interest in an unrestricted license never held, and bare comparators will not sustain an equal‑protection claim. Criminal and employment statutes generally do not translate to licensing disputes with state boards, and HCQIA does not create a private right to rewrite NPDB history.

Practically, the decision strengthens medical boards’ discretion to impose and report restrictions grounded in competence and public safety, provided they afford adequate process. For litigants, it charts the narrow path forward: tailor claims to recognized interests (existing license rights or cognizable liberty interests), allege specific process defects, and meet the comparator standard with concrete facts. Failing that, dismissal at the pleadings stage—and relegation of any surviving disputes to state‑law forums—will remain the norm.