From Eckart Rolshoven examines a patient at his clinic in Püttlingen Although Germany has a largely private health care system patients pay nothing out-of-pocket when they come to see him Eckart Rolshoven sees the long shadow of coal mining in his clinic near the big brownstone church that dominates this small town in Germany's Saarland ending centuries of mining in the Saarland a mostly rural state tucked between the Rhine River and the French border as they have in coal regions in the United States Many of Rolshoven's patients battle lung diseases and chronic pain from years of work underground "We had an industry with a lot of illnesses," said Rolshoven a genial primary care physician who at 71 is nearing the end of a long career The Saarland's residents are sicker than elsewhere in Germany business leaders and unions have labored to adjust to the mining industry's slow demise But this is a healthier place than West Virginia in many respects. The region's residents are less likely to die prematurely, data shows they live four years longer than West Virginians There is another important difference between this former coal territory and its Appalachian counterpart: West Virginia's economic struggles have been compounded by medical debt a burden that affects about 100 million people in the U.S It's so rare in Germany that the federal government's statistical office doesn't even track it has a largely private health care system that relies on private doctors and private insurers many Germans enroll in a health plan through work But Germany has long done something the U.S does not: It strictly limits how much patients have to pay out of their own pockets for a trip to the doctor Rolshoven's patients pay nothing when they see him It helps maintain what Rolshoven called social peace "It's really important not to have to worry about these problems," he said business leaders and economists say the access to affordable health care has also helped the Saarland get back on its feet economically bolstered by the assurance that workers could get to the doctor the Saarland would be dead," said Beatrice Zeiger managing director of the Arbeitskammer des Saarlandes whose wooded valleys and decaying industrial plants could be mistaken for the Saarland's access to health coverage has been important as the state weathered the decline of its mines A decade ago, state leaders moved to expand the Medicaid insurance program through the Affordable Care Act. And as of last year, just 6% of state residents were uninsured, less than half the rate before the 2010 law But growing numbers of West Virginians without government insurance are in private health plans with deductibles that require they pay thousands of dollars out of their own pockets before coverage kicks in The typical individual health plan an American gets through work now comes with a more than $1,500 deductible a particularly big sum in a state like West Virginia where residents often earn less than residents of other states That, in turn, is driving medical debt. A quarter of West Virginians with a credit report have medical bills in collections, almost twice the national rate, according to data compiled by the nonprofit Urban Institute And those figures likely understate the problem. Many more people put medical bills on their credit cards borrow from family or enroll in installment plans with a hospital or other providers to pay off their bills "It's a huge problem here," said Jessica Ice executive director of West Virginians for Affordable Health Care "Folks with medical debt aren't able to apply for loans to start a business or buy a starter home for their family It's really preventing people from climbing up the economic ladder." Physician visits are almost always free for patients Copays for most prescription drugs are capped at 10 euros or less And people admitted to the hospital pay only 10 euros a day "Access to medical care with minimal costs for patients has been essential," said Armin Beck regional director of the Knappschaft Bahn See a health insurance plan whose roots stretch back to the 13th century when miners set up a mutual aid society to protect one another in case of injuries or accidents "This has been a foundation of our community," Beck said rusting steelworks and shuttered coal-fired power plants bear testament to the region's economic struggles Many towns like Püttlingen carry on in the shadow of hulking mounds of debris — Berghalde as they are called — the detritus left behind as coal was separated from the rocky earth hauled up from underground The now-shuttered Bergwerk Saar coal mine in Germany's Saarland closed in 2012 Coal from the Saarland helped fuel Germany's industrialization and once employed tens of thousands of workers which has operated a car factory here for decades plans to shutter the plant in a few years and move production to Spain But at Rolshoven's clinic — a small set of offices tucked into a residential neighborhood — few patients can conceive of the burdens that medical bills put on Americans who has diabetes and came to see Rolshoven because recent tests revealed a concerning rise in her blood sugar In the U.S., the average price for insulin alone is nine times that in Germany, according to a recent report from Rand Corp. a former miner who left the industry 20 years ago after a series of accidents would likely pay even more out-of-pocket for his family's drugs Mang's wife recently underwent a course of chemotherapy that would cost thousands of dollars if not for Germany's limits on medical bills "I can't imagine what it would be like not to have this support," Mang said Christine Wagner said she's had a glimpse of what Americans face has Down syndrome and has required more than 20 surgeries In global Facebook groups with other parents who have children with disabilities Wagner said she's amazed to see how much fundraising American parents do to pay family medical bills "I'm so glad we don't have to worry about that," she said "We have enough to do looking after Jonas." International surveys underscore the difference Wagner observed between her experiences and those of American families In one recent study of health care in 11 high-income countries the nonprofit Commonwealth Fund found that 44% of Americans had out-of-pocket medical expenses that topped $1,000 in the previous year Just 16% of Germans reported paying that much where only 7% reported similar medical expenses patients were also more than twice as likely as patients in any of the 10 other countries studied to say they had serious problems paying medical bills "Many Americans may not understand how affordable health care is for patients in other countries," said Reginald D who oversees international research at the Commonwealth Fund It just doesn't happen in other countries." East Asia and elsewhere limit patients' out-of-pocket costs where patients enroll in private health plans as they do in Germany insurers typically cover all medical expenses after patients pay a standard deductible of 385 euros where medical care that is "free at the point of service" has been a foundation of that country's government-run National Health Service for almost 75 years there are rarely any doctor or hospital bills When the government asked Britons who'd gone into debt about the causes just 2% cited paying for medical treatment A similar share attributed their debt to gambling or another habit In the U.S., 41% of adults currently have debt from medical or dental bills, according to a KFF poll Germany's strict limits on medical bills have periodically stoked concerns about patients overusing the health system But when health plans tried implementing a copay of 10 euros for physician visits it was quickly rolled back amid criticism from patients and frustration among doctors who didn't like chasing after their patients for bills Germany's limits on how much patients pay out-of-pocket at the doctor's office have been critical to ensuring people get needed care especially in a mining region where many battle lung diseases and chronic pain "We had an industry with a lot of illnesses," he says Marion Bolte said asking patients to pay more isn't worth the risk "It's better to have 20 unnecessary visits than to have one patient get harmed because they didn't come to the hospital because they were worried about how much it would cost," said Bolte "We don't want patients to worry about money We want them to worry about getting better." Nationally, German patients are less likely than Americans to die from conditions that can be treated with good access to medical care, such as heart attacks, diabetes, pneumonia and some cancers, according to regional data compiled by the Paris-based Organization for Economic Cooperation and Development Germans are also less likely than Americans to say they had to wait to see a doctor, surveys show Lower-cost health care that protects workers from going into debt has meant fewer concerns for the Saarland's policymakers "All that our predecessors had to worry about was creating jobs," said Oliver Groll the Saarland shifted toward other industries which has been a major employer since Ford opened its factory in 1970 sparking the development of a robust auto parts sector The chamber and other business leaders are now working to lure technology and pharmaceutical jobs to the region knowing that medical bills wouldn't drive him into debt helped give him the peace of mind to switch careers "I never had to think about how much health care would cost me," said Mang Maintaining this system has required that Germany do something else that U.S This regulation occurs through a highly structured system in which insurers negotiate collectively with physician and hospital groups to set prices American hospitals and other medical providers for decades have fiercely resisted limits on their prices spending millions to fight government regulation Price regulation can put more financial pressure on providers can't just demand higher prices from insurers to bolster their bottom lines the hospital administrator who runs the Knappschaft hospital in Püttlingen said hospitals must instead compete to attract patients with better care and better customer service But Schüller said he wouldn't want to charge patients more "If I had to bill patients and then try to collect from them KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation) KFF is an endowed nonprofit organization providing information on health issues to the nation Become an NPR sponsor