Pasquale D’Angiolillo for KHN
PÜTTLINGEN, Germany — Almost every day, Dr. 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.
The region’s last-operating coal shaft, just a few miles away, closed a decade ago, ending centuries of mining in the Saarland, a mostly rural state tucked between the Rhine River and the French border. But the mines left a difficult legacy, as they have in coal regions in the United States, including West Virginia.
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. And like West Virginia, the region faces economic hurdles. For decades, German politicians, 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. And on average, 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. — in no state more than West Virginia.
In the Saarland, medical debt is practically nonexistent. It’s so rare in Germany that the federal government’s statistical office doesn’t even track it.
The reason isn’t government health care. Germany, like the U.S., has a largely private health care system that relies on private doctors and private insurers. Like Americans, many Germans enroll in a health plan through work, splitting the cost with their employer.
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, the hospital or the pharmacy.
Rolshoven’s patients pay nothing when they see him. That not only bolsters their health, he said. It helps maintain what Rolshoven called social peace. “It’s really important not to have to worry about these problems,” he said.
German health officials, 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