Experts: No link between Asperger's, violence

NEW YORK (AP) — While an official has said that the 20-year-old gunman in the Connecticut school shooting had Asperger's syndrome, experts say there is no connection between the disorder and violence.

Asperger's is a mild form of autism often characterized by social awkwardness.

"There really is no clear association between Asperger's and violent behavior," said psychologist Elizabeth Laugeson, an assistant clinical professor at the University of California, Los Angeles.

Little is known about Adam Lanza, identified by police as the shooter in the Friday massacre at a Newtown, Conn., elementary school. He fatally shot his mother before going to the school and killing 20 young children, six adults and himself, authorities said.

A law enforcement official, speaking on condition of anonymity because the person was not authorized to discuss the unfolding investigation, said Lanza had been diagnosed with Asperger's.

High school classmates and others have described him as bright but painfully shy, anxious and a loner. Those kinds of symptoms are consistent with Asperger's, said psychologist Eric Butter of Nationwide Children's Hospital in Columbus, Ohio, who treats autism, including Asperger's, but has no knowledge of Lanza's case.

Research suggests people with autism do have a higher rate of aggressive behavior — outbursts, shoving or pushing or angry shouting — than the general population, he said.

"But we are not talking about the kind of planned and intentional type of violence we have seen at Newtown," he said in an email.

"These types of tragedies have occurred at the hands of individuals with many different types of personalities and psychological profiles," he added.

Autism is a developmental disorder that can range from mild to severe. Asperger's generally is thought of as a mild form. Both autism and Asperger's can be characterized by poor social skills, repetitive behavior or interests and problems communicating. Unlike classic autism, Asperger's does not typically involve delays in mental development or speech.

Experts say those with autism and related disorders are sometimes diagnosed with other mental health problems, such as depression, anxiety, bipolar disorder or obsessive-compulsive disorder.

"I think it's far more likely that what happened may have more to do with some other kind of mental health condition like depression or anxiety rather than Asperger's," Laugeson said.

She said those with Asperger's tend to focus on rules and be very law-abiding.

"There's something more to this," she said. "We just don't know what that is yet."

After much debate, the term Asperger's is being dropped from the diagnostic manual used by the nation's psychiatrists. In changes approved earlier this month, Asperger's will be incorporated under the umbrella term "autism spectrum disorder" for all the ranges of autism.

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AP Writer Matt Apuzzo contributed to this report.

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Online:

Asperger's information: http://1.usa.gov/3tGSp5

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School Safety Questioned After Conn. Shooting

Along with fire drills, schools have been conducting lockdown drills -- often known as active shooter drills -- since the Columbine massacre in 1999.

But safety officials do not agree yet on what teachers and students should do when a homicidal gunman invades their school.

At Sandy Hook Elementary School, teachers, staff and students had been drilled on how to handle such a situation.

"We practice it, and they knew what to do, and you just think about protecting the kids, and just doing the right thing," library clerk Mary Ann Jacob said.

She said had been drilled to send the kids in the library to a back closet between book shelves, a plan developed in advance.

"You have to have a certain amount of fire drills, and evacuation drills, and a certain amt of lockdown drills," she said. "Kids know the routine, and the teachers know the routine, and everyone has a spot in the room where they are supposed to go to."

Click here for more photos of the scene.

School safety expert Ken Trump told ABC News that he thinks the Sandy Hook teachers did what they could to protect their students.

"It does sound as though the teachers did everything humanly possible, down to risking their lives, to protect the children in this Connecticut school," Trump said.

Connecticut Shooting Tragedy: Two Brothers' Escape Watch Video

Connecticut Shooting Tragedy: The Investigation Watch Video

Connecticut Shooting Tragedy: Remembering the Victims Watch Video

The school's principal and five other adults died in the Sandy Hook school shooting in Newtown, Conn.

"Teaching kids to lock down, securing your rooms, and, in some cases, teachers stepping forth to protect the children at the risk of their own lives, is something that we see occurring more and more over the years in school safety," Trump said.

He and others particularly praised the actions of first grade teacher Kaitlin Roig, who locked her classroom door and barricaded herself and her 14 students in a locked bathroom.

But former SWAT officer Greg Crane told ABC News that he thinks existing lockdown procedures aren't sufficient.

"What she [Roig] did was a fantastic move," said Crane, who founded a school safety program called ALICE, which stands for alert, lock down, inform, counter, evacuate.

"Was she taught that move? Did every teacher know to lock the door and also barricade it? If that's the case, why weren't other teachers taught that?" Crane asked.

Most schools tell teachers to lock their doors and sit quietly until helps arrives, Crane said.

Typical are the procedures, obtained by ABCNews.com, outlined by a New Jersey school district that calls their drills "Lock Down Yellow."

Instructions to the students include:

"Go to the room nearest your location in the hallway.

"No one will be able to leave room for any reason.

"Silence must be maintained (Use of cell phones are not permitted).

"Make sure you are marked present.

"Do not leave the classroom until directed by PA System, telephone or by an administrator."

But Crane founded ALICE because he believed there was something wrong with the lock down-only policies in most schools.

"We've taught a generation of Americans to be passive and static and wait for police," said Crane, whose wife was an elementary school principal in Texas at the time of the Columbine attack.

"We don't recommend just locking a door because locked doors have been defeated before," Crane said. "Try to make yourself as hard a target as possible."

ALICE argues students and teachers should not be passive and that they should improvise. He even suggests they throw things are their attacker.

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Egyptians vote on divisive constitution

CAIRO/ALEXANDRIA (Reuters) - Egyptians queued to vote on Saturday on a constitution promoted by its Islamist backers as the way out of a prolonged political crisis and rejected by opponents as a recipe for further divisions in the Arab world's biggest nation.

Soldiers joined police to secure the referendum after deadly protests during the buildup. Street brawls erupted again on Friday in Alexandria, Egypt's second city, but voting proceeded quietly there, with no reports of violence elsewhere.

President Mohamed Mursi provoked angry demonstrations when he issued a decree last month expanding his powers and then fast-tracked the draft constitution through an assembly dominated by his Muslim Brotherhood group and its allies. At least eight people were killed in clashes last week outside the presidential palace.

The liberal, secular and Christian opposition says the constitution is too Islamist and tramples on minority rights. Mursi's supporters say the charter is needed if progress is to be made towards democracy nearly two years after the fall of military-backed strongman Hosni Mubarak.

"The sheikhs (preachers) told us to say 'yes' and I have read the constitution and I liked it," said Adel Imam, a 53-year-old queuing to vote in a Cairo suburb. "The president's authorities are less than before. He can't be a dictator."

Opposition politician and Nobel Peace Prize laureate Mohamed ElBaradei wrote on Twitter: "Adoption of (a) divisive draft constitution that violates universal values and freedoms is a sure way to institutionalize instability and turmoil."

Official results will not be announced until after a second round of voting next Saturday. But partial results and unofficial tallies are likely to emerge soon after the first round, giving an idea of the overall trend.

In order to pass, the constitution must be approved by more than 50 percent of voters who cast ballots. A little more than half of Egypt's electorate of 51 million are eligible to vote in the first round in Cairo and other cities.

TRANSITION

Christians, making up about 10 percent of Egypt's 83 million people and who have long grumbled of discrimination, were among those waiting at a polling station in Alexandria to oppose the basic law. They fear Islamists, long repressed by Mubarak, will restrict social and other freedoms.

"I voted 'no' to the constitution out of patriotic duty," Michael Nour, a 45-year-old Christian teacher in Alexandria. "The constitution does not represent all Egyptians," he said.

Islamists are counting on their disciplined ranks of supporters and the many Egyptians who may fall into line in a desperate bid to end turmoil that has hammered the economy and sent Egypt's pound to eight-year lows against the dollar.

"I voted 'yes' for stability," said shopkeeper Ahmed Abou Rabu, 39. "I cannot say all the articles of the constitution are perfect but I am voting for a way forward. I don't want Egyptians to go in circles, for ever lost in this transition."

Mursi was among the early voters after polls opened at 8 a.m. (1:00 a.m. Eastern Time). He was shown on television casting his ballot shielded by a screen and then dipping his finger in ink - a measure to prevent people voting twice.

One senior official in the committee overseeing the referendum said Saturday's vote could extend to Sunday if crowds were too heavy to allow everyone cast ballots in one day. Voting for Egyptians abroad that began on Wednesday has been extended to Monday, the state news agency reported.

After weeks of turbulence, there has been limited public campaigning. Opposition politicians and parties, beaten in two elections since Mubarak's overthrow, only announced on Wednesday they backed a "no" vote instead of a boycott.

Flag-waving Islamists gathered peacefully at one of the main mosques on Friday, some shouting "Islam, Islam" and "We've come here to say 'yes' to the constitution".

PALACE SIT-IN

Opposition supporters assembled outside the presidential palace, where there has been a sit-in for days. The walls of the palace, ringed by tanks, are scrawled with anti-Mursi graffiti.

The referendum will be held on two days covering different regions, with the second round on December 22, because there are not enough judges willing to monitor all polling stations after some in the judiciary said they would boycott the vote.

Egyptians are being asked to accept or reject a constitution that must be in place before a parliamentary election can be held next year to replace an Islamist-led parliament dissolved this year. Many hope this will lead Egypt towards stability.

If the constitution is voted down, a new assembly will have to be formed to draft a revised version, a process that could take up to nine months.

The army has deployed about 120,000 troops and 6,000 tanks and armored vehicles to protect polling stations and other government buildings. While the military backed Mubarak and his predecessors, it has not intervened in the present crisis.

(Writing by Edmund Blair and Giles Elgood; Editing by Andrew Heavens)

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Public skydiving event in S'pore may become yearly affair

SINGAPORE: Daredevils can rejoice, as there are plans for a yearly public skydiving event to be held in Singapore, subject to authorities' approval.

The first of the plunges took place on Saturday above Sentosa, where 15 thrill-seekers took the leap of faith.

It was held in conjunction with Asia Pacific's inaugural indoor skydiving world championships, which runs from 14 to 16 December at iFly Singapore in Sentosa.

"The key thing about this tandem jump is to make the sports available to the Singaporeans," said Lawrence Koh, the founder of iFly.

"Skydiving seems to be very niche in Singapore, so we can show that we can actually do skydiving here, occasionally."

Some of the skydiving participants were children.

"As a tandem passenger, as long as you're (physically) fit, you can do it," said Pierre-Francois Vilquin, the tandem skydiving instructor at iFly.

"You know, we've taken people that are over 80 years old."

The event organisers had to seek clearance from agencies like the Defence Ministry, Civil Aviation Authority of Singapore and police.

A basic tandem skydiving package costs around S$1,400.

- CNA/xq

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Quota bill: Mulayam threatens UPA

MAINPURI (UP): Terming the proposed legislation on SC/ST quota in promotion as anti-national, Samajwadi Party supremo Mulayam Singh Yadav today said his party would review its stand on supporting the UPA government from outside, if the Bill is passed.

"If voting is done on the Bill in the House, I will reconsider my party's support to the government.... We will review party's outside support to the government," he told reporters here.

"The bill is anti-national and will divide the people. My party has opposed the bill inside and outside the House and will continue its opposition," Yadav said.

He said it was unfortunate that his party members who were opposing the "anti-people" bill were thrown out of the House.

Yadav said that he had asked the Prime Minister why he was not "bringing out the facts about the posts that will be captured by people" due to reservation in promotion.

"For just 22 per cent people, rest of the population including general candidates, backward castes and other communities will suffer immensely creating problem in society," he warned.

Yadav claimed that if the bill was passed "then no Prime Minister will get a cabinet secretary nor any chief minister will get chief secretary of any other caste".

The UPA has just over 250 MPs in the Lok Sabha after the TMC withdrew support from the government. The UPA is provided crucial support from outside by 21 MPs of the Samajwadi Party and 22 MPs of Mayawati-led Bahujan Samaj Party, which is batting for the quota bill.

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Fewer health care options for illegal immigrants

ALAMO, Texas (AP) — For years, Sonia Limas would drag her daughters to the emergency room whenever they fell sick. As an illegal immigrant, she had no health insurance, and the only place she knew to seek treatment was the hospital — the most expensive setting for those covering the cost.

The family's options improved somewhat a decade ago with the expansion of community health clinics, which offered free or low-cost care with help from the federal government. But President Barack Obama's health care overhaul threatens to roll back some of those services if clinics and hospitals are overwhelmed with newly insured patients and can't afford to care for as many poor families.

To be clear, Obama's law was never intended to help Limas and an estimated 11 million illegal immigrants like her. Instead, it envisions that 32 million uninsured Americans will get access to coverage by 2019. Because that should mean fewer uninsured patients showing up at hospitals, the Obama program slashed the federal reimbursement for uncompensated care.

But in states with large illegal immigrant populations, the math may not work, especially if lawmakers don't expand Medicaid, the joint state-federal health program for the poor and disabled.

When the reform has been fully implemented, illegal immigrants will make up the nation's second-largest population of uninsured, or about 25 percent. The only larger group will be people who qualify for insurance but fail to enroll, according to a 2012 study by the Washington-based Urban Institute.

And since about two-thirds of illegal immigrants live in just eight states, those areas will have a disproportionate share of the uninsured to care for.

In communities "where the number of undocumented immigrants is greatest, the strain has reached the breaking point," Rich Umbdenstock, president of the American Hospital Association, wrote last year in a letter to Obama, asking him to keep in mind the uncompensated care hospitals gave to that group. "In response, many hospitals have had to curtail services, delay implementing services, or close beds."

The federal government has offered to expand Medicaid, but states must decide whether to take the deal. And in some of those eight states — including Texas, Florida and New Jersey — hospitals are scrambling to determine whether they will still have enough money to treat the remaining uninsured.

Without a Medicaid expansion, the influx of new patients and the looming cuts in federal funding could inflict "a double whammy" in Texas, said David Lopez, CEO of the Harris Health System in Houston, which spends 10 to 15 percent of its $1.2 billion annual budget to care for illegal immigrants.

Realistically, taxpayers are already paying for some of the treatment provided to illegal immigrants because hospitals are required by law to stabilize and treat any patients that arrive in an emergency room, regardless of their ability to pay. The money to cover the costs typically comes from federal, state and local taxes.

A solid accounting of money spent treating illegal immigrants is elusive because most hospitals do not ask for immigration status. But some states have tried.

California, which is home to the nation's largest population of illegal immigrants, spent an estimated $1.2 billion last year through Medicaid to care for 822,500 illegal immigrants.

The New Jersey Hospital Association in 2010 estimated that it cost between $600 million and $650 million annually to treat 550,000 illegal immigrants.

And in Texas, a 2010 analysis by the Health and Human Services Commission found that the agency had provided $96 million in benefits to illegal immigrants, up from $81 million two years earlier. The state's public hospital districts spent an additional $717 million in uncompensated care to treat that population.

If large states such as Florida and Texas make good on their intention to forgo federal money to expand Medicaid, the decision "basically eviscerates" the effects of the health care overhaul in those areas because of "who lives there and what they're eligible for," said Lisa Clemans-Cope, a senior researcher at the Urban Institute.

Seeking to curb expenses, hospitals might change what qualifies as an emergency or cap the number of uninsured patients they treat. And although it's believed states with the most illegal immigrants will face a smaller cut, they will still lose money.

The potential impacts of reform are a hot topic at MD Anderson Cancer Center in Houston. In addition to offering its own charity care, some MD Anderson oncologists volunteer at a county-funded clinic at Lyndon B. Johnson General Hospital that largely treats the uninsured.

"In a sense we've been in the worst-case scenario in Texas for a long time," said Lewis Foxhall, MD Anderson's vice president of health policy in Houston. "The large number of uninsured and the large low-income population creates a very difficult problem for us."

Community clinics are a key part of the reform plan and were supposed to take up some of the slack for hospitals. Clinics received $11 billion in new funding over five years so they could expand to help care for a swell of newly insured who might otherwise overwhelm doctors' offices. But in the first year, $600 million was cut from the centers' usual allocation, leaving many to use the money to fill gaps rather than expand.

There is concern that clinics could themselves be inundated with newly insured patients, forcing many illegal immigrants back to emergency rooms.

Limas, 44, moved to the border town of Alamo 13 years ago with her husband and three daughters. Now single, she supports the family by teaching a citizenship class in Spanish at the local community center and selling cookies and cakes she whips up in her trailer. Soon, she hopes to seek a work permit of her own.

For now, the clinic helps with basic health care needs. If necessary, Limas will return to the emergency room, where the attendants help her fill out paperwork to ensure the government covers the bills she cannot afford.

"They always attended to me," she said, "even though it's slow."

___

Sherman can be followed on Twitter at https://twitter.com/chrisshermanAP .

Plushnick-Masti can be followed on Twitter at https://twitter.com/RamitMastiAP .

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School Shooting: Officials Seek Details on Gunman

The FBI is in at least three states interviewing relatives and friends of the elementary school gunman who killed 20 children, seven adults and himself, trying to put together a better picture of the shooter and uncover any possible explanation for the massacre, ABC News has learned.

The authorities have fanned out to New Jersey, Connecticut and Massachusetts to interview relatives of Adam Lanza, 20, and his mother, who was one of Lanza's shooting victims.

The victims died Friday when Lanza invaded Sandy Hook Elementary School in Newtown, Conn., and sprayed staff and students with bullets, officials said. Lanza also was found dead in the school.

Lt. Paul Vance said 18 children died in the school and two more died later in a hospital.

Six adults also were slain, bringing the total to 26. Among them was the school's principal, Dawn Hochsprung, multiple sources told ABC News. Another adult victim was teacher Vicki Soto, her cousin confirmed.

In addition to the casualties at the school, Lanza's mother, Nancy Lanza, was killed in her home, federal and state sources told ABC News.

According to sources, Lanza shot his mother in the face, then left his house armed with at least two semi-automatic handguns, a Glock and a Sig Sauer, and a semi-automatic rifle. He was also wearing a bulletproof vest.

READ: Connecticut Shooter Adam Lanza: 'Obviously Not Well'

Lanza then drove to the elementary school and continued his rampage, authorities said.

Newtown Teacher Kept 1st Graders Calm During Massacre Watch Video

Newtown School Shooting: What to Tell Your Kids Watch Video

It appeared that Lanza died from what was believed to be a self-inflicted gunshot wound. The rifle was found in his car.

"Evil visited this community today," Gov. Dan Malloy said at a news conference Friday evening.

CLICK HERE for more photos from the scene.

In the early confusion surrounding the investigation, federal sources initially identified the suspect as Adam's older brother Ryan Lanza, 24. Identification belonging to Ryan Lanza was found at the shooting scene, federal sources told ABC News.

Ryan Lanza soon took to Facebook to say he was alive and not responsible for the shooting. He later was questioned by police.

During the rampage, first-grade teacher Kaitlin Roig, 29, locked her 14 students in a class bathroom and listened to "tons of shooting" until police came to help.

"It was horrific," Roig said. "I thought we were going to die."

She said that the terrified kids were saying, "I just want Christmas. ... I don't want to die. I just want to have Christmas."

A tearful President Obama said Friday that there was "not a parent in America who doesn't feel the overwhelming grief that I do."

The president had to pause to compose himself after saying these were "beautiful little kids between the ages of 5 and 10."

As he continued with his statement, Obama wiped away tears from each eye. He has ordered flags flown as half staff.

It is the second worst mass shooting in U.S. history, exceeded only by the Virginia Tech shooting in 2007 when 32 were killed before the shooter turned the gun on himself. The carnage in Connecticut exceeded the 1999 Columbine High School shooting in which 13 died and 24 were injured.

Friday's shooting came three days after masked gunman Jacob Roberts opened fire in a busy Oregon mall, killing two before turning the gun on himself.

The Connecticut shooting occurred at the Sandy Hook Elementary School, which includes 450 students in grades K-4. The town is located about 12 miles east of Danbury, Conn.

The massacre prompted the town of Newtown to lock down all its schools and draw SWAT teams to the school, authorities said.

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Golf: Garcia shows his class at Johor Open

KUALA LUMPUR: World number 20 Sergio Garcia of Spain charged up the leaderboard to hold the second-round lead at nine-under through 12 holes at the weather-interrupted $2 million Iskandar Johor Open on Friday.

Almost three hours of play was lost to bad weather and play was suspended as darkness began falling, leaving 117 players to return at 7.30 am on Saturday to resume their round.

Opening round leader David Lipsky of the United States, who has yet to start his second round, shared the lead with Garcia after signing for a 63 in the morning.

Three-time Asian Tour Order of Merit winner Thongchai Jaidee of Thailand is six-under through 13 holes. He is among the five players who are three shots behind Garcia and Lipsky at the event, which ends the Asian Tour season.

Singapore's Lam Chih Bing returned with a four-under-par 68 and was one of only three players who managed to complete their round.

Garcia, who starred in Europe's Ryder Cup win in September, could only play three holes on the opening day. But he returned with a vengeance by snaring 10 birdies against one bogey over 33 holes.

"It was good. It has been a long day but it has been quite positive," the event's highest ranked player said in comments released by the organisers.

"I just hope I can keep going in the right direction and see what happens. Hopefully we will get lucky and can get all four rounds in."

Lipsky, who returned to complete two holes, did not manage to start his round but will head into the weekend atop the leaderboard with Garcia

Thongchai hopes to shake off fatigue when he resumes his title charge on Saturday.

"I'm happy with the way I played but I felt tired because of the suspensions. It was quite difficult to play on the course because the fairways are a bit wet. The greens are okay," he said.

"I played very solid. I think I played about 30 holes. I woke up at 5.15am and it will be the same tomorrow."

- AFP/de

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Rehman Malik in Delhi, says 'we have no love lost for Hafiz Saeed'

NEW DELHI: The India-Pakistan "journey to peace" is progressing "very well", Pakistan's interior minister Rehman Malik said on Friday.

Speaking to the media soon after his arrival on a three-day visit, Malik also promised to arrest Mumbai terror attack mastermind Hafiz Saeed if New Delhi provided credible evidence about his involvement in the 26/11 Mumbai terror attacks.

"Pakistan and India have to be friends," Malik said, adding that this would only be possible when there was deeper people-to-people interaction among the two peoples.

He said because of the meetings between the leaders of India and Pakistan, the "journey to peace is progressing very well".

"For this, I must give full credit to my leader, President (Asif Ali) Zardari, the prime minister, and equal credit to the Indian Prime Minister and (now finance minister) Chidambaram".

He said he would discuss with Indian Home Minister Sushilkumar Shinde ways to facilitate the entry of Indians and Pakistanis into each other's territory once the new visa regime became operational.

"When they (Indians) enter Pakistan, they should feel they are coming to their own home," he said. "Similar should be the case when people of Pakistan enter India.

"We are all here to take the peace process forward," he added.

Malik recalled how the India-Pakistan relationship had soured in the immediate aftermath of the November 2008 terror attack on Mumbai that was blamed on Pakistani terrorists.

Asked about Indian demands for Hafiz Saeed's arrest and deportation, he said: "Just a statement from (hanged Pakistani terrorist Ajmal Amir) Kasab is not enough.

"We have to follow the law of the land. And of course (satisfy) the court ... There has been a lot of propaganda about Hafiz Saeed.

"I assure you that we are still investigating the (Indian) evidence. And if that evidence can stand the test of courts of international standards, I will order his arrest even before returning home.

"We have no love lost for Hafiz Saeed," he added. "Our intentions are clear. Whoever does a crime, should be punished."

"I come with a message of love and peace from the people of Pakistan," he said.

Malik said Pakistan had always condemned terrorism.

"We have lost 40,000 innocent people (to terrorism), 42,000 have become handicapped (in terror attacks)... We all want peace ... India has also suffered (because of terrorism)."

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Fewer health care options for illegal immigrants

ALAMO, Texas (AP) — For years, Sonia Limas would drag her daughters to the emergency room whenever they fell sick. As an illegal immigrant, she had no health insurance, and the only place she knew to seek treatment was the hospital — the most expensive setting for those covering the cost.

The family's options improved somewhat a decade ago with the expansion of community health clinics, which offered free or low-cost care with help from the federal government. But President Barack Obama's health care overhaul threatens to roll back some of those services if clinics and hospitals are overwhelmed with newly insured patients and can't afford to care for as many poor families.

To be clear, Obama's law was never intended to help Limas and an estimated 11 million illegal immigrants like her. Instead, it envisions that 32 million uninsured Americans will get access to coverage by 2019. Because that should mean fewer uninsured patients showing up at hospitals, the Obama program slashed the federal reimbursement for uncompensated care.

But in states with large illegal immigrant populations, the math may not work, especially if lawmakers don't expand Medicaid, the joint state-federal health program for the poor and disabled.

When the reform has been fully implemented, illegal immigrants will make up the nation's second-largest population of uninsured, or about 25 percent. The only larger group will be people who qualify for insurance but fail to enroll, according to a 2012 study by the Washington-based Urban Institute.

And since about two-thirds of illegal immigrants live in just eight states, those areas will have a disproportionate share of the uninsured to care for.

In communities "where the number of undocumented immigrants is greatest, the strain has reached the breaking point," Rich Umbdenstock, president of the American Hospital Association, wrote last year in a letter to Obama, asking him to keep in mind the uncompensated care hospitals gave to that group. "In response, many hospitals have had to curtail services, delay implementing services, or close beds."

The federal government has offered to expand Medicaid, but states must decide whether to take the deal. And in some of those eight states — including Texas, Florida and New Jersey — hospitals are scrambling to determine whether they will still have enough money to treat the remaining uninsured.

Without a Medicaid expansion, the influx of new patients and the looming cuts in federal funding could inflict "a double whammy" in Texas, said David Lopez, CEO of the Harris Health System in Houston, which spends 10 to 15 percent of its $1.2 billion annual budget to care for illegal immigrants.

Realistically, taxpayers are already paying for some of the treatment provided to illegal immigrants because hospitals are required by law to stabilize and treat any patients that arrive in an emergency room, regardless of their ability to pay. The money to cover the costs typically comes from federal, state and local taxes.

A solid accounting of money spent treating illegal immigrants is elusive because most hospitals do not ask for immigration status. But some states have tried.

California, which is home to the nation's largest population of illegal immigrants, spent an estimated $1.2 billion last year through Medicaid to care for 822,500 illegal immigrants.

The New Jersey Hospital Association in 2010 estimated that it cost between $600 million and $650 million annually to treat 550,000 illegal immigrants.

And in Texas, a 2010 analysis by the Health and Human Services Commission found that the agency had provided $96 million in benefits to illegal immigrants, up from $81 million two years earlier. The state's public hospital districts spent an additional $717 million in uncompensated care to treat that population.

If large states such as Florida and Texas make good on their intention to forgo federal money to expand Medicaid, the decision "basically eviscerates" the effects of the health care overhaul in those areas because of "who lives there and what they're eligible for," said Lisa Clemans-Cope, a senior researcher at the Urban Institute.

Seeking to curb expenses, hospitals might change what qualifies as an emergency or cap the number of uninsured patients they treat. And although it's believed states with the most illegal immigrants will face a smaller cut, they will still lose money.

The potential impacts of reform are a hot topic at MD Anderson Cancer Center in Houston. In addition to offering its own charity care, some MD Anderson oncologists volunteer at a county-funded clinic at Lyndon B. Johnson General Hospital that largely treats the uninsured.

"In a sense we've been in the worst-case scenario in Texas for a long time," said Lewis Foxhall, MD Anderson's vice president of health policy in Houston. "The large number of uninsured and the large low-income population creates a very difficult problem for us."

Community clinics are a key part of the reform plan and were supposed to take up some of the slack for hospitals. Clinics received $11 billion in new funding over five years so they could expand to help care for a swell of newly insured who might otherwise overwhelm doctors' offices. But in the first year, $600 million was cut from the centers' usual allocation, leaving many to use the money to fill gaps rather than expand.

There is concern that clinics could themselves be inundated with newly insured patients, forcing many illegal immigrants back to emergency rooms.

Limas, 44, moved to the border town of Alamo 13 years ago with her husband and three daughters. Now single, she supports the family by teaching a citizenship class in Spanish at the local community center and selling cookies and cakes she whips up in her trailer. Soon, she hopes to seek a work permit of her own.

For now, the clinic helps with basic health care needs. If necessary, Limas will return to the emergency room, where the attendants help her fill out paperwork to ensure the government covers the bills she cannot afford.

"They always attended to me," she said, "even though it's slow."

___

Sherman can be followed on Twitter at https://twitter.com/chrisshermanAP .

Plushnick-Masti can be followed on Twitter at https://twitter.com/RamitMastiAP .

Read More..