North Carolina’s Medicaid program will expand on December 1 to offer fully subsidized health plans to virtually every legal resident whose household income is at or below 138% of the federal poverty line.

Notice I said “offer.” Many individuals and households who’ll now qualify for Medicaid are already enrolled in other health plans, either through workplaces or the Affordable Care Act insurance exchange. So when advocates claim this will cover half a million or more uninsured North Carolinians, you should know their claim is incorrect.

Expansion will reduce the ranks of the uninsured, to be sure, but not nearly by that much. Many new Medicaid enrollees will be exiting other health plans, shifting more of the cost to taxpayers.

Nevertheless, I write today not to relitigate the case against Medicaid expansion. That would be a moot point. The case has already been decided — and not just by Democratic Gov. Roy Cooper, who spent his entire term in office lobbying for expansion, and Republican leaders in the North Carolina General Assembly, who chose to concede the point last year.

No, the case was actually decided in 2018 when GOP leaders in Washington, enjoying control of the White House and both chambers of Congress, chose to take no substantive action on the core element of the Affordable Care Act — which was, contrary to popular belief, neither the insurance exchanges nor the individual mandate once thought essential to the operation of those exchanges.

Medicaid expansion was always the Obama administration’s primary goal. At the time, expansion was projected to consume a majority of ACA dollars and account for a majority of net enrollment in health plans.

In practice, the role of Medicaid expansion proved even more dominant. As of 2021, the ACA was responsible for some 17.4 million more Americans being enrolled in Medicaid. The increase in private health coverage was comparatively minor: 1.6 million. That represents the net effect of enrollment in the subsidized exchanges minus enrollment declines for employer-based plans and other private coverage.

That’s where we stand today. Ironically, neither Democratic nor Republican leaders seem satisfied with the results of the Affordable Care Act. Many of the former advocate further expansion of Medicare and Medicaid, with the ultimate goal being a government monopoly over the financing of medical care. Many of the latter continue to vilify “Obamacare” while offering no serious alternative to its current mix of rickety insurance exchanges and vastly expanded Medicaid.

What should North Carolina policymakers do next? Well, they shouldn’t expect any constructive from Washington. In my view, they should focus on matters over which they retain significant control, such as:

Competition. As a condition for supporting Medicaid expansion, Republican lawmakers got some modest reforms of state laws that currently protect hospitals and other providers from competition. Next steps should include completely phasing out our certificate-of-need system (as South Carolina recently enacted) and reforming scope-of-practice laws to let nurse practitioners provide primary care to willing patients at lower cost.

Transparency. These reforms won’t work if patients and their employers lack prior knowledge of prices and other relevant facts. Providers don’t want to share this information. State Treasurer Dale Folwell has been fighting for transparency on behalf of public employees. Other leaders should join the fight on behalf of all consumers.

Innovation. From the perspective of patients seeking longer, healthier, more fulfilling lives, some of the most promising developments of the past decade have little or nothing to do with the ACA or other changes in health care finance. They involve pathbreaking new treatments of cancer, heart disease, and other fatal or debilitating diseases, such as the use of Ozempic, Rybelsus, and other drugs to combat obesity. Our public policies should encourage such innovations, not subject them to undue regulatory or legal risk.

Empowering patients to make decisions for themselves — and keeping as many of those decisions out of the hands of politicians and interest groups — is the best way to improve health care. Let’s proceed.

John Hood is a John Locke Foundation board member. His latest books, Mountain Folk and Forest Folk, combine epic fantasy with early American history.