Accessing healthcare services as a precarious worker in Ireland

Abstract

The growth and the nature of precarious work has become an important subject of research on contemporary employment. Equally, there has been an increased interest among researchers in understanding the social consequences of precarious employment. There is an increasing awareness of the negative affect on health posed by precarious work. However, a relatively unexplored issue is the extent to which access to healthcare depends on the form of both precarious work and of healthcare provision in a specific nation state. This article explores the social implications of precarious work, with a focus on access to healthcare services in Ireland. 40 qualitative interviews were conducted with precarious workers living in Ireland that took place between July and October 2017.These were part of a broader study called the Social Implications of Precarious Work Project. A thematic analysis was conducted, which revealed the following: precarious employment often makes access to basic healthcare problematic, so that many are often unable to access essential medical treatment. On the one hand they are unable to access means-tested public services, but on the other hand cannot afford the cost of private treatment and private health insurance. This has negative consequences for workers’ health. Many precarious workers are pushed into relationships of dependency, creating new forms of social inheritance, since only some can access better healthcare by using family resources. For precarious workers who do not have this, inequality is further exacerbated.

Keywords

Ireland precarious work healthcare systems inequality universal healthcare

Introduction

Precarious work is usually contrasted negatively with the Standard Employment Relationship (Vosko, 2010). Precarious work is assumed to be inferior partly because of the nature of the employment relationship and the lack of autonomy it involves (Kalleberg and Vallas, 2018). However, precarious work may also have negative consequences for the workers’ lives outside of work – such as for example workers’ health.

The specificity of national healthcare systems makes Ireland an important test case to assess the possible negative social implications of precarious work. Precarious work in its different forms has become extensive in Ireland (Pembroke, 2018), while Ireland is almost unique in Europe in its lack of a universal system of healthcare (Wren and Connolly, 2017). Using Ireland as a test case, the contribution of the paper is to evaluate the extent to which the consequences of precarious work depend on the interaction between it and access to the healthcare system in place.

The first part of the paper presents the theoretical framework, reviewing conceptualisations of precarious work, the direct impact of precarious work on health and the possible role of national healthcare systems in exacerbating or restraining the impact of precarious employment. The next part of the paper presents the Irish context documenting the expansion of temporary work, within so-called lower professional occupations, and a health system with embedded unequal access to healthcare. The third part presents our research method; a thematic analysis of qualitative interviews with precarious workers. This is followed by an account of our findings and discussion/conclusion.

Precarious work, health, and the state

Conceptualising precarious work

There is now an extensive literature on precarious work (Bourdieu, 1998; Bauman, 2000; Beck, 1992; Vosko, 2010; Standing, 2011; De Grip et al., 1997; Kalleberg and Vallas, 2018; Allan et al., 2021). Sociological approaches toward precarious work have fallen under two broad perspectives. The first emerged from an understanding of precarious work through the concept of modernity. The second emanated from an empirical analysis by economic sociologists investigating the surge of precarious work over the last three decades. While both strands emerged separately, both offer complementary perspectives on the emergence of precarious work (Kalleberg, 2018).

Many prominent sociologists have looked at the concept of precarity. Bauman theorised about a new era of “liquid modernity” whereby ‘precariousness, instability, vulnerability is the most widespread as well as the most painfully felt feature of contemporary life conditions’ (2000: 160–161). Bourdieu sees precarious work as a weakening of workers’ standing within society. He argued that ‘casualisation profoundly affects the person who suffers it: by making the whole future uncertain, it prevents all rational anticipation…’ (1998:82). In more recent times Butler also concurred with Bourdieu's analysis, seeing precarity as ‘a regime, a hegemonic mode of being governed, and governing ourselves’ (2015: vii). In summary, this is not merely a temporary shift in the power balance between capital and labour but is in fact ‘the emergence of a new stage in the political economy of modernity’ (Kalleberg and Vallas, 2018: 4–5).

On the other hand, economic sociologists’ concern with precarious work focused on how the gains made by workers in the form of the standard employment relationship (permanent, full-time with benefits and a direct relationship between the employer and the employee) were becoming a thing of the past (Standing, 2011). The 1970s were identified as the decade when precarious work began to emerge. Firstly, shareholder power grew within corporations, promoting short-term profits through redundancies, and a reduction in workers’ rights (Tomaskovic and Lin, 2011). Secondly, union membership had been declining since the 1970s, allowing for little to no scrutiny of employers (Western and Rosenfeld, 2011). Thirdly, digitalisation also aided the growth of precarious work through the “gig-economy” and the use of digital platforms that define these workers as self-employed rather than employees (Schor, 2015).

From this perspective precarious work is defined by the extent to which the employment relationship does not provide a regular and predictable long-term income (Vosko, 2010). This is a common feature of the different forms of work usually described as precarious: irregular part-time including zero-hours contracts, ‘bogus self-employment’ (where workers are constrained to declare themselves self-employed) and especially important for our discussion, temporary work. Temporary work was traditionally mainly associated with seasonal work, especially in agriculture. However, temporary short-term or limited contracts have become widespread or even the norm in many occupations that would be classified as ‘lower professional’ (Casas-Cortes, 2014; Gherardi & Murgia, 2015), such as in teaching or healthcare.

Research has also begun to take a holistic approach to precarious work, with an understanding that not only does precarious work have consequences for people's working lives, but also for their well-being outside of work (Blustein et al., 2020). This includes the impact of precarious work on precarious workers’ lives as a whole - their overall financial situation, their access to social supports and to social services. Thus, Frase argued that ‘as work becomes more transient, struggles outside of the workplace such as with landlords, can become more significant than with employers’ (2013:14).

Some scholars have argued the benefits of precarious work for workers as offering flexibility and autonomy (Ravenelle, 2019). However, many scholars focus on the transition to adulthood as a major area of concern. Life events such as buying a house, getting married or having children become difficult (Allison, 2013; Lim, 2018). Consequently, ‘precarious work makes it difficult to construct a rational life plan or career narrative in post-industrial nations’ (Kalleberg and Vallas, 2018: 15).

Precarious work and health

A growing body of literature explores the impact of precarious work on health (Lewchuk et al., 2008; Benach et al., 2014; Van Aerden et al., 2016; Macmillan and Shanahan, 2021). Lewchuk et al. (2008) developed the “employment strain model,” (a framework to study the relationship between insecure employment and health) and found that high employment strain (associated with precarious work) led to bad health. Macmillan and Shanahan (2021) tested out a conceptual model that found that not only was precarious work bad for health, but ‘the effects of precarious work on perceptions of self and social relations are a key link to poorer health’ (2021:821). Attempting to describe health impacts, Benach et al. (2014) proposed a conceptual model that linked precarious work with poor health and well-being outcomes. These are: (1) a higher risk of negative psychosocial and physical outcomes, (2) a higher risk of occupational health and safety measures being undermined (3) a lack of social protection leading to material deprivation (for instance unemployment, sickness, and retirement).

Precarious work can directly impact on health because of the nature of the work itself. For example, regarding the impact of precarious work on physical health, Benavides et al. (2000: 494) reported that fatigue, backache, and muscular pains were positively associated with precarious employment. It has also been suggested that increased precarious employment, such as the growth of bogus self-employment in the construction industry (where a worker acting in the capacity of an employee is classified as self-employed by their employer) can involve the undermining of occupational health and safety measures (Wickham and Bobek, 2016). Quinlan and Bohle (2004) reported on the impact of precarious work on occupational health, via the “Pressures, Disorganisation and Regulatory Failure Model”. This highlighted how precarious work undermines and weakens health and safety regulations and procedures. Precarious work has been identified as undermining mental health (McGann et al., 2016; Escudero-Castillo et al., 2022). Finally, precarious work can make access to healthcare more difficult, either through a lack of social protection and/or material deprivation (Kim et al., 2011; Benach et al., 2014; Premji, 2018; Macmillan and Shanahan 2021).

The last two years saw the emergence of the COVID-19 pandemic. During this time, more research began to emerge on the health effects of precarious work (Allan and Blustein, 2022; McNamara et al., 2021; Bambra et al., 2021). Not only was job loss more common for precarious workers, (Allan and Blustein, 2022), when jobs were retained loss of hours and income were commonly experienced. Consequently, precarious work had low levels of meeting “survival needs” by not providing secure or continuous work to maintain income (2022:10). This culminated in a negative impact on the health of precarious workers as they experienced a “syndemic” where ‘the employment and health consequences of the pandemic may interact with and exacerbate pre-existing health and socioeconomic disadvantage’ (McNamara et al., 2021: iv40; Bambra et al., 2021). For instance, many precarious workers were unable to work from home and were in public-facing jobs. Furthermore, sick pay and other social supports were not available, and this led to a higher likelihood of workers avoiding self-isolating, as this would lead to a loss of earnings. All these individual risks experienced by precarious workers further heightened the likelihood of negative mental health outcomes, such as severe anxiety and depression (McNamara et al., 2021). Therefore, ‘the COVID-19 pandemic exposed and exacerbated these negative health issues’ already faced by precarious workers (Allan and Blustein, 2022: 10; Gunn et al., 2022).

The state and the supply of healthcare

Several studies have reviewed the impact of precarious work on health in international comparison, suggesting that one differentiating factor may well be the welfare state (Virtanen et al., 2005; László et al., 2010; Kim et al., 2011; Pirani and Salvini, 2015). Kim et al. argued that in Scandinavia ‘the combined effect of comprehensive employment welfare policies, high female labour participation rates, generally low unemployment rates, and universal health care systems have shaped a more positive environment for the health of precarious workers’ (2011: 113). Pirani and Salvini also concluded in their study that ‘the enhancing of social security protection, and the increasing of…benefits that ensure equal power relationships and rights between the two groups of workers (permanent and temporary), are all possible instruments for achieving effective equality’ (2015:128). However, Macmillan and Shanahan's study (2021) found that stronger welfare states did not disproportionately reduce the harmful effects of precarious work. Instead, the harmful effect is consistent amongst the general sample for all welfare regimes (Scandinavian, Continental, Mediterranean, Anglo-Saxon and Eastern European) (2021: 845).

Healthcare systems are differently organised in different countries. In the USA healthcare is dominated by private provision and funded largely by private insurance, with the state providing only a limited and ineffective safety net. Meanwhile in the UK, healthcare remains available to all through the National Health Service (NHS) with very limited charges and funded from general taxation. Although the covid-19 pandemic has accelerated demand for health insurance in the UK, it still amounts to only approximately 10–11 per cent of the population and is largely made up of work schemes (Foubister et al., 2006; Iacobucci, 2022). This contrast highlights the complex relationship between the healthcare system and the national welfare state: whereas the US and the UK are the most extreme contrast in terms of healthcare, they have long been treated as part of the same liberal ‘world of welfare’ (Esping-Andersen, 1990).

Within the European Union universal access to healthcare has been identified as one component of the recently promulgated ‘European Pillar of Social Rights’ (Pochet, 2017). However, the effective use of this right is clearly extremely variable just as is the extent to which access to healthcare depends on financial resources. Universal health systems are often a complex mixture of public and private provisions sometimes provided for via state-supported insurance schemes and sometimes provided as a public entitlement to residents.

In terms of the relationship to employment, it is plausible that a universal system such as the UK's NHS should ameliorate the health impact of precarious work, since access to healthcare does not depend on income level nor crucially on the extent to which income is regular and predictable (Virtanen et al., 2005). Furthermore, we can hypothesise that where access to healthcare depends on employment-based insurance, such as in the US, access will be more difficult for precarious workers, since in these insurance-based systems access to all forms of benefits has depended on regular employment. Ireland's lack of a universal healthcare system means that those on low incomes may experience difficulty accessing healthcare, and this will be exacerbated by insecure employment. This makes it an interesting case study to investigate how precarious workers navigate such a system.

Precarious work and healthcare in Ireland

Precarious work: Stability and growth

Despite the economic growth of recent decades, Ireland has continued to have a significant low wage sector (Wickham and Bobek, 2016). While overall there has been no clear growth in non-standard employment, sectoral analysis shows a growth in precarious employment in some key areas (Bobek et al., 2018).

In the homecare sector much part-time work is organised on ‘if and when’ contracts, and similar irregular part-time work is widespread in the hospitality sector. In both sectors before the pandemic many workers worked essentially on-call, only knowing what hours they would be working a few days in advance. Within hospitality occupations such as bar tenders that traditionally offered long-term full-time employment have been turned into part-time and casual employment (Bobek et al., 2018: pp.42–43).

While the overall rate of self-employment has remained constant, there has been a growth of what is often termed ‘bogus self-employment’ or ‘economically dependent workers’. While this is widespread in the so-called gig economy (Deliveroo etc.) it also has expanded in more traditional areas such as construction (Wickham and Bobek, 2016). Although subordinate to the employer in terms of the organisation of work, as notionally independent contractors such workers lack the protection of conventional employment relationship.

Perhaps the most significant change has been the surge in temporary work across the educational sector (Bobek et al., 2018: p.35). The expanded area of pre-primary (childcare) sector is now massively staffed by workers on temporary contracts. The growth of an industry of private English language schools has also meant a growing number of teachers in precarious employment, since fixed-term temporary contracts are widespread here (Bobek et al., 2018: pp.35–36). Finally, higher education has seen a dramatic expansion of precarious work. Lecturers and tutors are hired on teaching only contracts, are often paid by the hour and have no job security; researchers are hired on temporary contracts only for the duration of a specific project. Here work has been made precarious even though the commitment and skill required has increased: the educational workforce has become more qualified, more skilled – and more precarious (Cush, 2016).

Ireland's two-and-a half tier health system

Ireland's healthcare system is described as ‘a complicated mix of public, private and voluntary care providers with unfair, unclear, and complex routes in and through the system for the patients and users of health services’ (Burke and Pentony, 2011: 21). It is an outlier compared to other European countries in that there is no universal provision for access to healthcare services (Whyte et al., 2020). The health system is two-tiered, consisting of a public and a private sector (Thomas et al., 2018), ‘where access to services can be determined by ability to pay rather than clinical need’ (Whyte et al., 2020: 2).

People residing in Ireland are entitled to public hospital care. However, only medical cardholders get full access that is free of charge, including GP services, dental and public hospital services (HSE, 2020). People who are not entitled to a medical card are not entitled to free access to the public health system though in many cases they will receive free public care such as when referred by their GP. They also must pay for primary care services and some additional charges, such as an Emergency Department charge and in-patient charges for staying in the hospital overnight (currently 80 euros per night up to a maximum of 800 euro in one year). General Practitioners operate as sole traders or in health centres with other GPs and health professionals. For those who do not have a medical or GP card, the cost of a GP consultation can cost up to 65 Euros (HIA, 2018).

The medical card is means-tested and is largely restricted to welfare recipients, people on very low-incomes, and people who have long-term or severe illnesses (HSE, 2020). According to the Department of Health, 31.8 per cent of the population hold a medical card (Department of Health, 2021:44). For those who are not eligible, there is also the possibility of being financially assessed for the GP Visit Card, which entitles the holder to free GP appointments only. Furthermore, children under six years old, along with men and women over 70 are entitled to a GP Visit Card. However, it is important to note that the income assessment assumes regular employment; therefore, precarious workers employed part-time with irregular hours, who see their income fluctuate on a weekly basis, do not generally fit into the employment categories (HSE, 2020). This means that they must pay to access GP care and other services.

Ireland's voluntary health insurance market exists alongside the public health system. Competing companies offer a multitude of plans. Consequently, not all expenses are covered by each policy. Furthermore, in 2015, Lifetime Community Rating was introduced, where those over the age of 35 who have not taken out health insurance, or who take a break in cover for more than three months, must pay late entry loadings of 2 per cent per year when they take out a policy for the first time. The expansion of private healthcare in Ireland has meant that while access to the public system is rationed by queuing, the private health system depends on financial resources, and that those who can afford it will take the private health route. Currently, just over 47 per cent of the population have health insurance in Ireland (HIA, 2021). Accordingly, a significant proportion of the population have neither private health insurance nor completely free access to the public system.

The publication of the Sláintecare Report in May 2017 (Houses of the Oireachtas, 2017) by an all-party parliamentary committee on healthcare services in Ireland seemed to indicate a move towards a universal healthcare system in Ireland (Burke et al., 2018: 1280). However, progress has been slow on key recommendations.

Materials and methods

The research presented in this article was part of a wider study called the Social Implications of Precarious Work Project. We investigated the nature and extent of precarious work in Ireland and the impact on their lives. We wanted to understand how precarious work affected people's ability to plan their lives and fulfil their basic needs (Bobek et al., 2018). A thematic analysis was conducted on qualitative, semi-structured interviews with 40 precarious workers. From this, numerous themes were identified (including housing and family formation). This article focuses on further developing a major theme in the analysis, which is accessing healthcare services.

Recruitment inclusion criteria included participants who: 1) lived and worked in Ireland 2) worked part-time with irregular hours (also known as if-and-when contracts), short and fixed-term work (temporary work) or self-employed without any employees 3) were aged between 18 and 40 years old. We used a sampling matrix to ensure that all forms of precarious work and household situations were represented in the study (see Table 1). The household situations identified were 1) single (no children) 2) single with children 3) in a relationship 4) in a relationship with children. Given that people's experience of work depends massively on their household and life- course situation, it was important to include household situation in our sampling matrix.

Table 1.

Employment situation and relationship status.

	Part-time irregular hours	Self-employment no employees	Fixed term	Total
Single	7	2	4	13
Single with child/children	2	2	2	6
In a relationship	3	2	10	15
In a relationship with children	2	0	4	6
Total	14	6	20	40

Various recruitment methods were used including contacts through trade unions, NGOs, civil society organisations, and social media advertisements (Facebook and Twitter). Interviews took place between July and October 2017. Recruitment continued until data saturation was reached.

Ethical approval was obtained from the organisation where the research took place. Informed written consent was obtained from all participants. The interviews were fully anonymised. The names used in the subsequent analysis are pseudonyms that were assigned to guarantee their anonymity.

One-to-one interviews were conducted with consenting men and women. Interviews took place in a location and on a date that was convenient to the participant and were audio-recorded. The interviews were carried out by two of the researchers involved in the project, both with extensive experience in qualitative in-depth interview techniques. In-depth, semi-structured interviews that lasted approximately 40 min explored the participant's

first-hand experiences of precarious work, starting with their working conditions, followed by life outside of work. The interview protocol/guide used open-ended questions and prompts to ensure that issues were explored in detail, and yet was flexible enough to allow participants to raise subjects that were important to them.

The interview transcripts were analysed using thematic analysis (Braun and Clarke, 2006). We followed a six-step process where first we 1) familiarised ourselves with the interview data, 2) Generated initial codes from the interviews 3) from these codes, all three project researchers searched for themes individually 4) these themes were reviewed as a team and consensus was reached 5) finally each theme was defined and named 6) our analysis was written up. This article is based on one theme, which is access to healthcare services for precarious workers.

In total, 40 men and women were interviewed for the study; 28 were female, 12 were male. All were between the ages of 20 and 40 years old. While studies on precarious work tend to focus on workers under 30 years old, we expanded the age criteria to investigate how precarious work affects those who experience it for prolonged periods of time. 20 participants held a fixed term or temporary contract, 14 were part-time with irregular hours, and six were self-employed without any employees. Furthermore, 13 were single, six were single with a child, 15 were in a relationship and six were in a relationship with a child. Table 1 provides a breakdown of participants’ employment situation and relationship status.

Our sample disproportionately included participants who were largely from the lower professional occupational group and who held a third-level degree. The lower professional occupational group is a socio-economic group defined by the Central Statistics office (CSO) as those employed in occupations such as teaching, health, IT, journalism, technicians, administration, and artists (see Table 2 for more information).

Table 2.

Participants’ occupations.

Occupation	Number
Office Administrator	2
Retail Assistant	5
English Language Teacher	5
Researcher (private sector)	3
University Postdoctoral Researcher (public sector)	5
University Lecturer (public sector)	3
Early years educator	3
Archaeologist and commercial archaeologist	3
Catering and hotel accommodation	3
Gallery worker	1
Homecare assistant	2
Artist	1
Marketing consultant	1
Quality Control Assistant	1
Counsellor	1
Web developer	1

The overrepresentation of participants from the lower-professional category constituted a particular advantage to our study, as it allowed us to investigate how precariousness affects workers in sectors that were traditionally full-time, permanent and/or with better pay and social benefits. This is important in the context of accessing healthcare services in Ireland. As the subsequent analysis reveals, in the absence of universal access to public healthcare, these workers would be above the threshold for obtaining a medical card. They therefore must pay to access healthcare services in Ireland, even though the precarious nature of their employment means they are unable to afford to pay for medical services or to obtain health insurance.

Results

The analysis of the data collected as part of our study shows that precarious employment has important implications for accessing health services, particularly in the Irish context. The following analysis focuses on three aspects of this relationship. First, we demonstrate how precarious workers are often excluded from the two-tier system of state supported access to health and Private Health Insurance. Secondly, we show that the lack of affordable health services for precarious workers often result in deferring or not accessing essential healthcare at all. Finally, we explore the issue of dependency and the close networks’ support in the context of precarious work and healthcare.

Precarious work and accessing public and private healthcare

Our qualitative study demonstrated a relationship between precarious employment and access to health care, particularly for those with the middle-level incomes. First, only 7 out of 40 participants had a medical card; Six out of the seven participants who stated they had a medical card, did so because they were receiving a social welfare subsidy, as their wages were so low. Equal number had health insurance, while the majority (n = 33) responded that they did not have health insurance. Consequently, 26 participants had no access to a medical card nor health insurance. It is noticeable that of participants employed on a temporary contract, nearly three quarters lacked public or private healthcare coverage, as was the case for two thirds of the smaller number of self-employed, and just over half of those on irregular part-time hours. Table 3 provides a breakdown of this.

Table 3.

Employment situation and healthcare access.

	Part-time irregular hours	Self-employment no employees	Fixed term	Total
Medical card	4	1	2	7
health insurance	2	1	4	7
Neither	8	4	14	26
Total	14	6	20	40

In most cases, participants felt that they were not eligible for a medical or a GP card and thus had to pay for the costs of the medication or treatment themselves. The reasons for not qualifying are twofold, and sometimes paradoxical: first they fall outside the qualifying financial threshold set out by the HSE. Second, the eligibility assessment is based on the traditional notion of a steady weekly or monthly income. Irregularity of income was a factor held responsible for not being able to qualify for a medical card. This was particularly crucial for those on temporary contracts, as their monthly salary exceeded the HSE threshold, but the breaks in employment were often not considered.

Furthermore, income assessment is based on the household income, thus partners’ and parents’ income are also assessed if they live in the same property. For example, Mary, who had a fixed term contract, explained that the reason for not qualifying for a medical card was, ‘my husband earns too much’. Emily, also on a fixed term contract, said:

I don’t get a medical card even though my illness, like asthma is chronic; you’ve inhalers and tablets every month. But I am not entitled to one because I still live at home. So, it goes off my wages and it goes off my mum's wages.

Furthermore, most participants felt that they could not afford health insurance. For example, Michael disclosed that, ‘in addition to not being able to save, I can’t afford health insurance’. Ciara admitted that ‘I can’t really afford health insurance, which is a big issue for me now as I’m thirty-five’. Ciara is referring to the Lifetime Community Rating legislation (2015), where people aged 35 years and over who do not have health insurance and who decide to take a policy later in life, pay more for coverage.

Precarious work, material deprivation and bad health

All participants discussed how their employment situation caused financial difficulties and how this often influenced their ability to afford access to healthcare services. Thus, most participants admitted that they avoided going to the doctor, even when their health condition required such a visit. Peter who was a part-time worker with irregular hours revealed: ‘I have no health insurance. And I have no medical card…And when it comes to going to doctors, you just don’t go’. Consequently, several participants described situations where their health deteriorated further. This was, for example, the case of Ciara who worked on a fixed term contract:

I have also been in situations where I put off going to the doctor, and I remember in one situation starting with a cold and two weeks later, it was a chest infection, and I got really sick, and I had to take some days off and eventually had to pay some money.

For those who have a chronic health condition, and who don’t have the medical card or health insurance, accessing healthcare services becomes a life-long financial burden. This was, for example, the case of Barbara, who worked part-time, irregular hours, and who suffered from asthma. For Barbara, it was not just the GP cost, but also the cost of the inhaler and medications. This financial burden can involve sacrificing something else in the weekly budget, to have enough to pay the medical bills. This is how Barbara described her struggle in her own words:

I remember the feeling of, “shit what am I going to do? I don’t have enough money to do me for the next week?!” My limit was 40 euros a week. It would have had to come down to one or the other: food or inhaler.

As our interviews showed, the lack of affordable access to GP services, experienced by many precarious workers, also may impact reproductive health. Some of our female participants expressed their concerns in this regard. For example, Paula, an Early Years Educator working on a part-time temporary contract revealed, ‘I used to be on the pill, but you have to go back every six months to see your doctor again, which is 60 quid. So, I’ve come off that’.

As the above quote suggests, long-term health requirements may be affected by the affordability of healthcare services. This issue is usually mitigated by the accessibility of state-funded services. However, in the case of these precarious workers, whose incomes were too high on one hand, but not regular enough on the other, the access to the necessary services became limited, and often meant a choice between accessing healthcare or the ability to pay for other basic necessities.

Relations of dependency

Most participants described a network of people, such as parents or a partner, on which they depended for financial support. Three types of support were usually discussed in the interviews: first, help to pay for extra fees and charges related to accessing healthcare services, such as the GP fee; second, to pay for specific treatments or tests in a private hospital setting (after being on a public health system waiting list for a long time), and third to pay for health insurance.

The first type of support was reported by Paula, who asked her partner for financial help to pay for the dentist The second type was discussed by various participants, as they described situations where they had been on the public hospital system waiting list for a lengthy period. While these participants could not afford to go private, they recounted incidences where their family members had to step in and pay for private healthcare services, because the symptoms of their condition became too acute to wait. This was, for example, the case of Claire, working part-time with irregular hours, who revealed that she had a health issue that required an appointment with a hospital consultant. As she explained, the urgency relating to her symptoms meant she had no option but to go private:

I have this stomach problem, and I was on a waiting list for a year and a half to see a specialist who I finally got to see last week. I got a letter today with an appointment for the tests that need to be done for next year! So, my dad is saying to me to go private and that he will pay for it. I do not have the money to pay for it privately.

In relation to the third form of support, most of those who had health insurance had it because their parents or partner paid for it. Orla revealed, ‘I feel guilty, but my mother pays for my private health insurance’. Noel, who works as a homecare assistant with irregular hours revealed that even with the health insurance that his parents paid for, they still had to pay for extra expenses related to a back procedure he had:

With my recent back situation, I cannot pay those consultants; my parents must pay them. And I have Health Insurance through my parents, but they only give you a small percentage of some things back!

However, Noel also admitted they would prefer this not to be the case. As he revealed:

I am just a named person on the policy, so I do not even control it; I cannot call the health insurance and discuss the details, it has to be my parents. Talk about another bloody thing that makes me feel small!

The above quote demonstrates that relying on family support in relation to healthcare was not a choice for this participant, but rather a necessity. The precarious nature of his contract, and the consequent irregular nature of his income, limited his options in relation to private healthcare. Other interviewees who had health insurance through their family mirrored this opinion. For those participants without a support network, then it was simple; they did not take out health insurance. Such limited access to affordable healthcare in case of those interviewed for our project was directly linked to their precarious employment. As it will be discussed in the following section, precarity has important implications for accessing health services, at least in the Irish context.

Discussion

In this analysis, we explored the social implications of precarious work, focussing on one aspect: access to healthcare services. Research has shown that the state plays a role in mediating the effects of precarious work on health through investment in public services such as universal healthcare (Kim et al., 2011; Pirani and Salvini, 2015). Yet Ireland's healthcare system is the antithesis of this. It has been described as failing to address health inequalities (Thomas et al., 2018), because amongst other reasons, it is two-tiered, with a significant proportion of the population not covered by the public nor the private healthcare system (Burke and Pentony, 2011). Furthermore, Ireland is one of the only European countries not to have some form of universal access to primary care services (Wren and Connolly, 2017) and high pay-as-you-go fees, such as the Emergency Department fee.

Many of our participants were employed on temporary contracts (n = 20) and largely worked in lower professional occupations. This article contributes to the emerging discussion of “middle class” precarity (Cairns et al., 2014; Gherardi and Murgia, 2015); the growing number of workers with third level qualifications in professional occupations who are on short-term and temporary contracts. As the participants’ demographic profile highlights, precarious work is not always low paid. However, the insecurity of pay, working hours and job tenure mean that material deprivation is experienced even when on a comfortable wage. This cohort of precarious workers described experiencing financial difficulties in several areas including healthcare bills. Most strikingly, many of those interviewed worked in sectors such as higher education that were traditionally considered to provide good, permanent jobs (Cush, 2016).

A key finding to emerge from the study is that most precarious workers interviewed were neither covered by the public system (medical/GP card) nor the private system (health insurance). This supports Burke and Pentony's (2011) conclusion that Ireland's healthcare system is in fact three-tiered; there are those who are covered by the public system, those who are covered by health insurance, or who can afford to pay for treatment in a private hospital/clinic, and those who are covered by neither. A situation arises whereby only those who are on very low incomes or who are unemployed/ subsidised by social welfare can access the public health system without potentially paying user charges for hospital and primary healthcare services. Consequently, access to the healthcare system is blocked or limited for precarious workers who are unable to afford private health expenses, and the public system will not cover their medical expenses.

For our interviewees this contributed to a further deterioration of their health because difficult decisions had to be made about whether to forgo healthcare treatment, to pay for food and other household bills. This finding is complementary to Benach et al.'s (2014) material deprivation pathway, which linked precarious work with poor health. Most significantly, it was precarious workers in lower professional occupations, such as university lecturers, researchers, healthcare professionals, and administrators who described these scenarios. Whereas traditionally workers from this occupation group are assumed to be able to afford health insurance and other health expenses, the precarious nature of their employment has put them in financial difficulties, as the contractual and wage certainty associated with these jobs has been taken away.

Consequently, other ways had to be found to access healthcare services. The most common was a support network of people, such as parents and partners. Intergenerational dependency was the only way that they could afford (1) Health Insurance, (2) primary care services and/or (3) access to private healthcare facilities. Precarious work created a scenario that can be interpreted as forced infantilisation, whereby the ability to live an independent life, something normally associated with being an adult and being employed, was severely restricted. The analysis supports research done in this area that highlights how precarious work has prevented workers achieving the autonomy associated with adulthood to plan their lives (Blustein et al., 2020).

Forced infantilisation also has other consequences for precarious workers, including in the housing domain. Access to housing is difficult for precarious workers, and this has led to living in the family home for a much longer time than perhaps anticipated (Bobek et al., 2020). Consequently, this also has further implications for accessing the public healthcare system, because the household income is assessed for medical card applications. Consequently, forced infantilisation is further entrenched as family members are depended upon to help pay for medical bills.

Ultimately, healthcare services privileges those with access to intergenerational support. Thus, inequalities associated with access to healthcare services are not just dependent on the individual's occupation, but also reinforced by their social class status, because intergenerational dependency is only open to those who have relatively affluent parents or partners. Thus, the insecurity associated with precarious work is even more pronounced for those who do not have this social network.

The interviews for this study took place pre-COVID-19 pandemic. Therefore, we were unable to analyse the effects of the pandemic on precarious workers. However, as other studies have highlighted, we can ascertain that the pandemic exacerbated many issues for precarious workers and brought them to the fore (Allan and Blustein, 2022; McNamara et al., 2021). During the pandemic, much of the Irish government's response was income support payments through the Pandemic Unemployment Payment to maintain workers’ income (Wickham, 2022). However, even though the pandemic was a health emergency, access to healthcare services remains the same. Indeed, the healthcare system has deteriorated further as hospital waiting lists have increased (O’Reagan, 2022). The longer waiting lists for treatment have further exacerbated the situation for precarious workers as they cannot afford to purchase private healthcare services or health insurance. Even though the pandemic brought issues facing precarious workers to the fore, highlighting the negative impact of such working conditions, precarious work continues to exist The only policy intervention of significance to come out of the pandemic was the initiation of legislation for a Statutory Sick Pay Scheme. However, progress is slow and is yet to be enacted.

Slàintecare has been mooted as the Irish response to building a universal healthcare system in the Republic of Ireland. It contains recommendations that would benefit precarious workers and access to healthcare services. First, it proposes free access to GP care for all. Second, it will remove the extra hospital charges such as the emergency department charge and the in-patient charges for public hospital care. Finally, it will ensure the expansion of public hospital activity, along with the removal of private care from public hospitals and placing waiting time guarantees to decrease public hospital waiting lists for appointments and procedures. Ultimately, as precarious workers in this study almost unanimously could not afford health insurance nor the cost to access private healthcare, investment in the public hospital system would be most beneficial.

However, while there are some aspects of Slàintecare that benefit precarious workers, there are also limitations. First, although initially the report defines universal healthcare as providing access to services free at the point of use, as Connolly and Wren (2019: 96) observed, the report objective changes later to where the ‘cost of using services does not put people at risk of financial harm.’ (Houses of the Oireachtas, 2017: 57). This indicates that access to other primary and social care services, including dental services, will not be free at the point of entry but will potentially be provided at reduced cost Second, charges remain for prescribed medication. Third, it is highly ambiguous in the report whether the means-test approach currently adopted will be continued with the implementation of Slàintecare, for accessing other primary care services and subsidised prescriptions. As the results from this study have highlighted, means-testing does not benefit precarious workers. Fourth, tax subsidies for health insurance remain, which does not fit in with the premise of universality. However, the delay in implementing Slàintecare reforms means that there is uncertainty as to the final impact (Burke et al., 2018; Connolly and Wren, 2019), and the actual implications it has for precarious workers, remain unknown.

Precarious work not only affects working conditions, but also worker's private lives. Although precarious work exists all over the world, the experience of it is varied, and this depends on several factors including legislative intervention of working conditions, collective bargaining power, and universal access to state services and supports (Pembroke, 2018). Therefore, solutions to the issues discussed in this and other studies around precarious work are complex. While access to universal healthcare has been shown to mitigate the effects of precarious work on health, research has also shown that stronger welfare states did not buffer the harmful effects of precarious work, such as economic insecurity (Macmillan and Shanahan, 2021). Furthermore, studies have highlighted the negative consequences of precarious work for people's lives and that these workers want more job security than employers are willing to give (Kalleberg and Vallas, 2018; Allan et al., 2021). Therefore, there are no solutions that can truly mitigate all the negative implications precarious work has for working conditions and worker's lives. As modernity theorists argued, this is not merely a temporary shift in the power balance between capital and labour but is a new stage of governance (Butler, 2015) and control, weakening the position of the workers in society (Bourdieu, 1998). If this is the case, then the response will need to go further than stronger welfare states. The response will need to challenge the existence of precarious work, which is already starting through the Trade Union movement, civil society organisations and the Mayday movement (Kalleberg and Vallas, 2018; Armano et al., 2017).

Conclusion

Access to the Irish healthcare system is not universal and is means-tested. Most participants in our study were unable to afford health insurance yet were not eligible for a medical card. Consequently, access to healthcare was blocked or limited because they could not afford it. Forced infantilisation increases the dependency of precarious workers on their family members to pay for healthcare expenses, and further reinforces health inequalities as only precarious workers with affluent parents can fully access healthcare. Although Slàintecare is the Irish response to providing universal healthcare, the biggest limitation at present is that it has yet to be meaningfully implemented and is not on track to meet the various implementation targets set out in the plan. Although this plan also has its limitations, were it to be fully implemented it would make a difference to precarious workers’ health. However, it will still not solve economic insecurity and other negative effects of precarious work.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Foundation for European Progressive Studies, Think-Tank for Action on Social Change (TASC),

ORCID iD

Sinead Pembroke

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