House Republicans showed last month that they're reluctant to upend the healthcare system in the Obamacare era.
The health plan that the House GOP proposed last month forgoes some of the big changes conservatives pushed for a decade ago, before President Obama's 2010 healthcare law, while being careful not to immediately deprive people of coverage they already have.
Instead of eliminating the tax break for employer-sponsored coverage, it would simply cap the exclusion. Rather then providing a tax deduction to buy coverage, it would supply Americans with tax credits, an option that would ensure poor people getting Obamacare subsidies would continue getting help, but would also cost the government more.
And instead of immediately scrapping the Affordable Care Act's Medicaid expansion, it would allow states to shift those dollars to a higher-needs population while gradually reducing the extra funding.
The healthcare plan, spearheaded by Speaker Paul Ryan, is a major step for House Republicans, who had promised to present their own replacement to Obama's law but only now have rallied around a set of ideas.
They're touting it as their blueprint for repealing and replacing the Affordable Care Act. But six years into the healthcare law, Republicans were also forced to write it with a nod to the millions of Americans who have gained coverage, despite their deep and abiding dislike of the measure.
"I think this plan this time takes a more transitional approach to health reform, where in previous plans it really was a visionary kind of, 'Here's where we stand,' rather than a practical step by step," said Nina Owcharenko, director for health policy studies at the Heritage Foundation.
Avoiding far-reaching healthcare changes, such as ditching the tax break for employers, could help shelter Republicans from political attacks they've faced in the past. In the 2008 presidential campaign, Obama's yarn-unraveling ad attacking Sen. John McCain's health proposal became one of the most-aired political ads of all time.
"It could all unravel — your healthcare under John McCain," the ad said, as an orange ball of yarn unraveled across the screen. "McCain would tax health benefits for the first time ever."
Two years earlier, President George W. Bush proposed his health reform plan, which would also have eliminated the employer tax break, replacing it with a standard tax deduction of $15,000 for families and $7,500 for individuals.
Liberal and conservative policymakers have long criticized the employer tax exclusion, which has essentially tied insurance coverage to Americans' jobs and disadvantaged those without access to an employer-sponsored plan. But Obama's yarn ad was effective because it played into people's fears about losing their health plan.
"There was a sense that attack was very effective," said Yuval Levin, who worked in domestic policy in the Bush White House. "To advance the type of system Bush and McCain had been proposing, you would have to show people the employer system wouldn't unravel."
Instead of doing away with the exclusion, Ryan's plan would cap it above a certain threshold in order to discourage employers from offering extravagant health plans that push up healthcare spending.
"Most people get insurance from their jobs, and that's great," Ryan said in a speech announcing the GOP plan at the American Enterprise Institute. "The problem is with this open-ended tax break is it encourages businesses to buy bigger and bigger benefits."
Then there's the pressing question of what to do for those without employer-sponsored coverage. Conservatives have long debated whether to provide a tax deduction, which leaves lower-income people without assistance, or go with a refundable tax credit, which provides assistance to virtually everyone but costs more.
Bush's plan would have relied on a standard tax deduction. But in the last few years, as more Americans have received the Affordable Care Act's federal subsidies, conservatives have shifted toward a credit approach, showing they feel it's important to provide immediate assistance to the low-income.
With the exception of former Louisiana Gov. Bobby Jindal, all the Republican presidential contenders for 2016 who announced health reform plans included refundable tax credits. That's also the approach taken in the Ryan plan.
"That argument has definitely moved in the direction of the credit side," Levin said.
On the question of Medicaid, the GOP plan irked some further-right conservatives, including the Heritage Foundation, who felt it didn't phase out the healthcare law's expansion quickly enough. Under the Affordable Care Act, those earning up to 133 percent of the federal poverty level could enroll in the health insurance program if their state opted in.
Republicans have long called for getting rid of expansion, but in a nod to the healthcare law, the House plan allows states to maintain the elevated level of funding for several years instead of abruptly halting it.
"There's obviously an increasing sense some kind of transition would need to happen if we were to undo Obamacare," Levin said.