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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Innovative housing for the homeless being built in downtown L.A.

The Skid Row Housing Trust has spent decades revitalizing abandoned buildings and hotels in downtown Los Angeles' most destitute neighborhood to serve as shelter for the city's chronically homeless.

But for its latest housing project, the trust abandoned its usual technique for a seemingly elementary construction concept. A 102-unit, $20.5-million complex is being built by stacking pre-outfitted apartments atop one another in a Lego-like fashion, limiting construction costs and fast-forwarding the project timeline. It is believed to be the first multi-tenant residential building in the nation to be constructed this way.

Like all of the Skid Row Housing Trust's 24 homes for the homeless, the sleek and distinctive Star Apartments are meticulously styled to look nothing like typical low-income housing.

The project, designed by award-winning architect Michael Maltzan, will include basketball courts, art centers, community gardens and hundreds of feet of green space. The stacking of apartment units began last week, and the bulk of the construction should be done by mid-January.

"What we're trying to create is something that feels like a microcosm of the city itself," said Maltzan, who has designed two other apartment complexes for the homeless in partnership with the trust.

Unlike dark, drafty and dreary low-income housing, where residents reside in monochromatic buildings, Maltzan's project, he said, infuses color and community with a layout and amenities that force residents to interact. That sense of community, housing trust officials believe, is paramount to rehabilitating the chronically homeless.

Because the pre-fabricated construction method is typically used for single-family homes, planners had to work with officials to clarify regulations and standards for shipping in the pre-constructed apartments, which the architect characterized as a tedious and at times frustrating process.

"The hope is that we've created a replicable pathway for similar projects," Maltzan said last week, as he watched a towering blue crane lift a pre-fabricated apartment unit onto a building platform. "When people look at this building, what they see is a vision of the future."

The Star Apartments will house up to 100 formerly homeless, with an emphasis on residents who are repeat patients at area emergency rooms or who have never received needed treatment for chronic medical conditions, said Mike Alvidrez, executive director of the Skid Row Housing Trust.

Residents will pay 30% of their monthly job or government assistance income as rent but are not required to seek on-site medical treatment, psychiatric counseling, drug or alcohol treatment or therapy as a condition of residency.

"The thought is, how do we help people make the choice that is best for them," said Alvidrez, who stressed the trust's Housing First model — a philosophy that has caught fire nationwide. Alvidrez said the first step to helping someone recover from a chronic drug or alcohol problem is to give them a home and sense of community.

"We're not going to build our way out of homelessness," Alvidrez said. While the housing trust's buildings are now home to more than 1,500 formerly homeless people, some estimates say as many as 51,000 people remain homeless in L.A. County.

The goal of the apartments is to fully rehabilitate residents through on-site social services, community space and professional development. While many eventually leave the housing trust's buildings and move into other homes, if they keep paying rent they're free to stay as long as they'd like. Lawrence Horn, 62, said he spent years on the streets of Los Angeles, afraid that his adult daughter might run into a destitute, shabby and drugged-out version of him while she was out on the town with her friends.

But a confident and polished Horn, in a crisp black shirt and suit, stood behind a lectern in front of about 50 people in the Last Bookstore on Tuesday and captivated them with a frank, 20-minute narrative of his life before and after moving into permanent housing offered by the trust.

Two years ago Horn moved off the streets and into the Carver Hotel, a circular structure designed by Maltzan next to the 10 Freeway. For the last year, he has been learning to become a spokesman for the trust through its resident ambassador program.

"I felt inferior, I felt less than," Horn said of his time living on the street. But now, he said, "my story is no longer a doom-and-gloom story."

wesley.lowrey@latimes.com

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Hillary Clinton Suffers a Concussion After Fainting

WASHINGTON — Secretary of State Hillary Rodham Clinton suffered a concussion early last week after fainting and striking her head, the State Department disclosed on Saturday.

As a result, Mrs. Clinton will not testify as scheduled on Thursday before Congressional committees investigating the September attack on the American diplomatic outpost in Benghazi, Libya.

The fainting episode occurred after Mrs. Clinton, who is being widely discussed as a possible presidential candidate in 2016, became dehydrated because of a stomach virus she contracted during a trip to Europe, according to statements released by Philippe Reines, a close adviser to Mrs. Clinton, and by her doctors.

“Secretary Clinton developed a stomach virus, leading to extreme dehydration, and subsequently fainted,” her doctors, Dr. Lisa Bardack of the Mount Kisco Medical Group and Dr. Gigi El-Bayoumi of George Washington University, said in their statement on Saturday. “Over the course of this week we evaluated her and ultimately determined she had also sustained a concussion.”

One State Department official said Mrs. Clinton fainted when she was alone at her home in Washington but added that the concussion was not diagnosed until Thursday. He said the concussion was not severe.

Acting on the advice of her doctors, Mrs. Clinton will not go to the State Department this week but will work from home, the State Department’s statement said.

William J. Burns and Thomas R. Nides, both deputy secretaries of state, will testify before the Senate Foreign Relations Committee in place of Mrs. Clinton, according to a spokesman for the panel. They are also expected to testify before a House committee about the attack, in which Ambassador J. Christopher Stevens and three other Americans were killed.

Besides the Congressional hearings, the State Department is preparing for an eventful week on the Benghazi attack, which had led to considerable partisan fighting about what precipitated the attack and what arrangements were made to defend the compound.

On Monday, an independent panel that was established to investigate the attack is expected to present its report to the State Department. The panel, called an accountability review board, is led by Thomas R. Pickering, a veteran diplomat. It includes four other members, including Mike Mullen, the retired admiral who formerly served as chairman of the Joint Chiefs of Staff. The board is authorized by a 1986 law intended to strengthen security at United States diplomatic missions.

The State Department plans to share the report with Congress and will also provide its own recommendations on how security for diplomats can be improved. Mr. Pickering and Admiral Mullen are expected to meet with lawmakers in closed sessions on Wednesday.

Then on Thursday, Mr. Burns and Mr. Nides will testify before the Senate committee, which is led by Senator John Kerry, the Massachusetts Democrat who is expected to succeed Mrs. Clinton as secretary of state.

Mrs. Clinton has said that she takes responsibility for the failure to successfully defend the Benghazi compound in the Sept. 11 attack. But she has never been questioned by lawmakers about how decisions were made by the Obama administration to establish the compound and protect it.

When a House oversight committee held a hearing on the Benghazi attack in October, the State Department was represented by a senior management official and a midlevel official from the department’s Bureau of Diplomatic Security. The former chief security officer for the embassy in Libya, Eric A. Nordstrom, told that panel that some of his requests for additional security were ignored. But the State Department’s under secretary for management, Patrick Kennedy, countered that none of the steps proposed by Mr. Nordstrom would have altered the outcome in Benghazi because the embassy was based in Tripoli.

The political debate over the Benghazi attack has already claimed one victim: the ambassador to the United Nations, Susan E. Rice. Ms. Rice had been the Obama administration’s top choice to succeed Mrs. Clinton as secretary of state, but last week she withdrew her name from consideration for the job because of the controversy over her initial description of the attack as a spontaneous demonstration that spun out of control.

On Tuesday, Mrs. Clinton canceled a planned trip to Morocco, where she was expected to formally recognize a new Syrian opposition coalition as the legitimate representative of the Syrian people. President Obama conveyed the recognition instead in an interview with ABC News.

Last week, State Department officials gave a mixed picture about the severity of Mrs. Clinton’s illness. On Wednesday, a State Department spokeswoman, Victoria Nuland, described Mrs. Clinton as having a “very uncomfortable stomach virus.”

The next day, Ms. Nuland said Mrs. Clinton was “under the weather.” Ms. Nuland did say that Mrs. Clinton’s illness had prevented her from making any calls to foreign leaders.

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Connecticut Shooting: Hero Teacher Died Saving Students

By Sara Hammel and Mike Fleeman

12/15/2012 at 06:30 PM EST

Out of the chaos and horror emerged an incredible act of selflessness and bravery by one teacher, who spent her final moments trying to protect her young students from harm.

Victoria Soto, 27, a first-grade teacher at Sandy Hook Elementary School in Newtown, Conn., ushered her students into a closet and in so doing placed her body between them and the assailant.

"She was found huddled over her children, her students, doing instinctively what she knew was the right thing," her cousin Jim Wiltsie tells ABC News. "I'm just proud that Vicki had the instincts to protect her kids from harm,” he continued. “It brings peace to know that Vicki was doing what she loved, protecting the children and in our eyes she's a hero.”

Soto was among the six adults – all women – killed in Friday morning's massacre that also took the lives of 20 children – 12 girls and eight boys. The gunman, identified as 20-year-old Adam Lanza, took his own life. His mother was also found killed in a different location.

"It doesn't surprise me at all she would do this," Sabeena Ali, the parent of a girl who was in Soto's class two years ago, tells PEOPLE.

Ali calls Soto a "vibrant woman who loved the kids and would be with the kids and spend time with them and sit on the floor with them. "

Two years later, her daughter – now a third-grader – still idolized Soto.

"Every day there was some new Miss Soto story we had to listen to: 'This is what she did, this is how wonderful she was today,'" says Ali. "She would bring in snacks for the kids and do special days.

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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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Healthcare crisis: not enough specialists for the poor

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.

PHOTOS: Waiting in vain to be seen

"I want to see again," he said. "I've been waiting a long time."

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation's healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence's problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

"Specialists are paid so poorly that they don't want to take Medi-Cal patients," said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. "We're really disappointed and concerned what it's going to do for patient access."

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients' conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

"Where needs are absolutely critical, we are able to work out special arrangements," said Rise Phillips, chief executive of T.H.E. Clinic. "That is not the norm. That is, rather, the exception."

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon's cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center's clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she's juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can't afford to pay for the test out of pocket. "I'm hoping it's not anything like cancer," she said.

De Leon promised to update Barrera's referral paperwork to indicate she is experiencing pain. "Hopefully that will help," she said.

Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.

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Man Stabs 22 Children in China

BEIJING (AP) — A man wielding a knife wounded 22 children and one adult outside a primary school in central China as students were arriving for classes on Friday, the police said.

The attack, in the village of Chengping in Henan Province, happened shortly before 8 a.m., said a police officer from Guangshan County, where the village is located.

The attacker, Min Yingjun, 36, was subdued by security guards and taken into custody by the police, said the officer, who declined to give her name, which is customary among Chinese civil servants. Guards have been posted at schools across China after a spate of attacks in recent years.

A Guangshan County hospital administrator said there were no deaths among the nine students admitted to the hospital, although two badly wounded children were transferred to better-equipped hospitals outside the county.

A doctor at Guangshan’s hospital of traditional Chinese medicine said that seven students had been admitted there, but that none were seriously injured.

It was not clear how old the wounded children were, but Chinese primary school students are generally 6 to 11.

A notice on the Guangshan County government’s Web site confirmed the number of wounded and said an emergency response team had been set up to investigate the stabbings.

No motive was given for the attack, which resembled a string of similar assaults against Chinese schoolchildren in 2010 that killed nearly 20 and wounded more than 50. The most recent such attack took place in August, when a man broke into a middle school in the southern city of Nanchang and stabbed two students before fleeing.

Most of the attackers have been mentally disturbed men involved in personal disputes or unable to adjust to the rapid pace of social change in China, underscoring grave weaknesses in the antiquated Chinese medical system’s ability to diagnose and treat psychiatric illness.

In one of the worst attacks, a man described as an unemployed, middle-aged doctor killed eight children with a knife in March 2010 to vent his anger over a thwarted romantic relationship.

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Principal Dawn Lafferty Hochsprung Was Loved By Kids: Friend

By Julia Haskins

12/14/2012 at 07:30 PM EST

Dawn Lafferty Hochsprung, the Sandy Hook Elementary School principal killed in Friday's mass shooting, will be remembered as a committed educator who was loved by her students.

The principal of the Newtown, Conn., school died trying to protect the students she cared for every day. The gunman, identified as 20-year-old Adam Lanza, started his rampage in the school's main office, where Hochsprung had reportedly come out of a meeting.

Hochsprung was killed in the shooting, the sound of which was reportedly broadcast over the school's PA system.

"She was really nice and very fun, but she was also very much a tough lady in the right sort of sense," Tom Prunty, a friend whose niece goes to Sandy Hook and was uninjured Friday, told CNN. "She was the kind of person you'd want to be educating your kids. And the kids loved her."

In all, the death toll in the tragedy has been put at 28 total: 20 children, six adults – including Hochsprung – the gunman and the gunman's mother, who was a kindergarten teacher, at a secondary location.

Safety In Mind

Hochsprung was committed to school safety, having recently installed a visual monitoring system on the campus. Visitors had to wait to be let in after the school doors locked at 9:30 a.m., and then sign in at the main office. In a letter to parents about the security system, Hochsprung said the lengthy process of the new system would take some getting used to, but that it was for the greater good of the school. And Hochsprung would have done anything to make Sandy Hook Elementary School a great place to be.

"I don't think you could find a more positive place to bring students to every day," she told the Newtown Bee when she was first hired.

Vito Kala, the owner and manager of The Villa, an Italian restaurant down the road from Sandy Hook Elementary School that was frequented by Hochsprung and other staff members, tells PEOPLE he had no doubt about Hochsprung's courage.

"It doesn't surprise me at all to hear the principal was a hero," he said. "That's [in line] with what I know. That is what she would have done, no question."

Danbury Deputy superintendent William Glass would agree. "She had a tremendous intellect and a wonderful way with children," Glass said of the always-smiling principal. "She was an amazing educator. She was everything you would want."

And a dad of triplets who go the school says of Dawn: "Every year she'd do a sock hop at the school, and she'd dress up in hoop skirts and bobby socks. She really got into it. She was so great with the kids. They loved her. It does not surprise me at all she'd do something heroic."

Hochsprung maintained an active Twitter account, where she updated followers with news about the school. Her last Tweet expressed her excitement about a school event. "Setting up for the Sandy Hook nonfiction book preview for staff... Common Core, here we come!"

Hochsprung, of Waterbury, Conn., came to Sandy Hook Elementary School in 2010 with 12 years of administrative experience. She received a bachelor's degree in special education from Central Connecticut State University in 1993, a master's in special education from Southern Connecticut State University in 1997, and a sixth-year degree in educational leadership from Southern in 1998, according to NewsTimes.

She had two daughters and three stepdaughters, according to CNN.

– With reporting from Sara Hammel

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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..

Some chafe at downtown L.A.'s business improvement districts

At the start of each morning, a private army of workers descends on downtown Los Angeles in bright-colored shirts, providing security, collecting trash, scrubbing graffiti, power-washing sidewalks and otherwise keeping downtown presentable.

The crews work for downtown's network of business improvement districts and have become familiar parts of the area's fabric. Many in downtown credit the business improvement districts, or BIDs, with helping turn around the once-desolate downtown, providing the kind of aggressive maintenance and security services that City Hall simply cannot afford and helping to market the area to new investors.

But this extra layer of municipal services doesn't come cheap: together, the eight districts collect more than $15 million in annual tax assessments, which come on top of the regular taxes local businesses and residents pay for city services.

Now, some in downtown question whether the BIDs are worth their hefty costs. Two of the largest downtown improvement districts are facing lawsuits from property owners who no longer want to pay their fees, which in some cases top $100,000 a year.

Some critics say the BIDs have too much of a Big Brother feel, describing them as a kind of police force under the control of private executives whose aggressive cleaning up can sometimes feel like harassment. In the arts district, critics have posted bright orange "RID THE BID" banners and launched a petition online.

At the heart of the conflict is also a larger question: Should BIDs be a permanent part of downtown or something temporary — like training wheels for an area now gentrified enough that it can ride on its own.

"This concept of BIDs, for me, is kind of something of the '80s and '90s," said Yuval Bar-Zemer, a loft developer in the arts district who brought one of the lawsuits. "I think there are better ways to enhance the quality of life."

There are more than 80 business improvement districts across California, including Hollywood, Brentwood and Monterey. But they are coming under increased legal scrutiny; in addition to Bar-Zemer's case, the owners of the Angelus Plaza have targeted the Downtown Center Business Improvement District in a lawsuit, saying they should be exempt from the agency's fees. Similar disputes have been popping up throughout the state in recent years.

Cases against the BIDs generally argue that because they provide a general community benefit — such as security patrols or sidewalk sweeping — it's unfair for property owners to be asked to fund them exclusively. Legal experts said they expect the state Supreme Court to weigh in on the issue soon.

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For Estela Lopez, it's hard to forget the way some streets in downtown L.A. looked in 1993, when she started the area's first BID on Broadway.

It was a year after the L.A. riots, and many parts of the Central City were still recovering. Downtown was a "desolate ghost town," she recalled.

The idea of the BID was to tax local businesses and use the money to keep streets clean, encourage economic development and serve as a lobbying force at City Hall and other government agencies.

As a change in state law allowed them to assess property owners, the BIDs in downtown began to spread and flex their political muscle. BID leaders became major advocates for the Staples Center and the city's adaptive reuse ordinance, which allowed for old office buildings in the Central City to be more easily converted into residential lofts and apartments.

BIDs now cover almost every foot of downtown, from the Figueroa corridor around USC to the skyscrapers of the financial district and shopping malls in Chinatown and Little Tokyo.

Lopez runs BIDs in the industrial core and arts district through an organization called the Central City East Assn. The work involves everything from networking with city officials and courting developers to overseeing security operations. She and her staff lead tours of the area for investors and home buyers, and consult regularly with Los Angeles police.

"Don't let anyone kid you, the heavy lifting is done by the BIDs," Lopez said in an interview. "We brought the developers here. We brought the investors here."

On a recent Friday morning, George Peterman, Lopez's operations director, found himself on Ceres Avenue, trying to convince a homeless man to take down a 12-foot fort he'd built on the sidewalk.

Peterman, a burly, 67-year-old former LAPD sergeant, was friendly but firm.

"It's an everyday deal," he said. "We don't take no for an answer."

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