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JOHN: A technician sits gazing at a panel of cardiac monitors watching the status of critical heart patients. This is the fourth floor of Immanuel St. Joseph's Hospital in Mankato, the city of 40,000 in south central Minnesota. Most of the patients being monitored are within the Mankato hospital, but on one bank of monitors are taped the names of five small towns, each of them a half hour or more outside of Mankato.

SPEAKER 1: Arlington, Le Sueur, Sleepy Eye, Saint James, and Wells. We used to have Gaylord, but they closed. So we just have those five hospitals on now.

JOHN: Registered nurse Maureen Corcoran explains that the monitors are connected by telephone lines to cardiac hookups in hospitals in those communities.

SPEAKER 1: The nice thing about it is that there is always someone. We always have a monitor tech like Ronny here. He's always here watching these monitors so that they can be assured that when they've got a patient on, that somebody is always watching them, and then we can call and let them know if there's a problem so that they can take care of it.

In the small hospitals, they can't afford to have someone there observing these all the time. So it's a real benefit to them.

JOHN: Meanwhile, outside Emmanuel Saint Joseph's, construction is underway on a major expansion. This is what's happening in out state health care while small rural hospitals struggle to survive and two in Gaylord and Caledonia closed this year.

Regional hospitals like this one are thriving. The Mankato Hospital now has 100 doctors, up 13 from 10 years ago, and it draws customers from all over Southern Minnesota and Northern Iowa. Just as they come to towns like Mankato for the greater variety of clothing stores and movie theaters, they come to regional hospitals to see specialists and use technology that their small town hospitals can't offer.

SPEAKER 2: We the time he's been on for almost five minutes, and he's going about 2.3 miles an hour on a level surface. Looks good.

JOHN: This is the cardiac rehabilitation center at Emmanuel Saint Joseph's. Patients recovering from heart attacks walk on a treadmill and ride sophisticated stationary bicycles supervised by nurses. There are only a few other such facilities in Southern Minnesota in bigger towns like Rochester, Albert Lea, and New Ulm.

Nurse Cathy Ahearn runs the center.

SPEAKER 2: The program is widely utilized by Saint Peter and Mableton and Waseca. Yeah, we had someone drive up from Wells, too.

JOHN: Those people traveling to regional centers for medical treatment are often passing their rural hospitals on the way. Experts say that's one reason that a lot of small town hospitals are losing money, though there are other reasons, like shrinking populations and lower Medicare reimbursement rates.

Emmanuel Saint Joseph's administrator Annette Macbeth says the Mankato Hospital is not trying to take business away from its rural neighbors. She says the hospital is providing specialty treatment for which rural people would otherwise have to go to Rochester or the Twin Cities.

ANETTE MACBETH: We see ourselves as augmenting what is needed in this area and to assist in that process, in other words, keep as much of the primary care as possible as close to where the population lives and then augment what it is that's needed.

SPEAKER 3: Can you open real big? Yeah. Yeah, you don't got no big tonsils at all, do you? Well, we have a fair chance of clearing this with medicine.

JOHN: Regional hospitals aren't just drawing patients in from surrounding towns. They're going out to them, as well. At the Saint James area family clinic, 35 miles Southwest of Mankato, doctor Willard Michalski examines a six-year-old patient.

Michalski is one of three ear, nose, and throat specialists from Mankato, who between them, have office hours one day a month in Saint James. They do the same in several other towns outside of Mankato. One of Michalski's patients, 87-year-old Golda Holland, says she appreciates that the doctors come to her town.

SPEAKER 4: Because it's hard for me to make it to Mankato because the ones that I do ride with, well, they don't care to drive to Mankato, so my daughter comes down from Cambridge and takes me to Mankato if I need to go there. So it saves time this way.

JOHN: But specialists who travel to visit patients don't do so only for the convenience of their patients. Dr. Michalski says there isn't enough ear, nose, and throat business in Mankato to keep him and his partners busy, so they branch out.

SPEAKER 3: Well, to maintain the referral line, really, doctors do come out of the cities now to service the rural area for the same reason that they're not as busy in the city as they'd want to be. And so they come to rural setting to pick up surgery, really.

JOHN: Medical specialists have, for a long time, been concentrated in big hospitals in large cities. What's changing is that now, even family doctors are badly distributed, with too many in the Twin Cities and other larger towns and not enough in the country. Very few doctors coming out of medical school want to work in rural communities.

So experts say before long, even primary care in rural areas may have to come from regional centers. The state of Montana is trying a system of minimally staffed treatment centers in isolated rural areas, which deal only with emergencies and send everything else to the nearest city.

Mary Ann Miller, who's director of the Health economics program with the Minnesota Department of Health, suggests another vision of the future, emergency rooms on wheels.

MARY ANN MILLER: Now, with sophisticated ambulances, it's almost like a traveling emergency room, and it would be better to get patients into that and make sure that system is sufficient and well equipped, rather than put resources into the local low-technology hospital or something.

JOHN: That kind of talk is anathema to rural people who are fighting to save their local hospitals. Small towns don't want to substitute ambulance service for a hospital and clinic that may employ dozens of people. Rural advocates say what's needed is cooperation between regional centers and rural hospitals that helps small town people get care in their communities, like the remote monitoring set up in Mankato.

Another example is telecommunications. Experts say it will soon be commonplace for rural physicians to consult with big city specialists by interactive television. What makes rural people uneasy is the sense that they are increasingly at the mercy of larger centers for access to health care. Beth Wessel, whose daughter was examined by the Mankato specialist on his monthly visit to Saint James, expressed that concern to the doctor.

SPEAKER 5: I guess I wish that you could come more often to Saint James because that's only disadvantage is you have to wait a whole-- you have to wait a month. But other than that, I like it because--

JOHN: Rural advocates say whatever the future course of the health care system, what matters is that rural people get a say in shaping that future. This is John Biewen reporting.