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North Carolina’s average premium increases on the Obamacare exchange are among the highest in the country, according to federal data. The Obama administration warned this open enrollment period, which closes Jan. 31, could be particularly tough because many of the sickest, and therefore most motivated, people already bought plans.

And yet, sign-ups in North Carolina are on pace to be substantially higher than the two previous years. Roughly 95,000 more North Carolinians selected a plan during the first two months of this enrollment period compared with the last one. Across the country, only two states using the federal exchange saw more sign-ups over the same period: Florida and Texas.

Sue Martin, who’s from the small town of Mebane, North Carolina, about two hours northeast of Charlotte, said, “I hate to sound hyperbolic, but it’s kind of a matter of life and death.” Her experience is a case study of how the health law is playing out in the state and how individuals have navigated surging premiums.

Martin couldn’t afford treatment for Lyme disease and a thyroid condition without health insurance. She got covered through healthcare.gov two years ago, and a federal subsidy cut her premium to $238 a month.

But the insurance company cancelled that plan for 2016 and suggested a similar one, with a big caveat. Martin said it would cost her $491 a month.

“To go up that much on premium, that’s prohibitive for me,” she said. “There’s no way, being a retired single lady. That’s, well, double what I was paying before.”

The company behind that plan, Aetna, declined our interview request. Instead, Aetna provided a statement that said its goal is to use rates that’ll cover the cost of doing business.

In North Carolina and nationwide, health insurance rates were still a work in progress in this third year of Obamacare open enrollment. Coverage got cheaper in states like Indiana and Mississippi but more expensive in North Carolina, Arizona and Pennsylvania, among others, according to federal data.

Insurers aim for a sweet spot regarding premium price tags. They want them high enough to cover the cost of people’s medical care, but low enough to attract customers.

Georgetown University researcher Sabrina Corlette said when the Obamacare exchanges first opened, “for many insurance companies, that was a real guessing game.”

“They didn’t know what kind of policyholder they would attract,” she said. “They just had no idea what their costs would be.”

Now that companies have actual data on who signed up and how much care they needed, “they’re saying, ‘Whoa, wait a minute, we didn’t price the way we should have to actually reflect our costs, and so we need to adjust,’” Corlette said.

In North Carolina, the adjustments were huge. All three insurers on the exchange raised average premiums at least 20 percent. Sue Martin’s insurer, Aetna, raised rates 24 percent. The state’s dominant player, BlueCross BlueShield of North Carolina (BCBSNC), raised rates 33 percent.

Managing Actuary Brian Tajlili said BCBSNC landed a long way from that sweet spot.

“The assumption was the sick would come in the first year in 2014 but then in 2015, healthier people would enroll,” he said. “We made that assumption. Many others in the industry did as well.”

Preliminary research is mixed on whether that happened nationally. But Tajlili said it didn’t in North Carolina.

“Another thing that we had assumed is many people would go in, get a lot of services done all at once in the first year — something we sometimes call pent-up demand — and that cost would level out after that,” he said. “That proved to not be the case either.”

Instead, he said, the enrollees’ care started off expensive and stayed that way.

The bad projections meant premiums weren’t even close to covering costs, Tajlili said, and BCBSNC lost more than $120 million on that part of its business.

Still, it’s a small part of the business: less than 10 percent of BCBSNC customers are on the exchange. The premium increases of Obamacare plans don’t affect most people who have insurance through their jobs.

So were North Carolina’s insurance companies just worse at predicting who’d sign up?

“Premium increases really vary state by state, and there hasn’t been, at least at this point, a really clear pattern that has emerged,” said Elizabeth Carpenter of Avalere Health. She consults with insurance companies and other clients navigating the exchanges.

North Carolina Insurance Commissioner Wayne Goodwin has his own theory for why premiums are so high in this state.

“North Carolinians would have had lower rate adjustments and more competition and more choices for plans if we had gone a state-based route,” he said.

Goodwin said Republican state lawmakers and the governor made a mistake by choosing the federal exchange (as about three dozen other states did) rather than setting up their own.

The data is not clear on that. Jon Gabel at the University of Chicago has researched this point.

“Last year, the rate of increase in state-based exchanges and the federal exchanges was basically [the same.] There was no statistical difference,” he said.

Government data show that a benchmark plan for Indiana dropped an average of 13 percent, while the same plan in Oklahoma rose an average of 36 percent — and both states use the federal exchange.

Gabel acknowledged, though, that there can be advantages to the state exchanges.

“You have much more decision-making power, that is for sure,” he said.

In other words, you’re in control of the red tape. Commissioner Goodwin argued that could have allowed North Carolina to attract more insurance companies.

“That alone would’ve been a major factor for consumers here if there were more companies available,” Goodwin said.

The data does back up the idea that more competition equals lower premiums. North Carolina and the other states with the highest increases tend to have the fewest insurance companies selling on the exchange.

Back in Mebane, Sue Martin shopped around healthcare.gov and found a new plan she could afford, albeit with skimpier benefits.

“Even if the premiums are a little higher than I like or everything isn’t covered or whatever, I still have the option to see my doctor,” she said. “I can still afford my medications.”

One factor working in Martin’s favor is that federal subsidies rose in North Carolina, along with the insurance rates. That’s because the premium increase for North Carolina’s second-lowest-cost silver plan — the benchmark plan — was 22.8 percent.

Martin is among about 150,000 North Carolinians who already had coverage on the Obamacare exchange but switched plans during this open enrollment, according to a federal report. She’s also among the roughly 90 percent of North Carolinians who signed up with the help of federal subsidies.

This story is part of a reporting partnership that includes , and Kaiser Health News.