The Finns do it. The Germans do it. Even the Portuguese andGreeks do it.

Across most of the developed world, single-payer, universallyavailable health care is the norm. Legislators briefly consideredsingle-payer coverage in the United States during the health caredebates, but ultimately settled on the hybrid public/privatesolution that is the Patient Protection and Affordable CareAct.

As of this autumn, the health insurance exchanges that are thecenterpiece of PPACA will have been live for a year. But thesubject of a single-payer system—one in which the government,rather than private insurance companies, pays all health carecosts—has not disappeared. Vermont is moving to a single-payerhealth care delivery, and many other states have coalitions infavor of single-payer plans on either a state or federal level.Both the Kaiser Family Foundation and the Robert Wood JohnsonFoundation have explored the system's potential benefits.

Is a single-payer system a likely successor to PPACA in theU.S.? We talked to a variety of benefits industry professionalsabout the chance that the U.S. might adopt a single-payersystem—and what that might mean.

A slippery slope?

Before PPACA's rollout, some observers thought that the law wasengineered to deliberately move the U.S. toward a single-payersystem.

“I think that, on the law's initial passage, there weredefinitely people who thought it was a slippery slope to asingle-payer system,” says Joshua Weinstein, an employee benefitsconsultant at Northrim Benefits Group, LLC in Anchorage, Alaska.“They were going to regulate insurance companies to the point thatthey couldn't compete, with plans moving toward a sort of plainvanilla benefit. You could differentiate yourself in terms ofcustomer service, but not so much on other things.”

The new system's lack of appeal to insurance companies wasn'tthe only concern, Weinstein adds. “Some people thought PPACA wouldbe so complicated that employers would want to get out of itcompletely and want to go to a single-payer system,” he says.

Now that the exchanges at the core of the law have been live fornearly a year, there's less worry about new regulations drivingcarriers out of the market, but more concern over the technologythat powers the exchanges.

“The rollout has absolutely been a mess,” says Jay Starkman, CEOof Engage PEO in St. Petersburg, Florida. “There's mass confusionand changes in the law. We have all these uncertainties andunknowns, and that's made it very difficult for the Americanbusiness owner or company to figure out how to deal with it.”

Single-payer? Some think so

“I think we're headed toward single-payer, though it breaks myheart to say that,” says Shannon Enders, a chartered benefitconsultant at Lake Shore Employee Benefits in Muskegon,Michigan.

The reason, he says, is that PPACA is just too complicated.

“Single-payer would be dramatically less complex than what wehave today,” he says. “I even wonder if the current mess wasdesigned to be a mess, so that we'd be more willing to gosingle-payer.”

A single-payer system, Enders says, would eliminate much of thechoice to which Americans are accustomed. “With hassle, comeschoice. With simple, comes no choice,” he says.

Even so, Enders thinks that American consumers and businessowners might be sufficiently sick of hassle to make the switch.

“I think people are in the place where they just don't want todeal with this anymore,” he says. “Some of the business owners Iknow are fairly conservative, and they would still consider asingle-payer plan, because they're so tired of dealing with thisevery year. They would throw money at the headache.”

Medicare would be the likely model for a universal single-payersystem, Enders says, adding that “it would be the most logicalthing to adopt.”

The insurance industry wouldn't be thrilled by a single-payersolution, Enders points out, and probably wouldn't survive in itscurrent formation.

“Health plans are drooling over all the new people. It'sguaranteed issue, but people are forced to buy their product. Ithink many of these well-heeled, well-connected corporations arenot going to just stand there and say sure, single-payer is the wayto go. I agreed to go to guaranteed issue, you agreed to send mecustomers, and now you're saying that I'm out?”

But the industry would regroup and survive, he says. “AFLACsells products to cover the things that insurance doesn't, and thatkind of coverage will be more popular,” Enders says. “Asingle-payer plan won't be able to be all things to all people, andinsurers would [still be able to] sell gap coverage.”

Single-payer? Probably not

Other benefits industry participants think it's unlikely that asingle-payer system will succeed PPACA—at least in the foreseeablefuture.

They point to states that have created their own exchanges,rather than relying on the federal model, and the successes thesestate exchanges have enjoyed.

“Many states have had successful rollouts, most of them bystarting early and establishing their own state exchanges,” saysSean Corry, president of Sprague Israel Giles Inc. in Seattle, anda member of the task force that created the Washington state healthinsurance exchange. “Almost half a million people, more than in the36 states covered by the federal exchange, signed up throughexchanges in California, Connecticut, Kentucky, New York andWashington. Where there were concerted efforts, it's beenremarkably successful.”

The federal and some state exchanges were a mess when theybegan, Starkman agrees, but many of them have improved. “You don'thear the horror stories about going on the exchanges anymore,” hesays.

Moreover, Weinstein says, PPACA is a market-based reform thatkeeps carriers in a place to insure people under a new set ofrules.

“Some people thought that PPACA would run the insurancecompanies out of the market, through the required benefit ratio,”he says. “That doesn't seem to be happening. In some respects, thenew model is working.”

It's working especially well for the insurance industry, Corryargues.

“The criticism of PPACA has been around the idea that this is agovernment takeover. But if you look at how it is actually working,it is a carrier-based, market-based solution,” he explains. “Whereit's working, there's more competition, more plans available thanever before, all from private companies. It's enhancing the privateinsurance market, making it much healthier and more robust. Thecurbs and rules make it easier for companies to compete.”

The absence of underwriting pressure has removed the competitionfor the healthiest patients, but has opened the gates tocompetition around other points, Corry continues.

“In the states where it's working well and in states where itcould have worked well, it takes away underwriting competition,” hesays. “In Washington, the Blues and a couple of others had a lockon the market, and carriers could use a health screen to sendpeople to the state high-risk pool. They couldn't afford to havericher plans than competitors, because they would attract thesick.”

Now, Corry says, plans are enriched, underwriting pressure isgone, and both enrollment and plan choices have grown.

“Going into 2015, we're going from eight to 12 carriers, and thenumber of plans has increased by 240 percent,” he says. “The rulesmake it much safer for insurers to be in our market.”

Instead of competing on underwriting, insurance companies arecompeting on customer service, costs and offerings within the gold,silver, and bronze plan levels, and drug formularies.

“The real competition that's going on right now is also aroundlimited provider networks,” Corry says, which are a place thatcarriers may be able to significantly pare costs.

There are other reasons to suspect that PPACA—or something likeit—will stick. Anne Lennan, president of the Society ofProfessional Benefit Administrators in Chevy Chase, Maryland,thinks that the scrambled technology that marred the exchange debutshowed the public just how complicated it is to manage third-partyhealth-benefit plans.

“The embarrassment of the exchange rollout makes it seemmind-boggling to even consider a single-payer system,” she says.“The planning that would need to go into it, the strategy, process,coordination—it's proved insurmountable for many states. Thefederal exchange also had a ton of problems.”

A move to Medicare would remove the cost-containmentimprovements PPACA has brought to U.S. health care, Lennanadds.

“Lots of plans emphasize prevention and wellness, which hasproven very helpful in getting a handle on costs. That's not athing that Medicare does well,” she says.

If employers were likely to dump workers into the exchanges,that might be a reason to implement a single-payer system. But theIRS notice that came out in the fall of 2013, which sets penaltiesfor firms that fail to offer employers health coverage, “makes itclear that the administration, through this guidance, is sending aclear message to the employer community. People were initiallythinking that this could have been lip service, but it reallyappears to be backed up with action,” Lennan says.

No political will

Like any law, PPACA's future depends on future presidents andcongressional members. The longer the new system is in place,however, the bigger a hassle it will be to tear it down andimplement something else. Many think that, despite continuingRepublican calls to repeal PPACA, Washington simply doesn't havethe political will to dismantle it.

“I see PPACA getting more settled,” says Erin Thurston, a seniorassociate at the health care strategy firm Wilson StrategicCommunications in Seattle. “North Carolina is a good example. Therewere people there who opposed [the law], and now they actuallyreally like what they have through it.”

Big changes have a history of needing time to take root, says DJWilson, president of Wilson Strategic Communication as well asState of Reform, an online health care strategy magazine.Medicare became law in 1965, for instance; Arizona finally adoptedit in 1982.

“PPACA will increasingly become accepted as the law of theland,” he says.

The botched exchange rollout, coupled with the VeteransAdministration scandal, isn't likely to push Americans further intothe federal government's arms, Wilson adds.

Wilson dismisses the idea of PPACA as a deliberate route tosingle-payer coverage.

“That would suggest that Congress is good at doing anything,that it's really smart, and that members can get together to pullthe wool over everyone's eyes,” he says.

Starkman points out that a single-payer system would need achampion—and there are no obvious candidates in Washington.

“Moderate Democrats presented and passed PPACA. The oppositionhas not been the extreme left—it's been the extreme right, andthey're not going to implement a single-payer solution,” hesays.

If a single-payer system's chances don't look good on a federallevel, they look only slightly better for individual states.“Vermont is just one state,” Wilson says. “Texas ain't goinganywhere.”

There's no way of knowing for sure what PPACA's future holds,particularly when the Supreme Court may revisit parts of the law.As far as he can tell, though, “some form of PPACA is here tostay,” Starkman says.

“I don't foresee it being repealed. Tweaked, yes, and maybemajorly tweaked. There will be political fuss, but it's here tostay.”