'We Can't Tolerate This Anymore,' Obama Says

President Barack Obama said at an interfaith prayer service in this mourning community this evening that the country is "left with some hard questions" if it is to curb a rising trend in gun violence, such as the shooting spree Friday at Newtown's Sandy Hook Elementary School.

After consoling victims' families in classrooms at Newtown High School, the president said he would do everything in his power to "engage" a dialogue with Americans, including law enforcement and mental health professionals, because "we can't tolerate this anymore. These tragedies must end. And to end them we must change."

Mandel Ngan/AFP/Getty Images

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The president was not specific about what he thought would be necessary and did not even use the word "gun" in his remarks, but his speech was widely perceived as prelude to a call for more regulations and restrictions on the availability of firearms.

The grieving small town hosted the memorial service this evening as the the nation pieces together the circumstances that led to a gunman taking 26 lives Friday at the community's Sandy Hook Elementary School, most first graders.

"Someone once described the joy and anxiety of parenthood as the equivalent of having your heart outside your body all of the time, walking around," he said, speaking of the joys and fears of raising children.

"So it comes as a shock at a certain point when you realize no matter how much you love these kids you can't do it by yourself," he continued. "That this job of protecting kids and teaching them well is something we can only do together, with the help of friends and neighbors, with the help of a community, and the help of a nation."

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Egyptians narrowly back constitution, say rival camps

CAIRO (Reuters) - Egyptians voted narrowly in favor of a constitution shaped by Islamists but opposed by other groups who fear it will deepen divisions, officials in rival camps said on Sunday after the first round of a two-stage referendum.

Next week's second round is likely to give another "yes" vote as it includes districts seen as more sympathetic towards Islamists, analysts say, meaning the constitution would be approved.

But a close win, if confirmed, would give Islamist President Mohamed Mursi only limited cause for celebration as it would show a wide rift in a country where he needs to build consensus on tough measures to fix a fragile economy.

The Muslim Brotherhood's party, which propelled Mursi to office in a June election, said 56.5 percent backed the text. Official results are not expected till after the next round.

Mursi and his backers say the constitution is vital to move Egypt's democratic transition forward. Opponents say the basic law is too Islamist and tramples on minority rights, including those of Christians who make up 10 percent of the population.

The build-up to Saturday's vote was marred by deadly protests. Demonstrations erupted when Mursi awarded himself extra powers on November 22 and then fast-tracked the constitution through an assembly dominated by his Islamist allies.

However, the vote passed off calmly with long queues in Cairo and several other places, though unofficial tallies indicated turnout was around a third of the 26 million people eligible to vote this time. The vote was staggered because many judges needed to oversee polling staged a boycott in protest.

The opposition had said the vote should not have been held given violent protests in the Arab world's most populous nation, which is watched closely from abroad to see how Islamists, long viewed warily in the West, handle themselves in power.

"It's wrong to have a vote or referendum with the country in the state it is - blood and killings, and no security," said Emad Sobhy, a voter who lives in Cairo. "Holding a referendum with the country as it is cannot give you a proper result."

INCREASINGLY DIVIDED

As polls closed, Islamists attacked the offices of the newspaper of the liberal Wafd party, part of the opposition National Salvation Front coalition that pushed for a "no" vote.

"The referendum was 56.5 percent for the 'yes' vote," a senior official in the Brotherhood's Freedom and Justice Party operations room set up to monitor voting told Reuters.

The Brotherhood and its party had representatives at polling stations across the 10 areas, including Cairo, in this round. The official, who asked not to be identified, said the tally was based on counts from more than 99 percent of polling stations.

"The nation is increasingly divided and the pillars of state are swaying," opposition politician Mohamed ElBaradei wrote on Twitter. "Poverty and illiteracy are fertile grounds for trading with religion. The level of awareness is rising fast."

One opposition official also told Reuters the vote appeared to have gone in favor of Islamists who backed the constitution.

The opposition initially said its exit polls indicated the "no" camp would win comfortably, but officials changed tack during the night. One opposition official in the early hours of Sunday said it would be "very close". There was no formal statement from the opposition National Salvation Front.

"Even if this result is correct, that does not mean that this constitution can pass, because it means more than 40 percent of the people didn't agree with it," said Issam Amin, speaking on a Cairo street and echoing the opposition line that the constitution needed consensus backing not a simple majority.

A narrow loss could still hearten leftists, socialists, Christians and more liberal-minded Muslims who make up the disparate opposition camp, which has been beaten in two elections since Hosni Mubarak was overthrown last year.

They were drawn together to oppose what they saw as Mursi's power grab and his constitution push. The National Salvation Front includes prominent figures such as ElBaradei, former Arab League chief Amr Moussa and firebrand leftist Hamdeen Sabahy.

If the constitution is approved, a parliamentary election will follow early next year. Opposition leaders say the Front could help unite the opposition for that poll after their divided ranks have split the vote in previous elections.

DEADLY VIOLENCE

But analysts question whether the opposition group in this form will survive until a parliamentary election. The Islamist-dominated lower house of parliament elected earlier this year was dissolved based on a court order in June.

Violence in Cairo and other cities has plagued the run-up to the referendum. At least eight people were killed when rival camps clashed during demonstrations outside the presidential palace earlier this month.

Several party buildings belonging to the Muslim Brotherhood's party have been burned by angry protesters in recent weeks. On Friday, a day before the vote, rival factions armed with clubs, knives and swords fought in Alexandria.

In order to pass, the constitution must be approved by more than 50 percent of those casting ballots. There are 51 million were eligible voters in the nation of 83 million.

Rights groups reported some abuses, such as polling stations opening late, officials telling people how to vote and bribery. But Gamal Eid, head of the Arab Network for Human Rights Information, said abuses were not enough to invalidate the vote.

"We accepted the referendum so we accept the result," said Ahmed Mohamed, a Cairene who backed the draft. "If the majority said ‘yes', so be it. I didn't see forgery where I voted."

Islamists have been counting on their disciplined ranks of supporters and on Egyptians desperate for an end to turmoil that has hammered the economy and sent Egypt's pound to eight-year lows against the dollar.

If the constitution is voted down in a second round, which now looks unlikely, a new assembly will 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.

(Additional reporting by Tamim Elyan, Shaimaa Fayed and Reuters Television; Writing by Edmund Blair and Giles Elgood; Editing by Andrew Heavens)

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Pakistan police battle militants after deadly airport raid

PESHAWAR, Pakistan: Six people were killed on Sunday as police and troops battled militants armed with automatic weapons, grenades and mortars in northwest Pakistan's Peshawar, a day after a deadly Taliban raid on the city's airport.

Fierce firing broke out after police acting on an intelligence report stormed a building near the airport, where a suicide and rocket attack on Saturday killed five civilians and the five attackers, and wounded 50 other people.

The assault late Saturday, claimed by the Pakistani Taliban, sparked prolonged gunfire and forced authorities to close the airport, a commercial hub and Pakistan Air Force (PAF) base in Peshawar on the edge of the tribal belt.

It was the second Islamist militant attack in four months on a military air base in nuclear-armed Pakistan. In August 11 people were killed when heavily-armed insurgents wearing suicide vests stormed a facility in the northwestern town of Kamra.

Police backed by troops launched a raid early Sunday on a building under construction near the airport following reports that five militants who fled after the airport attack had taken refuge there, according to provincial information minister Mian Iftikhar Hussain.

In the fierce shootout that followed, three militants and a policemen were killed, police said, while two other officers were wounded.

The clashes ended after six hours when the two remaining militants detonated their suicide vests inside the building, another senior police officer, Imtiaz Altaf, told AFP.

"All five militants are dead now and the area has been cleared," Altaf said.

"All of them were wearing suicide jackets. Three were killed in a shoot out with police, while two others blew themselves up in the building under construction."

A PAF statement said five attackers were killed on Saturday and no damage was done to air force personnel or equipment.

Dr Umar Ayub, chief of Khyber Teaching Hospital near the airport, said five civilians had also been killed and some 50 wounded.

"The base is in total control and normal operations have resumed. The security alert was also raised on other PAF air bases as well," the air force added.

Peshawar airport is a joint military-civilian facility. Civil Aviation Authority spokesman Pervez George said the passenger side had reopened after an 18-hour closure and there was no damage to the terminals.

The air force said Saturday's attackers used two vehicles loaded with explosives, hand grenades, rocket-propelled grenades and automatic weapons. One vehicle was destroyed and the second badly damaged.

Security forces found three suicide jackets near one of the vehicles, it said.

"Security forces consisting of Pakistan Air Force and Army personnel who were on full alert, cordoned off the base and effectively repulsed the attack," the air force said.

Television pictures showed a vehicle with a smashed windscreen, another damaged car, bushes on fire and what appeared to be a large breach in a wall.

Five nearby houses were destroyed after rockets landed on them and several other houses developed cracks, while the bomb squad detonated five out of eight bombs found near the base after the attack.

Pakistani Taliban spokesman Ehsanullah Ehsan told AFP by telephone from an undisclosed location that the group would continue to target the airport.

"Our target was jet fighter plans and gunship helicopters and soon we will target them again," he said.

The armed forces have been waging a bloody campaign against the Taliban in the country's northwest in recent years and the militants frequently attack military targets.

Aside from the August attack on Kamra, in May 2011 it took 17 hours to quell an assault claimed by the Taliban on an air base in Karachi. The attack piled embarrassment on the armed forces just three weeks after US troops killed Al-Qaeda leader Osama bin Laden in Pakistan.

Pakistan says more than 35,000 people have been killed as a result of terrorism in the country since the 9/11 attacks on the United States. Its forces have for years been battling homegrown militants in the northwest.

- AFP/xq

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Karnataka concerned over Savitha, Jacintha deaths: Former CM

MANGALORE: The state government has taken due note of back to back deaths of two women of Karnataka origin abroad- Savitha Halappanavar and Jacintha Saldanha— and urged the centre to ensure that Indian citizens abroad get due protection, abroad said DV Sadananda Gowda, former chief minister.

Chief minister Jagadish Shettar has written letters to the PM and MEA due to the back to back deaths of two women of Karnataka origin abroad- Savitha Halappanavar and Jacintha Saldanha— and expressed state's concern over these deaths.

Sadananda Gowda, accompanied by members of Kaup assembly constituency unit of BJP met family members of Ben Barboza, Jacintha's husband at Shirva earlier in the day. "We consoled the bereaved family at their loss," Gowda told reporters here later. Describing the incident as tragic and one that should not have happened, Gowda said, "I handed over messages to the bereaved family on behalf of the chief minister Jagadish Shettar."

The CM has written letters to PM Manmohan Singh and minister of external affairs Salman Khurshid, expressing the state government's concerns over these two deaths, Gowda said adding that there is a sense of despondency among people of the state at these incidents.

"It has created a fear psychosis among people of the state about welfare of their friends and relatives abroad," he said hoping the Centre will take necessary steps to prevent recurrence of such events.

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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."

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.

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.

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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.

Click here for more photos of the scene.

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.

Click here for live updates.

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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Obama calls for solidarity after school massacre

WASHINGTON: President Barack Obama on Saturday called for Americans to "come together" to prevent tragedies like the school massacre that killed 20 young children and six adults, one of the worst mass shootings in US history.

"This weekend, Michelle and I are doing what I know every parent is doing -- holding our children as close as we can and reminding them how much we love them," said Obama, father of Sasha, 10, and Malia, 14.

"There are families in Connecticut who can't do that today. And they need all of us now," he added, in his weekly address.

Twenty-seven people, including the shooter, were killed on Friday morning at an elementary school in Connecticut. US media reported that a 28th victim, found at a residence in the town, was the shooter's mother.

"While nothing can take the place of a lost child or loved one, all of us can extend a hand to those in need -- to remind them that we are there for them; that we are praying for them; and that the love they felt for those they lost endures not just in their own memories, but also in their community, and their country," he continued.

"Every parent in America has a heart heavy with hurt," Obama said. On Friday, he fought tears in an emotional address about the tragic incident.

"We grieve for the families of those we lost. And we keep in our prayers the parents of those who survived. Because as blessed as they are to have their children home, they know that their child's innocence has been torn away far too early," the president said.

Obama said the tragedy was all too familiar, after similar deadly shootings at a shopping mall in Oregon, at a Sikh temple in Wisconsin, and at a movie theatre in Colorado earlier this year.

"Any of these neighbourhoods could be our own. So we have to come together and take meaningful action to prevent more tragedies like this. Regardless of the politics," the president said, echoing his message from the day before.

Obama did not give details, but some US politicians called for a serious look at gun control laws, a subject which Obama, re-elected on November 6, did not tackle strongly in his first term.

- AFP/xq

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Aung San Suu Kyi praises Indian Air Force pilots

YANGON: Not treated well by her own military junta, pro-democracy icon Aung San Suu Kyi today praised Indian Air Force pilots for being "professional" and "sweet".

"I enjoyed my time in India thoroughly from beginning to end, particularly impressed by the Air Force Pilots who flew me back. They are the kind of professional military men I like to see," said the 67-year-old Suu Kyi who was placed under house arrest for 15 of the past 21 years on different occasions.

She added: "They (IAF) are very very sweet. So very soldierly in the best kind of way, officers and gentlemen."

During her visit to India last month, Suu Kyi was flown in and out of Yagon by IAF pilots in military planes.

After a 40-minute meeting with Salman Khurshid, a beaming Burmese leader also so praised the kind of reception she received from the Indian government and Indian people during her visit.

"It is an experience I wish to repeat," she said.

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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."

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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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