One of Trump’s main campaign promises was to repeal and replace the Affordable Care Act. You may know it better as Obamacare, a sobriquet devised by those opposing the scheme that has now passed into near universal usage. Republicans have been promising this for years, but now that Obama will no longer be in office to veto a proposed bill they might actually attempt to do it.

Let’s start with  the repeal part of this promise. Republicans really, really hate Obamacare. So the will is certainly there. But as I have mentioned so many times before it is much easier to stop things happening in the American system than to push them forward. Witness the soul-crushing, years-long slog Obama, Pelosi and Reid had to go through to pass the dashed thing in the first place. Repealing it would be a long and hard campaign for the GOP, not least because they can count on stiff Democratic opposition.

Many Democrats, particularly the now ascendant Liberal wing of the party, didn’t like the Affordable Care Act because it was a messy compromise. Many wanted a system analogous to the rest of the developed world where the government simply paid for medical treatment for those who need it. They were brought along kicking and screaming, eventually acceding to the reality that there were not the required 60 votes for such a proposal in the Senate. The Republicans can probably repeal it. But if the Democrats choose, and I think they will, they can make the process time costly in both time and political capital. The increasingly desperate and angry progressives who wanted more to start with will not go gently into the night.

That brings us to the replace part of the plan. This, friends, is where the wheels really start to come off. Trump has at this stage promised to keep the parts of the law that make it illegal to refuse coverage to those with pre-existing medical conditions. That is good. He has also said he want’s to have ‘universal health care’. That is also good. But Trump says he will do it without mandating individuals purchase health insurance on the one hand or providing government insurance on the other.

This is total nonsense. You can’t have universal healthcare without either mandating private healthcare or providing public healthcare. That isn’t what those words mean. Moreover, one of the problems with Obamacare is that not enough young and healthy people signed up, meaning the risk pool wasn’t sufficiently diverse and premiums kept rising to try and make up the difference. Remove the mandate and the numbers get much worse. It just doesn’t  work.

The Republican plan a la Paul Ryan would basically make healthcare cheaper to those who don’t need it and more expensive for those who do. The bottom line is that if you want everyone to have healthcare, and insurance companies to cover people on whom they will never make a dime because of chronic and pre-existing conditions, someone has to pay. Either other consumers or the taxpayer.

Trump is essentially trying to have his cake and eat it as well. Nobody really likes the individual mandate, but it’s the part that makes the whole thing function. So his promise and stated policy are obviously bunk. What then should we expect?

Well, it’s pretty clear what his pick for Secretary of Health and Human Services (HHS) wants, and it isn’t anything good. Tom Price has been one of the harshest critics of health care reform, advocating repeatedly and vociferously for measures that would totally the progress that has been made over Obama’s two terms in the oval office. If Trump wanted a conciliatory plan that protected the most vulnerable he certainly picked the wrong guy to execute it.

Of course, this isn’t really news. It shouldn’t surprise any of us that Trump obviously has no understanding of the American healthcare system. I myself doubt if he understands any system at all with the possible exception of bankruptcy courts. But it demonstrates very neatly the problems he will run into as he tries to make headway with what we may charitably call his policy program.

Because Trump wasn’t elected as the leader of a party of pragmatic center-right conservatives. Doing what he seems to genuinely be his inclination, keeping exemptions for pre-existing conditions and ensuring everyone has health care, will require measures utterly unacceptable and antithetical to both his base and the cavalcade of sycophants and mediocrities with which he now surrounds himself.

A time is rapidly approaching when Trump can’t simply exist in the world of tweets and word-salad, easily forgotten by the next news cycle and impervious to decryption. He cannot be all things to all people as President. He will have to take a stance and codify his position in black and white. And once he does that there are going to be a lot of very, very angry people on one side of politics or the other.

And in case you thought he might have some master plan up his sleeve, if he waits too long he will lose the initiative. Paul Ryan knows exactly what he wants to do about health care. He has been thinking, writing, filling ring-binders with detailed tables and spreadsheets for years. The same goes for many of the hardline, anti-government conservatives within his party. If Trump fails to take the lead on the issue he is likely to be led by the nose as the congressional wing of his party, scared witless by the rabidity of the base they must face in only two years, starts writing the next chapter without him.