08/18/2014 11:56 am ET Updated Oct 18, 2014

Culture Clash

Raton is the county seat of Colfax County, NM, located on the old Santa Fe Trail half a day's drive from Albuquerque, Amarillo or Denver. Raton is the kind of remote settlement that is targeted by the Affordable Care Act for outreach. Once a thriving mining town with a quarter horse track, the mines and the track are long since shuttered. The hospital in town, Miners' Colfax Medical Center, serves many on Medicare, Medicaid, Veterans, ranchers with private insurance, and a handful in town with employer coverage. Also, the many who don't qualify for any of these programs: those without coverage of any kind. New Mexico is tied with Florida for the highest rate of uninsured in the country at 21 percent of the population.

As a nurse traveler, I worked at the hospital in 2004. There would be ten or twelve of us in the small rural facility at night: a nurse and aide in maternity; a lab tech to analyze body fluids; an RN or two teamed with nurses aides; along with a unit secretary and a security guard who doubled as a transporter. One of the RN's from the medical floor would go to the emergency room entrance for the occasional after-hours visit. The unit secretary would tag along to register the patient, I'd spruce up one of the three alcoves -- no more than a gurney with a privacy curtain. For ambulance arrivals we had advanced radio contact and could get all hands on deck for a heart attack or car accident. But, for routine back aches, stomach aches and headaches the secretary would register the patient and I'd do a quick assessment and a make a brief inquiry of the patient's complaint, allergies, notable medical history and then place a call to the local doctor on-call. The doctor might order a bag of IV fluids and a blood draw on the phone, and then arrive shortly thereafter. In the event of a suspected fracture, I'd call the radiology tech at home and roust him out of bed. On a busy night we might have three or four visits to the ER -- more often, none.

That was then.

Six years later I did a second stint in Raton. The ER was now the tail that waged the dog. Five exam rooms, 24/7 staffing, a dedicated ER unit clerk, an in-house radiology tech, an ER nurse and nurse's aid dedicated to the ER and a certified ER physician.

My associate, Lana Sharon Helton, RN, texted me only a few days ago that they had had a record of 25 visits on a recent night shift. Meanwhile, Colfax County's population census is trending down.

So, what's up?

The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 may finally be getting traction.

Enacted in 1986, this Act was to end the practice of ambulances being diverted to charity hospitals. Hospitals receiving Medicare were mandated to accept unstable patients regardless of means to pay.

This Act has morphed by regulations and case law into full hospital services for the uninsured. The distinction between stable and unstable blurred and then disappeared: the emergency room now take in all comer and, in fact, serve as 24 hour community centers much as the firehouse did 50 years ago.

In practice, EMTALA offers health care on demand for the uninsured.

Both the Affordable Care Act (Obamacare) and EMTALA are health reforms generated by Congresses (the 99th and the 111th) dominated by Democrats.

The Affordable Care Act stresses wellness, good nutrition and weight management, drug and smoking counseling, immunizations and cancer screenings, as well as prevention of heart disease and diabetes through a healthy lifestyle. A variety of gatekeepers like medical homes, advanced practice nurses and accountable care organizations will track their patients' health closely and schedule them for further lab work, imaging and scheduled hospitalization if necessary..

EMTALA, on the other hand, promises 24/7 walk-in clinics with CAT scans, X-rays, blood analysis, respiratory therapy, IV therapy, the undivided attention of a physician within the hour, and immediate hospitalization.

In a preamble to the mandates, the Affordable Care Act states in section 1501, under the title of Individual Responsibility, "The cost of providing uncompensated care to the uninsured was $43,000,000,000 in 2008. To pay for this cost, health care providers pass on the cost to private insurers, which pass on the cost to families. This cost-shifting increases family premiums by on average over $1,000 a year. By significantly reducing the number of the uninsured, the requirement, together with the other provisions of this Act, will lower health insurance premiums."

Sound Victorian reasoning, but, for those unconcerned with credit reports, EMTALA already offers free, full-service health care.