The Greensboro News and Record

Many North Carolina residents are unhealthy.

The facts have been documented extensively: Diabetes, stroke, heart disease, lung cancer and many other diseases take a heavy toll. Obesity and smoking are leading contributors. Poverty and lack of regular medical care for many let chronic ailments develop into disabling conditions.

No wonder so many North Carolinians have signed up for Affordable Care Act programs since coverage became available in 2011. They had no alternative. Many more would enroll in Medicaid if the state had accepted the expansion offered by the federal government.

North Carolina’s 2017 ACA enrollment is 549,158, fourth-highest in the country, according to the U.S. Department of Health and Human Services. Yet, there’s just one insurer in the market: Blue Cross Blue Shield of North Carolina, and it expects to lose money despite hiking premiums by 24 percent.

The reason for the losses is directly related to the poor general health of the North Carolina population. People who have high incidences of severe diseases or even chronic conditions consume a lot of costly medical care.

Meanwhile, healthier younger people without other coverage still tend to avoid enrolling in ACA plans. Without their premiums coming in to help pay for their sicker elders, the insurance company can’t make a profit. Worse, if the same healthy younger people come down with unexpected illnesses or experience catastrophic accidents, they’ll be unable to pay medical providers — leaving others to pick up the bills.

The final burden is that so many ACA enrollees in North Carolina — about 90 percent — qualify for federal subsidies, according to a study by Wake Forest University researcher Mark Hall.

Most of them pay less than $75 a month out of their own pockets. Taxpayers cover the rest.

This adds up to an unsustainable system but also poses a difficult problem for policymakers in Washington who promise to “repeal and replace Obamacare.”

They can repeal it, but President Donald Trump has set a high bar for a replacement. He says it should cover everyone, provide better care and cost less.

No one should believe that will be the end result. And, despite Trump’s vow to produce his plan immediately, it is yet to materialize and probably doesn’t exist.

Nevertheless, his administration is taking steps that could both help and hurt the ACA in the short run. It’s moving to restrict open enrollment periods that have allowed consumers to sign up when they’re sick and drop coverage when they’re better. If the effort is successful, it could plug some losses. At the same time, it’s relaxing enforcement of the individual mandate requiring people to purchase insurance. That will rob the system of revenue.

In the meantime, Republican representatives and senators around the country are hearing from constituents who demand health care coverage — so many of them that the politicians are starting to worry about the political cost of casting millions of Americans off the insurance rolls.

Some are avoiding town hall meetings and other forums where they might have to face angry voters. U.S. Rep. Ted Budd of North Carolina’s 13th District has set up “telephone town halls” with constituents, which lets him address them in a tightly controlled environment.

Years of promises to repeal Obamacare have yielded to a complex reality: Replacing it will be terribly difficult and potentially unpopular. People don’t want to be excluded from coverage if they have pre-existing conditions. They don’t want low ceilings on annual or lifetime benefits. They don’t want to be forced to enroll in insurance if they don’t think they need it. Employers don’t want to be required to insure their employees. And, most vexing of all, no one wants to pay what good medical care really costs.

The smartest way to address the root problem would be to provide preventive care and health maintenance for everyone. If Americans were healthier in the first place, insurance might be affordable. Getting there won’t be accomplished simply by repealing Obamacare.