Republican doctors in Congress are increasingly becoming frustrated with the American Medical Association, citing what they call the group's "woke" policies on abortion and gender-affirming care as a turning point in their relationship, Victoria and Caitlin Owens report.

Why it matters: The tension could make it more difficult for Republicans and the AMA to work on less controversial and bipartisan issues such as prior authorization, physician reimbursement rates and provider mental health and burnout.

What they're saying: Several members of the Doctors Caucus told Axios they met with AMA leadership last week.

• "[W]hen they told us their priorities, they aligned with our priorities. But it's like, it doesn't look like those are your priorities. What looks like your priorities are abortion and transgender issues," Rep. Brad Wenstrup, one of the co-chairs of the Doctors Caucus, told Victoria.
• "It looks like all you care about are woke issues," Wenstrup said — defining the group's policies on abortion and transgender issues as "woke" because they don't align with the Doctors Caucus' "pro-life" stance and feel like a mandate to practice medicine they don't agree with.
• And it's not just in the House. Sen. Rand Paul told Caitlin that the AMA "has been very much left-wing or left-of-center for a long time ... they are also disproportionately represented by university physicians."
• "If I had time I could probably tell you 20 things the AMA has done in the last five years that I disagree with," Paul said.
• Not all Republicans are voicing such strong opinions about the AMA. "I'm a member of the AMA," Rep. Michael Burgess, another co-chair of the Doctors Caucus, told Victoria. "We've all got to talk. We got a lot of problems that we have to solve."

Zoom in: AMA issued new policies last year in response to everything from the Dobbs decision to climate change.

• In June 2022, the AMA issued a policy stating that restricting access to abortion care is a "violation of human rights."
• In November 2022, the AMA announced new policies around abortion that included not criminalizing doctors for performing abortions, preserving access to abortion training for medical students and supporting access to abortion care.
• And it has said it opposes restrictions on transgender medical care.
• The AMA has also issued policies declaring climate change a public health crisis and supporting gun reform.

Between the lines: House Republicans have been frustrated with the AMA for a while, but things seem to have reached a breaking point in the last year.

• "I think the AMA, it's been going on for maybe longer, but this summer when they were up on the Hill testifying about gun violence and to some extent the Dobbs decision, that might have been the end," said Joe Grogan, a USC-Schaeffer senior fellow and former Trump administration official.

The other side: Jack Resneck, president of the AMA, told Axios in an interview that while he knows some of AMA's policies may be seen as controversial, no doctor is likely to agree with all of the group's stances.

• "With this group of physicians in Congress we do have alignment," said Resneck, who cited the prior authorization and payment rates as issues with bipartisan support. "But yes, there are going to be a few issues that we don't always agree on as well."

PBMs aren't just waiting around for Congress to take whacks at them — they're releasing their own policy proposals aimed at lowering drug costs, Peter reports.

Why it matters: The move from the Pharmaceutical Care Management Association is a way to seek to be proactive and show alternatives, rather than just opposing policies as they face increasing bipartisan scrutiny.

The proposals include:

• Increasing competition by cracking down on ways drug companies can hold off competitors, such as "pay for delay" agreements and "patent thickets."
• Seeking to improve data use and make things easier for patients by expanding use of real-time benefit tools that can recommend lower cost alternatives, as well requiring electronic prescribing and prior authorization.
• Making changes to FDA policies, such as authorizing the agency to assess a drug's value at the time of approval. If a drug is deemed to have low additional value, PCMA says payers could use that information to negotiate lower prices.

Between the lines: The PBM proposals are also notable for what they don't say. They're calling for increasing competition within the private sector, but steer clear of calling for direct government regulation of drug prices.

• The proposals also unsurprisingly do not include regulatory measures that have drawn PBM industry objections, such as requiring rebates to be passed on to patients to help lower out of pocket costs.
• Asked about such proposals, PCMA CEO JC Scott told Axios that they would mean the government is "dictating terms" and "limiting the ability of the employer or the plan sponsor to design the benefits that they need, based on their specific patient population."

The bottom line: "The reality is that the private market system works reasonably well for millions of patients who routinely get the prescription drugs they need at the cost they expect, and that the system can also work better to address areas where affordability is a challenge," Scott said.