North Carolina’s largest insurance provider will soon decide whether it will continue writing policies through the Affordable Care Act’s online marketplace, a top official said Friday.

Brad Wilson, CEO of Blue Cross and Blue Shield of North Carolina, said a decision will come in two to three weeks.

If Blue Cross abandons that line of business, North Carolina would be left with no major carrier to write ACA policies – meaning “the ACA effectively will not exist in our state,” Wilson told an audience at the Hood Hargett Breakfast Club at Carmel Country Club. Aetna and UnitedHealthcare, the state’s other ACA providers, announced plans earlier this year to exit that market in North Carolina, starting in 2017.

Blue Cross, by far the state’s largest ACA provider, covers 500,000 to 600,000 people, the bulk of whom get a federal subsidy to buy the policies.

Despite those numbers, Wilson said the Durham-based company is losing money on ACA customers – about $405 million over the last two years, he said.

Wilson said ACA losses stem from the fact that too many young, healthy people are refusing to buy health insurance, a federal mandate under the Affordable Care Act. That leaves older and sicker residents as the primary ACA buyers, but the amount they pay in premiums, Wilson said, is not enough to cover the costs of their escalating health care.

“You don’t have to get an MBA to understand that, if you’re not taking in enough to pay for what’s going out, that that is an unsustainable business model,” Wilson said. “…It’s clear something’s wrong.”

Wilson called the current situation a “death spiral” for ACA – unless Congress moves to fix the controversial program championed by President Barack Obama and loathed by congressional Republicans.

Citing the ever-rising cost of health care in the state and nation, Blue Cross is seeking an 18.8 percent rate increase on average for 2017, according to The Charlotte Observer. The state insurance department won’t announce the approved rates until Oct. 28. For 2016, Blue Cross was approved an average 32.5 percent rate increase.

Wilson said ACA has done little to slow the nation’s rising health care costs, which, according to some estimates, will account for about 20 percent of the total U.S. economy by 2020.

“That’s one of every five dollars in your pocket will be dedicated to health care somehow, some way,” he said.

Wilson outlined some broad steps that he said are needed to make ACA sustainable for insurers.

• Stronger enforcement of the mandate: For every North Carolina resident who has purchased insurance through the ACA marketplace, he said, an equal number qualify but have not signed up. “The mandate has been too weak,” he said.

• Tighter controls on enrollment periods. Wilson said too many consumers are letting their policies lapse then buying new ones when they need medical care. “Right now,” he said, “there are far too many opportunities for people to jump in and jump out. That destabilizes the whole market, and it runs costs up.”

•  Shorter grace periods for paying premiums. Under ACA, policyholders who are behind in their payments are given 90 days to get caught up before their policies are terminated. Wilson said this encourages abuse – allowing people to get treatment and medications during the grace period without ever paying.

Wilson said the ACA in North Carolina also would be strengthened if state lawmakers voted to expand federally funded Medicaid to include an additional 500,000 to 700,000 low-income residents – a moved proposed by the Obama Administration but rejected by Republican governors in most Southern states, including North Carolina. But even with an expansion of Medicaid, he said, other measures will be needed to correct the system.

Founder and publisher of Qcitymetro, Glenn has worked at newspapers including the Los Angeles Times, St. Petersburg (Fla.) Times, Philadelphia Inquirer, Wall Street Journal and The Charlotte Observer.