Self-employment, a status that comes at the cost of your health

Falling ill as a self-employed person or as a freelancer means facing a dilemma. Do you react as the company owner and focus on the financial continuity of your business, or do you react as an employee and take time off to recover? An international and multidisciplinary team of researchers shows that self-employed workers most often prefer the first option.

At the height of the health crisis that confined the world in March 2020, the incessant criss-crossing of bicycle couriers did not fail to provoke multiple debates. Mostly self-employed, Uber, Deliveroo and Amazon couriers amongst others defied curfews to the detriment of their health and safety. They ensured their financial continuity and indirectly boosted the platforms. The following year, in response to the growing economic crisis, 15% more workers opted for the famous autoentrepreneur status. Created in 2009 and largely encouraged by the government, this status now represents 2.2 million workers. However, it is not the only way to be an independent worker. In France, more than one person in ten practises her profession outside a salaried contract including not only farmers, computer developers, trainers, graphic designers, craftsmen, and shopkeepers, but also doctors, lawyers, architects and so on. In Europe, this is even the case for one in seven workers, a figure that has been rising since 2002.

Within the research community, studies in many disciplines demonstrate inequalities in access to care and the negative effects of certain working environments: carrying heavy loads, night work, exposure to solvents, etc. While the literature on the impact of work on health is abundant, the literature on the impact of a health problem on the activity and employment situation is rarer. This is the line of research that the economist Alain Paraponaris and his co-authors, health sociologists, specialists in occupational health and rehabilitation medicine, have chosen to explore. The article Work-Related Outcomes in Self-Employed Cancer Survivors: A European Multi-country Study examines cancer survivors who were self-employed at the time of the diagnosis of the disease and how their work trajectory was impacted compared to salaried workers. The findings from independent surveys in seven European countries are clear. Self-employed workers suffer the most from the disease, in terms of career trajectory, health impact and financial loss.

Mortgaging your health to save your business

Despite international differences in social protection systems, in all the countries concerned, those who are their own bosses are the ones who more often continue to work following a cancer diagnosis, thus neglecting care and rest. The hours worked by self-employed people, although greatly reduced, are also higher than those of employees. This difference can also be explained by a higher starting volume at the time of diagnosis. Finally, they more rarely receive resources to compensate for the loss of income and consequently declare a greater financial loss than employees.

In general population surveys, however, the self-employed and self-employed generally report better health than the general population. This could of course be an expression of the benefits, including health benefits, of self-employment and self-employed people's independence, e.g. freedom of organisation, autonomous decision making, absence of subordination or hierarchical links. But this may also point to the condition of entry into this type of activity: to be self-employed, one should have a very good health status. In this perspective, in an ongoing research carried out on European data from the European SHARE survey1 , A. Paraponaris and two other economists, Clémentine Garrouste and Nicolas Sirven, are working on a study of the health of self-employed people in Europe. They note a regular erosion of the physical health of the self-employed throughout the professional activity cycle, which can be explained by the physical and psychological demands of their profession and by a lack of recourse to health care, the opportunity cost of which seems prohibitive. Despite a late recourse to care at the time of their retirement, their health status is notoriously deteriorated and inferior to that of wage-earners.

In return for the benefits of their professional practice, self-employed and liberal professionals report long and irregular working hours, coupled with stress induced by social, physical and financial insecurity. In France in 2019, more than a quarter of the self-employed earned less than half of the minimum wage2 , thus revealing the strong heterogeneity within the professional categories. However, they all share a common behaviour of mortgaging their health capital and arbitrating in favour of the survival of the economic activity of the shop, workshop, office or practice, when health shocks occur.

• 1SHARE, the Survey of Health, Ageing and Retirement in Europe, is a research infrastructure for studying the effects of health, social, economic and environmental policies over the life-course of European citizens and beyond. https://share-eric.eu
• 2Slightly more than one in ten self-employed earn less than half the annual minimum wage and live below the poverty line. Insee Première. https://www.insee.fr/fr/statistiques/6017572

A multitude of ways of looking at health

The results of the study on the consequences of a cancer diagnosis must be qualified, however. The spectrum of profiles that make up the self-employed is very broad: one can imagine that the deficit in health care consumption of a solicitor or another office profession is very likely to be different from that of a bicycle deliveryman or a general practitioner3 . In France, until 2018, self-employed and liberal professionals subscribed to the Régime Social des Indépendants, which guaranteed them the same unconditional access to care as the general population. However, self-employed persons were required to take out voluntary contracts with private insurers to guarantee replacement income, comparable to wage earners’ sickness pay, in the event of health events forcing them to stop working. Today, although all self-employed persons are now integrated into the general scheme, compensation for loss of income still necessitates private insurance policies.

In Europe, in the countries that were surveyed, differences in profiles are also noticeable. In Belgium, Ireland, the Netherlands and the United Kingdom, self-employment and the liberal professions mainly concern qualified or older profiles who wish to escape unemployment or delay retirement. In France, these activities, particularly self-employment, are often the way to access a first job. In this respect, they concern in particular young people and/or low-skilled workers, with an average age of 35 and a majority of men4 . In the Netherlands, Ireland or the United Kingdom, the self-employed do not have public social security coverage, unlike in Belgium, Norway or Finland. Unsurprisingly, in the latter group of countries, self-employed people with cancer have longer periods of sick leave.

• 3Four out of five doctors told Ifop in 2018 that they had voluntarily given up their sick leave. Gomant, Fabienne, et François Legrand. s. d. « Sondage Ifop pour COMM Santé & La Mutuelle du Médecin ».
• 4Boom in french company start-ups and micro-entrepreneurs in 2021. Insee Première. https://www.insee.fr/fr/statistiques/6041208

Policies to be put into perspective

Should social policies be updated to allow workers who do not benefit from the protection of a contract to stop sacrificing their health? Is it simply a matter of guaranteeing the same social rights to the self-employed and liberal professions as those of employees? It is not that simple. In Norway, often cited as a model, social protection is exactly the same for all workers, whether salaried or not. However, the situation is the same as in other countries: the self-employed take less sick leave after a cancer diagnosis, for a shorter period of time and later.

Using the case of Norwegian self-employed as a counterfactual, the researchers conclude that the solutions proposed to the self-employed are not adapted to the specificities of this status. Traditionally, social security and sickness benefits include relations with the hierarchy and colleagues, organisation of workstations and working hours, etc., which is not relevant for the majority of the self-employed, who often work alone. It was also noted that with the presence of a partner, an employee or a relative on hand to replace them, they were able to take better care of their health.

Following these results, there are many avenues to explore. The first is to measure the effectiveness and improvement of measures to limit the deleterious effects of cancer on the work relationship of cancer survivors. They could thus make fewer constrained choices and promote their health. According to the researchers, taking into account the health risks and specificities of a significant proportion of workers would also generate benefits for their families, their employees, and more broadly for the economy and society as a whole.

This does not only involve financial measures, which are essential. The separation of the survival of the self-employed from the survival of their professional activity can, for example, be envisaged by means of resource persons who would take the place of the self-employed, during the time of treatment or convalescence. Such mechanisms certainly already exist, but they are exclusively based on the fraternal relations that professionals can maintain between themselves (taking over a doctor's patients list for a while, transferring activities to another craftsman, etc.). It would essentially be a matter of ensuring access to them, when they do not occur spontaneously, within the framework of institutionalised schemes for recourse.