American Scientist

In a model mine shaft at the Mining Museum in Bochum, Germany, the last double drum shearer left in the country sits on display. Before Germany ended coal mining in the surrounding Ruhr Valley in 2018, such machines cut through coal seams belowground. Hans Mohlek, an engineer who once operated a similar shearer, retired in 2010 as part of the planned phasing out of the coal industry in Germany. Now he leads tours at the museum. The Ruhr Valley has made a similar transition. Once, it relied on hard coal as the basis of the economy; today, that industry has ended, but its influences remain.

At age 64, Mohlek remains in good health, enjoying a fulfilling retirement playing with his grandchildren, connecting with other retired mine workers as chair of the State Association of Miners’ and Mining Associations of North Rhine-Westphalia, and teaching about the region’s industrial past. He doesn’t know anyone who has had trouble accessing medical care when they are sick and has never heard of a current or former mine worker in medical debt, even though he lives in the German state with the highest rates of pulmonary diseases in the country.

Former coal miners in the United States cannot say the same, with some of the highest rates of medical debt and lowest life expectancies in the country. Residents in the coal-producing state of West Virginia die an average of eight years earlier (at age 72) than their counterparts in Mohlek’s state of North Rhine-Westphalia. A 2024 survey of 10 high-income nations, conducted by the Commonwealth Fund, found that the United States has the highest out-of-pocket health care expenses, whereas Germany has one of the lowest. In the United States, 41 percent of residents incurred out-of-pocket medical expenses exceeding $1,000 in a single year.

Because health coverage is mandatory in Germany, 99.9 percent of residents are insured, and almost everyone has a regular doctor. In contrast, 26 million people in the United States remain uninsured, leaving them exposed to crushing medical debt. U.S. miners also continue to show persistent and elevated mortality from respiratory disease. Coal regions such as Appalachia therefore face a double burden of high chronic disease rates and a medical debt crisis affecting millions of people.

Compared with their U.S. counterparts, German residents living in coal-producing regions show fewer severe health outcomes, indicating that systematic workplace controls and health monitoring with accessible treatments help reduce long-term mortality from lung disease. Germany’s former industrial heartland has also benefitted from a dramatic decline in air pollution that has decreased incidences of chronic diseases, reduced hospital visits, and added years to people’s lives.

“As far as I can judge, the overall health of retired hard-coal miners has improved significantly,” Mohlek says. “Silicosis, or black lung disease, has practically disappeared. This was achieved, among other things, by clearly improved working conditions and by mining companies providing workers with personal protective equipment free of charge.” An industry-funded long-term cohort study in the Ruhr published in 2018 in the Annals of Lung Cancer supports his perspective.

Germany’s success in fostering better health outcomes for coal miners is the result of policies emphasizing a “just transition” that pair strong environmental laws with a mandatory, nonprofit health care system built on the historical solidarity of the miners themselves. Germany’s model of joint self-administration, which mandates cooperation between health care payers and providers and includes strict price negotiations, offers policy solutions for U.S. regions struggling to balance fossil fuel decline with the right to breathe and the right to affordable care.

A Region Once Defined by Coal

Mohlek remembers that, as a child in the 1960s and 1970s, pollution in the Ruhr Valley was so bad that just going outside would stain a white shirt collar black. “My mother had to clean everything outside before hanging up the freshly washed clothing to dry, because everything was full of the dust from the coal,” he says.

The legacy of the coal industry is stubborn, but Germany is making notable progress. Today, satellite images of the Ruhr region look green rather than bare. The change is the result of environmental regulations, including regional rehabilitation planning, Germany’s flagship energy transition called Energiewende, and the European Union’s Just Transition Fund. Over the past 50 years, the Ruhr Valley has experienced the largest declines in air pollution in Germany, although air pollution levels there still remain the highest in the country.

What policymakers in Germany do so well is population-level prevention, rather than leaving disease prevention up to individual behavior.

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Even today, North Rhine-Westphalia has the highest rates of asthma, lung cancer, and chronic obstructive pulmonary disease in the country, largely due to the state’s industrial legacy. Exposure to tiny particles in the air that mostly result from combustion, called PM_2.5, was linked to 32,600 attributable deaths in Germany in 2022, even though premature deaths from this important air quality metric fell by 45 percent between 2005 and 2022.

What policymakers in Germany, and Europe overall, do so well is population-level prevention, rather than leaving disease prevention up to individual behavior. This approach is evident in the region’s health care system and energy transition, and also in its approach to air pollution. “It is really difficult for an individual to reduce exposure [to air pollution],” says Barbara Hoffmann, an environmental epidemiologist at the University of Düsseldorf who grew up in the Ruhr. “Just like clean water and safe food, it’s the state’s responsibility to take care that people have clean air to breathe.”

Even though air pollution in Germany hasn’t vanished, the country is making progress, spurred on by stricter limits set by the European Union in 2024. Cleaner air plus early and consistent health care access saves lives and livelihoods in former coal regions. By contrast, the United States’ recent erosion of the Clean Air Act and setbacks to the energy transition—not to mention what will happen if Affordable Care Act subsidies end—are making its residents sicker and poorer.

The Engine of Equity

The elements of the German health care system are not so different from those in the United States; what’s different is how they are applied. The German health system, like the U.S. model, uses private providers and insurers, with many residents obtaining coverage through employment. However, statutory health insurance is mandatory, which ensures universal coverage. A defining characteristic of the German system is the country’s emphasis on equity, achieved through income-based cost-sharing and strict limits on out-of-pocket spending.

Most citizens pay 14.9 percent of their income to nonprofit “sickness funds” (Krankenkassen), which are required to accept all applicants and include coverage for children. These independent entities originated from historic worker solidarity communities, such as the miners’ Knappschaft, which provides support for sick coworkers. Germany’s model offers a potential road map for the United States to move toward universal, regulated insurance without dismantling private organizations.

By blending private administration with public financing, Germany maintains high health care performance and minimizes medical debt—a contrast to the United States, where costs systematically push millions into financial crisis. This framework prioritizes stability and ensures basic needs are met regardless of income. For example, an inhaler costing $286 in the United States is only $9 in Germany due to national price assessments. In Germany, copayments are capped at 2 percent of income for most patients, and 1 percent for chronically ill patients. In the United States, the 2026 out-of-pocket limit for Health Insurance Marketplace plans under the Affordable Care Act cannot be more than $10,600 for single plans and $21,200 for family plans—the latter amount is about a quarter of the U.S. median household income.

Whereas about 8 out of 100 U.S. adults carry medical debt, the German government doesn’t even track that metric because it is so rare. The problem is especially bad in U.S. coal-producing regions, because high rates of chronic disease are the biggest driver of medical debt. For example, in West Virginia the rate of medical debt is almost double the national average: 15 out of 100 residents have medical bills in collections, among the highest rates in the country.

Glück Auf for the Future

Germans have an emotional and even romantic attachment to mining, much as many Americans do. But in Germany, that nostalgia is paired with policy compassion for the miners, which is a much more meaningful tribute to the labor they put into building an industrial society. “My father was a miner and my grandfather was a miner,” Mohlek says. “But my father didn’t want me to be a miner.” When asked if he felt the same way about his kids, he says that knowing how dangerous the work is, he hadn’t wanted them to be miners either, because he values their lives differently than he had valued his own. Still, he has no regrets. “I can’t explain it, but I loved being a miner,” he says.

Much like Mohlek’s tours at the German Mining Museum, memorials throughout the Ruhr prompt residents to remember coal’s history there. Mohlek wants people to honor that past. He also wants his children and grandchildren to have a good future. The progress underway in the Ruhr Valley will mean that public health improvements will continue to unfold in the region over the next decade.

A common salutation in the Ruhr is fitting in the context of this future: Glück Auf, which means “lucky up.” Miners once said “Glück Auf” to one another to impart good fortune underground. The Ruhr is showing the world a fortunate path upward, by improving air quality and health as they transition from fossil fuels to industries of the future.

This story was produced as part of the Association of Health Care Journalists' German Health Care Work Study Group, with support from the Commonwealth Fund.