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. The rates were even lower in France, at 10%, and Great Britain, where only 7% reported similar medical expenses. "Many Americans may not understand how affordable health care is for patients in other countries," said Reginald D. Williams II, who oversees international research at the Commonwealth Fund. "Medical debt is a largely U.S. phenomenon. It just doesn't happen in other countries." 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. 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. [Dr. Eckart] 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.