One example of how hard it is to change health care.

One example of how campaign cash chases efforts at change.

It's a complex example but symbolic of challenges to improving health-care access and costs.

So here we go.

Among many Rendell administration health-fix proposals is a bill allowing nurse anesthetists to secure their role in patient care or, as nurses contend, confirm common practice.

Anesthesiologists (physicians) oppose it and lobby hard against it.

The bill says a special class of nurses, Certified Registered Nurse Anesthetists, can administer anesthesia "in collaboration" with a doctor or dentist, even by phone, with an emphasis on cooperation rather than supervision.

The stated purpose is to expand access - nurses say seven central and western Pennsylvania counties have no anesthesiologists for outpatient facilities - and cut costs.

While salaries vary with location, an anesthesiologist might make $350,000 a year, a nurse anesthetist $144,000.

Nurses say they have the same training as docs in putting people under and bringing them back, that they routinely do so (have for 130 years) and that they stay with each patient while docs monitor several at once.

They say the bill puts into law what's now regulation, prevents restricting payments for the same job docs do, and alleviates demand for anesthesia services against any shortage of docs.

And safety of patients handled by nurses vs. docs?

"There is no study that's proven different outcomes," says Pa. Association of Nurse Anesthetists President Joe D'Amico.

Doctors, however, say there's no shortage of anesthesia providers, no operations canceled or postponed for lack of access and no need for a new law.

"There's no way you can eliminate physicians and insure quality of care," says John Milliron, the Pa. Society of Anesthesiologists' principal lobbyist.

So, we have an impasse - a major one.

Every other bill expanding or legally defining "scope of practice" for nurses, physicians' assistants and dental hygienists sailed through the House Professional Licensure Committee, where the anesthesia bill languishes and has since last summer without even a vote.

You could say it was put to sleep.

The other bills are law; most passed unanimously.

They allow docs more physicians' assistants, dental hygienists to practice basic dental care, nurses to order various therapies, and midwives to write prescriptions - all to help access and cut costs.

It is, of course, possible that the anesthesia bill can't be resolved on merits.

It's also possible that it faces resistance because it strikes at a lucrative specialty in a state known for that specialty.

The U.S. Bureau of Labor Statistics says Pennsylvania has more anesthesiologists than any other state (it also has more nurse-anesthetist schools than any other state) and lists anesthesiologists' mean annual wages highest among health-care practitioners.

This doesn't mean they make more than every other doc (the federal data don't list all practices; they don't, for example, break out neurosurgeons from general surgeons) but it does mean anesthesiologists are among health care's best-compensated.

In the last two years, through their political-action committee, Z-PAC, they showered the Professional Licensure Committee with cash.

They gave to 17 of 29 committee members, a majority. They gave to nine Democrats, who control the committee, and eight Republicans.

They gave most members at least $1,000 (generous for rank-and-filers), more to committee leaders, for a total topping $30,000.

Chairman Rep. Mike Sturla, D-Lancaster, got $3,000 from Z-PAC and another $1,000 from Milliron's own PAC, according to campaign-finance records.

Minority Chairman Rep. Bill Adolph, R-Delaware County, got $1,800 from Z-PAC.

They and others might well have gotten more, indirectly, because PACs give to other PACs that then can give to candidates.

Z-PAC, for example, gave $4,000 to the House Democratic Campaign Committee and $1,000 to the House GOP campaign committee.

After the bill was blocked last summer, the anesthesiologists' society Web site urged "every anesthesiologist" to attend a fall legislative reception in Harrisburg to "personally thank" lawmakers.

The first contribution reports for 2008 are due next week.

Nurses give, too. Just not as much - in fact, not one-fourth as much.

In the last two years, nurses gave $6,575 to 11 committee members: seven Democrats, four Republicans. They gave most members $250 to $500. They gave $1,000 to Chairman Sturla, $300 to Adolph and $1,000 each to Democratic and GOP campaign committees.

When I ask a veteran lawmaker familiar with the anesthesia fight if the issue and result are about the money, the lawmaker says, "Isn't everything we do?"

Sturla tells me differently.

He says that he can't "find a middle ground," that he isn't sure which side is right, and that the outcome "has little to do with campaign contributions."

Adolph says that he rarely sees who writes him checks, and that his money goes to his campaign treasurer, but that docs do a better job of making their case.

I don't know enough about medicine to know what's right here.

But I know enough about Pennsylvania politics and policy to know that both too often are driven by dollars, not by what's right.

And to me? This looks like one example.