Four doctors arrived at the State Capitol in January prepared to bring a fresh medical perspective to a range of health care battles, from insurance coverage and prescription drug prices to smoking.

Five months later, they left a bit frustrated with a number of "little wins" but a big unfilled prescription for next year.

The four, all elected within the past three years, are informally known as the Doctors Caucus. They represent the largest number of physicians to serve in the state Legislature in 113 years, a post-Obamacare reflection of health care spending and access as breakout issues in American politics.

As rising health care costs dominate town halls, campaign speeches and state budget debates, more doctors and medical students are turning to policymaking and advocacy to improve public health. The number of physicians serving in Congress also has grown over the past three decades, from two in 1990 to 16 now.

In Minnesota, the number of doctor-legislators has jumped from zero to four since 2016. Meanwhile, the University of Minnesota has added an advocacy and community engagement program for medical residents. And participation in the Minnesota Medical Association's annual Capitol advocacy day has nearly doubled.

"Health care is really the central issue of our time. ... People find extreme financial barriers to really just taking care of their well-being, and we're better than that," said Democratic state Sen. Matt Klein, an internal medicine doctor.

A desire to improve health care access prompted Klein to run in 2016, at the same time as Republican Sen. Scott Jensen, a family practitioner. Democratic Reps. Alice Mann, also a family practice physician, and Kelly Morrison, an OB-GYN, joined them in the Legislature this year.

The four doctors often landed at the center of health care discussions this past legislative session, frequently wielding their influence to push for drug price transparency and access to services or medication.

They weren't always successful.

All four received prominent Health and Human Service committee positions and said their colleagues often deferred to their judgment. But they are still rookie legislators discovering how the system works. A couple noted that, to their frustration, the data-driven decisionmaking they are used to in medicine doesn't always translate to the rough-and-tumble of Capitol politics.

One successful bipartisan measure sponsored by Jensen and Mann will license and monitor some of the middlemen in the pharmaceutical supply chain, with the aim of controlling drug costs. But other bipartisan drug price transparency efforts fell apart.

Jensen and Klein backed the idea of a Prescription Drug Affordability Commission, to which drug manufacturers would have to report certain price hikes or the introduction of expensive new drugs. Klein likened the board to the Public Utilities Commission and said it would provide some industry oversight and regulation. Jensen said he will press the issue again in 2020 and "maybe do some horse trading" to try to make it happen.

Morrison saw more momentum this year on a similar measure that would give more oversight power to the state health commissioner. She plans to continue to fight for it but said its failure this session "reflects the power of the pharmaceutical industry" at the Capitol.

She was not the only one reckoning with the political realities of St. Paul.

The Doctors Caucus faltered on a high-profile bill to provide emergency insulin for diabetics, Jensen said, partly because they did not come together to offer a solution to fund it. But given the splintered opinions and "the overall hostile milieu" around that bill, Jensen questions whether their voices would have mattered.

"If the four doctors got together and tried to say, 'This is what we think would work,' I'm afraid the response would be, 'Who the hell cares?' " Jensen said.

Despite the setbacks, doctors both in and out of the Capitol are poised to add their voices on a number of politically divisive fights brewing at the Capitol.

Klein sponsored Gov. Tim Walz's ONECare proposal this year that would allow all Minnesotans to buy into a public health care option. He and Mann both said they will continue to push for the idea, although they believe it would take an all-DFL Legislature to make that a reality. The two chambers are now split, with a Democratic majority in the House and Republicans controlling the Senate.

Meanwhile, efforts to prevent gun violence, improve vaccine rates and raise the age to buy tobacco to 21 are motivating more doctors to advocate both at the state and local levels, said Dave Renner, a lobbyist for the Minnesota Medical Association.

Concerns about low vaccine rates prompted medical students involved with the association to create a "Hands on Advocacy" program in 2016, said Thomas Schmidt, a fourth-year medical student at the University of Minnesota and program participant. The students have since lobbied at the Capitol on vaccines, opioid addiction and mental health access.

Schmidt said his internal medicine rotation recently included a discussion with Morrison. Schmidt has considered running for a seat in the Legislature in the future, and he said Morrison offered to help any of the students interested in pursing political positions.

While young doctors are being encouraged to get involved, there are persistent barriers keeping them from government service. Among the top obstacles are their stressful, full-time jobs and heaping student loans, Mann said.

"It's impossible when you graduate with $250,000, $300,000 in debt — you can't take a job that pays $45,000 a year," she said.

But physicians don't need to run for office to fight for legislation. In his short time at the Capitol, Klein said he has seen a "dramatic change" in doctors' patient-focused advocacy.

"Even just three years ago it seemed like a lot of professional groups — labor groups, educators and lawyers — had a real presence for advocacy at the Capitol," he said. "I really always felt like physicians were the odd man out on that and weren't exerting their political muscle in a way they should."

He said that has changed, adding that he was particularly proud to see the Minnesota Medical Association take a stand on gun violence regulations.

Renner said he has seen an advocacy shift during his 30 years with the association, which has more than 10,000 members. The group traditionally focused on making Minnesota the best state for practicing medicine, he said. Now there's an increased emphasis on making the state the healthiest.

A crucial moment in the transformation might have been the Freedom to Breathe Act of 2007, which restricted smoking in public places. The state association's president at the time said that bill would save more lives than he had in 30 years as a surgeon.

"I think there's this realization that ... there's health care, and there's health," Renner said. "And if you really are serious about improving health, we need to be involved in more than just health care."