Social Science & Medicine 319 (2023) 115190

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Social Science & Medicine

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Health insurance for the good European citizen? Migrant sex workers’
quests for health insurance and the moral economy of health care
Ursula Probst
Institute of Social and Cultural Anthropology, Freie Universität Berlin, Landoltweg 9-11, 14195 Berlin, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: European health insurance systems have become increasingly fragmented due to neoliberal health care reforms
Health insurance and the privatization of health care. Attempts to enable transnational access to public health care services
Citizenship throughout the European Union (EU) have contributed to this process by spreading ideas of EU citizens as
Belonging
consumers having to make informed choices about health insurance. However, marginalized populations such as
Sex work
Migration
EU migrant sex workers are presented with only limited choices within these systems.
Eastern europe This article highlights how these limitations in access to health insurance are not only related to financial
Germany precarities, but are also caused by underlying racialized, classist, and sexualized assumptions about citizenship
Privatization of health care and belonging which influence the legal framework of both national and EU-wide health insurance provision.
Based on ethnographic research with migrants from eastern EU countries involved in sex work in Berlin, the
article discusses their attempts to gain access to health insurance as a salient example of the moral economy of
health insurance provision in a supposedly universal health care system.
Following how migrant sex workers from eastern European countries experience and negotiate exclusions
from health insurance systems, the article addresses how meanings and interpretations of health insurance
change towards an understanding of health insurance not as a right, but as a privilege for those conforming to
narrow ideas of European citizenship. This indicates that current restructurings of health insurance systems are
not only characterized by increasing privatization. Equally, the (re-)emergence of links between access to health
insurance and restrictive ideas of belonging and citizenship rights are undermining aspirations for transna­
tionally available universal health care.

1. Introduction expressed, for example, in a lack of health insurance – to an inevitable

“This is again one of these problems,” Felicia said angrily; “I am
unable to get public health insurance in Germany.” “Why?” I asked, to
which Felicia simply replied: “I do not know.” Felicia was a cis woman in
her late twenties from Romania who had been working in Berlin’s sex
industry for a few years, mainly in small apartment brothels. We met in
one of these brothels in the summer of 2018 while I was conducting
fieldwork on the lived realities of migrants from eastern European
countries who engaged in sex work in Berlin. Felicia eagerly agreed to
take part in my study, as she was weary of representations of “eastern
European prostitutes” as helpless victims in the German media and saw
our conversation as an opportunity to challenge these narratives.
Through a combination of anti-migration sentiments, the othering of
“eastern European” migrants in Germany, and stereotypical represen­
tations of sex work, these discourses reduced the complex and socially
embedded vulnerabilities of eastern European migrant sex workers – as
result of their engagement in sex work. Without glorifying her profes­
sion, which she described as “hard work,” Felicia contested these rep­
resentations by highlighting that her uncertainties about insurability
had less to do with sex work, but rather with complicated health in­
surance systems throughout the European Union (EU), which rendered
her access to (especially public) health insurance mostly “hypothetical”
(Birn and Nervi, 2019, p. 6).
Portraying herself as an industrious woman who had made use of the
freedom of mobility for citizens of the EU to take up work in Germany,
she nevertheless struggled with bureaucratic hurdles in both Germany
and Romania when it came to accessing public health insurance. In
Romania, public health insurance was provided through a social insur­
ance system preconditioned on employment in the country, which she
no longer had. At the same time, being neither unemployed nor a per­
manent resident in her country of origin, she was not eligible for state-
subsidized public health insurance through social welfare schemes. This

E-mail address: ursula.probst@fu-berlin.de.

https://doi.org/10.1016/j.socscimed.2022.115190
Received 25 November 2021; Received in revised form 17 April 2022; Accepted 30 June 2022
Available online 8 July 2022
0277-9536/© 2022 Elsevier Ltd. All rights reserved.
U. Probst
also made her ineligible for the European Health Insurance Card (EHIC),
which allows card holders to access health care services in all partici­
pating countries, provided that they were publicly insured in one of
them.
In Germany, Felicia engaged in sex work – which constitutes a legal
and taxable form of income in this country – as a self-employed worker.
Like many other low-income self-employed workers, this placed her on
the fringes of the German social insurance system, which is centered
around social insurance costs being shared between employers and
employees. In the case of self-employment, the monthly fees for public
health insurance – which at the time amounted to roughly 400 euros at
the regular rate or around 200 euros at a reduced rate in case of severe
hardship – had to be paid in total by the insurant.
With public health insurance therefore very expensive for Felicia, she
could make use of various private insurance options throughout the EU,
but her involvement in sex work represented a “risk factor” which raised
private insurance fees beyond her financial means. As a temporary so­
lution to comply with Germany’s statutory health insurance re­
quirements, she had acquired cheap private work and travel insurance in
Romania. This, however, further complicated her access to German
public health insurance, as the legal health insurance framework in
Germany hinders changes from private to public health insurance,
particularly in the case of self-employment.
When I asked Felicia to elaborate on her problem, she responded:
“The problem is, I am trying to register for [public] health insurance, but
everybody tells me that I have to pay for the last eight years retroac­
tively. Now I am trying something different, I am still trying.” These
retroactive payments referred to the fact that, as far as public health
insurance providers were concerned, she had not made sufficient health
insurance payments during her time in Germany, as they did not
recognize her private insurance as an adequate equivalent to German
public health insurance. So they demanded a retroactive payment to
cover the fees for the entirety of her stay, which by legal definition could
not be waived. Therefore, fear of debt prevented her from registering
with public health insurance providers. In short, Felicia was stuck in an
intricate assemblage of private and public health insurance systems in
the EU (Stan, 2015, p. 353), which, despite its claim to universality,
excludes those not conforming to particular gendered, sexualized,
classist, and racialized ideas about “proper” work and (mobile) citizens.
2. The moral economy of health insurance provision in Europe
Following Felicia’s and other participants’ quests for health insur­
ance, this article discusses migrant sex workers’ struggles with European
health care sectors as a salient example of “an unevenly developed Eu­
ropean healthcare assemblage and citizenship regime” (Stan, 2015, p.
353), which highlights the moral economy of health insurance provision
in a supposedly universal health care system in Europe (Fassin, 2005;
Kehr et al., 2018; Taylor-Gooby et al., 2019; Watters, 2007). Public
health insurance and free or subsidized health care have long repre­
sented a key feature of social citizenship in both western European
welfare states and formerly socialist states in eastern Europe (Busse
et al., 2017; Esping-Andersen, 1990; Prince, 2017, p. 155; Saltman et al.,
2004; Vargha, 2018), making health insurance not only a means for (re-)
distributing health care costs, but also an expression of idealized visions
of collective and universal health care. Yet, the privatization and
commodification of health care in recent decades has created increas­
ingly stratified systems of health care provision and coverage
throughout Europe (Stan et al., 2020). As scholarship on contemporary
European health care systems highlights, these systems contain various
modes of exclusion, especially for highly mobile and/or marginalized
populations (Giovanella and Stegmüller, 2014; Lebano et al., 2020; Stan,
2015; Stan et al., 2020). Additionally, efforts by the EU to expand social
citizenship rights to health care beyond the boundaries of national
health care systems largely build on neoliberal ideas of
consumer-citizenship, which stress informed choices about health
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Social Science & Medicine 319 (2023) 115190
insurance while neglecting the needs of those who are financially or
otherwise incapable of making such choices (Stan et al., 2020, p. 4).
The fragmentation of health care provision was further exacerbated
by austerity policies and the neoliberal health care reforms that have
been implemented in various member states since the 2000s (Kornai and
Eggleston, 2001; Maarse, 2006; Pavolini and Guillén, 2013). Austerity
policies imposed by the EU and/or national governments, alongside the
restructuring of public health insurance systems and their financing,
have pushed the public health care sector in many EU countries to their
limits. This promoted the proliferation of private health insurance,
leading to a highly fragmented health care system throughout the EU,
particularly for intra-EU migrants who access health care services in
multiple countries (Stan, 2015).
Eastern European migrant workers are especially affected by the
exclusionary effects of these fragmented health care assemblages, as
they “often diverge from images of EU consumer-citizenship” (Stan
et al., 2020, p. 6) which are constructed around particular
ethno-racialized, classist, and gendered ideas of “Europeanness” (Keinz
and Lewicki, 2019). In the case of eastern European migrant sex
workers, this connection between access to health insurance and
neoliberal constructions of citizenship becomes further obscured
through the stereotyping of (particularly migrant) sex workers as
vulnerable Others whose health care needs are reduced to questions of
sexual health (Probst, 2015). However, these tacit assumptions become
tangible in migrant sex workers’ attempts to obtain health insurance and
the barriers they face in accessing health care.
By engaging with participants’ experiences and interpretations of
health insurance provision, this article firstly highlights the contradic­
tions and gaps within contemporary health insurance systems in Europe,
which make it difficult, if not impossible, for migrant sex workers from
eastern European countries to obtain public health insurance in both
Germany and their countries of origin. These gaps and contradictions
not only exemplify the fragmentation of health insurance systems in
Europe, but also have to be understood as part and expression of the
moral economy of health care provision in Europe, that is, “those legal,
ethical and political realities in the domain of health care, illness
experience and medical science, in which economic, moral and political
forms of valuation and subjectivation intersect, and are rearranged in
times of excessive neoliberal economies“ (Kehr et al., 2018, p. 11). In
this context, I secondly analyze the connections between health insur­
ance provision and narrow notions of “good” citizens, who contribute to
national welfare states through work and tax payments and embody
normative ideas about European citizenship and belonging (Keinz and
Lewicki, 2019; Mattes and Lang, 2020; Yuval-Davis, 2006). While
lingering ideas of welfare states providing for vulnerable populations
means that groups such as migrant sex workers are not explicitly
excluded from health insurance systems, these underlying assumptions
nevertheless complicate their inclusion into the public health care
sector.
Following the anthropological interest in the “social life of health
insurance” (Dao and Nichter, 2016), thirdly I discuss how these expe­
riences with exclusion from health insurance systems contributed to
changes in definitions and interpretations of health insurance by those
positioned on the fringes of these systems. I argue that through the close
connection of health insurance with norms and values of “good” Euro­
pean citizenship, participants perceived health insurance as detached
from its theoretical, or ideal, purpose as a means of solidary health care
provision (Kehr et al., 2018, p. 6). Rather, obtaining health insurance
acquired new meanings as an expression of belonging and successful
integration, turning the idea of welfare states providing health care
around towards an understanding of public health insurance as a priv­
ilege for those conforming to ideas of (national and/or European)
belonging. Therefore, I conclude that current developments in the field
of health insurance systems in Europe should not be understood merely
as a sphere where the effects of neoliberal health care reforms become
tangible. Connectedly, the experiences of participants show that this
U. Probst
field is also characterized by ongoing negotiations of “Europeanness” as
a basis for health care provision and coverage. As the example of eastern
European migrant sex workers’ quest for health insurance shows, it is
especially this combination of the neoliberal governance of health care
and constricting racialized, classist, and sexualized ideas of the “good”
European citizen, which limits universal health care coverage in the EU.
3. Researching migrant sex workers’ health care practices
The findings presented here are part of a larger ethnographic
research project discussing negotiations of “Europeanness” by migrants
from eastern Europe who engage in sex work in Berlin. The fieldwork for
this project took place between 2017 and 2018. It mainly consisted of
regular participant observation in areas of street-based sex work, bars,
and strip clubs in Berlin, as well as informal conversations and narrative
interviews with sex workers contacted at these locations, through visits
to brothels and online advertising platforms for sex workers. Following
the principles of Grounded Theory (Glaser and Strauss, 1999; Timmer­
mans and Tavory, 2007), both participants and observation sites were
selected through theoretical sampling (Vollstedt and Rezat, 2019, p. 83).
This sampling method allowed me to negotiate the intricacies of this
legal yet reclusive field, and to account for the lack of reliable quanti­
tative data on the demographics of sex workers in Germany (Döring,
2014).
Accordingly, initially a broad definition of potential participants was
applied, including everybody over the age of 18 who had permanently or
temporarily migrated to Berlin from one of the countries considered to
constitute “eastern Europe” (in its broadest definition in Germany,
which includes Albania, Armenia, Belarus, Bosnia and Herzegovina,
Bulgaria, Croatia, Czechia, Estonia, Georgia, Hungary, Kosovo, Latvia,
Lithuania, Moldova, Montenegro, North Macedonia, Poland, Romania,
Russia, Serbia, Slovakia, Slovenia, and Ukraine) and engaged in sex
work in the German capital as a main or part-time job. After the first
stages of research, this definition was limited to cover only sex workers
from Bulgaria, Romania, Hungary, Poland, Russia, Ukraine, and the
Baltic states, as preliminary findings suggested that migrants from these
countries make up a significant proportion of eastern European migrant
sex workers in Berlin. Participants with experiences in different sectors
of the sex industry – street-based sex work, brothels, escorting, strip
clubs – were included to incorporate a broad range of perspectives
before ending the fieldwork after theoretical saturation was achieved.
Ultimately, 45 people took part, mainly cis women, but also a small
number of trans women and cis men. The age of the participants ranged
from 18 to 52 years, with the majority of them being in their twenties
and thirties. About a third of the participants (17) had at least one child,
whom they were raising mainly as single parents with the support of
family members. Of the 45 participants, 26 took part in narrative-
biographical interviews. Most of the interviews were audio-recorded
with permission and transcribed verbatim. When permission for
audio-recordings was not given, notes were taken during the interview,
based on which interview reports were written. With the other 19 par­
ticipants, informal conversations were conducted during observations
and arranged meetings throughout fieldwork. These conversations were
documented in conversation reports. Observations were recorded in
written memos. Interviews and conversations were conducted in
German, English, and/or Russian by the researcher, except two in­
terviews, which were conducted in Hungarian and Bulgarian respec­
tively with the help of paid translators recruited from the sex working
community in Berlin.
Additional semi-structured interviews were conducted (in German)
with 19 employees of support services, NGOs, and administrative bodies
which served migrant sex workers as clients and/or were involved in the
governance of sex work in Berlin. These interviews also were audio-
recorded with permission and transcribed verbatim or documented in
the form of interview reports. The interviews provided further insights
into the legal and bureaucratic frameworks of migrant sex work in
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Social Science & Medicine 319 (2023) 115190
Berlin. Some of the services supported sex workers in obtaining health
insurance in Germany, enabling the assessment of additional perspec­
tives from social workers and public officials on the problems described
by participants.
The material was analyzed through coding based on the principles of
Grounded Theory. Starting from detailed open coding, themes and hy­
potheses were developed through subsequent axial and selective coding
(Vollstedt and Rezat, 2019). As only one segment of the research project,
the material provided in the following analysis corresponds with the
themes of health care and health insurance, which emerged during
fieldwork as one sphere in which notions of European citizenship and
belonging were negotiated and contested. Two of the participants were
non-EU citizens and are therefore not included in the following analysis,
as problems around health insurance for these participants, while also
present, differed from those of the EU participants due to their migration
status and visa requirements, discussing which would go beyond the
scope of this article.
At the time of the research, neither the university nor the funding
body required ethics approval prior to conducting fieldwork, particu­
larly since no ethics review board for social sciences existed at the
university at the time. Nevertheless, conducting research with margin­
alized groups such as migrant sex workers demands careful consider­
ation of a number of ethical questions throughout all stages of the
research. Research design, fieldwork, analysis, and the presentation of
findings were developed in accordance with the ethics guidelines pro­
vided by professional anthropological associations (AAA, 2012;ASA,
2021 ; Hahn et al., 2009) and discussed with supervisors and academic
peers throughout the research project. Furthermore, solutions to ethical
questions were designed in engagement with sex workers’ organizations
and scholarship on the ethics of research with sex workers (Dewey and
Zheng, 2013; Sanders, 2006; Sinha, 2017). This engagement included a
thorough reflection on my own positionalities and roles in the field
throughout the research process (Dilger et al., 2015). Informed consent
was obtained verbally after establishing contact with participants, who
were provided with my contact details to enable them to contact me at
any time to address issues or withdraw their participation. Furthermore,
participants were given the opportunity to review interview transcripts
and conversation memos in case they wanted to remove information
from the material that could reveal their identity. Sex working partici­
pants also received a remuneration of twenty euros per interview.
4. Contradictions and gaps in European health insurance
systems
Radko and I had arranged to meet at a subway station. I arrived early
and waited for him in front of the station entrance. He arrived on time as
always, but seemed distraught. After greeting him I suggested we go to a
nearby café, as we usually did at our other regular meeting place. He
replied that he would rather not go to a café because he cannot afford it
right now. He told me that he had to go to the dentist today for severe
tooth pain and explained that he managed to receive treatment, and that
even some drilling was necessary, but due to his lack of health insurance
he had to pay up front for the procedure, leaving him broke for the
moment. He asked me if I could lend him money until our next meeting,
to which I agreed. But since I did not have much cash on me, I could not
afford both to lend him money and to invite him for a drink at a café. So I
suggested I buy him a lemonade from the shop instead, which he
accepted, and afterwards we sat down near the subway station, where he
continued to tell me about his experience with the dentist.
Radko was a young cis man from Bulgaria who had come to Germany
at the age of 18 in search of a well-paying job. However, with little
formal education, this proved difficult for him. Although he managed to
enroll in a language course, he struggled to get by financially, accepting
various informal jobs and occasionally engaging in transactional sex
with men. At the time of our meetings, Radko had no health insurance.
This strongly affected his interactions with the German health care
U. Probst
sector, which relies on a complex health insurance system as a basis for
access to and cost coverage of health care services.
Such health insurance systems have a long history in Europe,
particularly in Germany, which “is often considered to be the source of
this approach” (Saltman et al., 2004, p. 21). While this article focuses on
the most recent developments in European health insurance systems,
efforts by the EU since the 2000s to provide EU-wide health care
coverage for its citizens and residents build on these histories of public
health insurance provision. At first only available to members of
particular professions (Busse et al., 2017, p. 883), public health insur­
ance systems were expanded in the 1960s and 1970s to include most, if
not all, of the population in western European countries (Esping-An­
dersen, 1990). Here capitalist welfare states took a prominent role in,
and were entrusted with, ensuring a “good” life for their citizens by (re-)
distributing financial resources for health care. The notion of social
solidarity presented a key theme in the process of institutionalizing and
expanding health insurance access. However, interpretations of soli­
darity, as well as the relationship between states and citizens in
contributing to health care systems, differ significantly among different
western European capitalist welfare states (Esping-Andersen, 1990). On
the one hand, countries like Sweden follow a national health service
approach, where “coverage is universal (based on residency re­
quirements), funding is based on taxation and the provision of care is
almost exclusively public” (Reibling, 2010, p. 6). On the other hand,
countries like Germany follow a social insurance approach, with “qua­
si-universal access to care through employer-based but compulsory
health insurance” (Reibling, 2010, p. 6).
The histories of health care provision in former socialist countries in
Europe differ significantly from the trajectories of European capitalist
welfare states, not only due to ideological differences, but also because
of diverse engagements in the emerging fields of public and global
health (Vargha, 2018). Following the end of the Second World War,
socialist countries in eastern Europe established health care systems that
were centrally funded and organized by the state, which therefore took
an even more prominent role in health care provision than in western
European countries at the time (Marrée and Groenewegen, 1997, pp.
7–8; Rechel and McKee, 2009, p. 1187). This system, although adapted
differently by various socialist states (Rechel and McKee, 2009, p. 1187),
provided universal health care funded by the state. However, after the
transformations of the 1990s necessitated health care reforms, social
insurance models were introduced throughout the region (Rechel and
McKee, 2009) in which access to public health insurance became linked
to certain requirements such as employment (Kornai and Eggleston,
2001; Stan, 2015, p. 350). Therefore, during the time of my research,
participants had to engage with largely residency- and/or
employment-based and only partially state-subsidized social insurance
frameworks both in their countries of origin and in Germany, which, in
combination with various options of private health insurance, form the
basis of the aforementioned health care assemblages.
Within the German social insurance system, it was not possible for
uninsured patients like Radko to simply visit a doctor or a hospital and
receive treatment. Rather, as Radko would repeatedly complain, every
interaction with German health care providers began with a lengthy
discussion of his insurance status. His lack of health insurance posed not
only a financial, but also an administrative problem: with health in­
surance being statutory in Germany, the broader legal framework for
public health care generally does not account for uninsured patients.
While uninsured patients would not be denied treatment in cases of
medical emergencies, Radko made the experience that doctors operating
within the public health care system would not accept him as a patient in
matters not considered an emergency – even if he was prepared to pay
the costs of treatment himself. Doctors offering services to privately
insured patients were less strict about his insurance status, but would
charge higher rates, which presented a financial barrier to Radko. As a
result, he generally aimed to avoid interactions with the German health
care sector for as long as possible. He usually only went to a doctor when
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Social Science & Medicine 319 (2023) 115190
he was in severe pain and had collected sufficient funds to pay for
treatment. So, he had ignored his toothache for many weeks and had
only gone to the dentist after his condition became an emergency for
which treatment could not be denied.
Radko’s situation highlights central contradictions within contem­
porary health insurance systems: while health insurance provides
(almost) universal access to and cost coverage of health care in Germany
and other European countries, access to health insurance is not uni­
versally given. Yet, with health insurance representing a precondition of
access to and cost coverage of health care, those without any health
insurance face various barriers in accessing even basic health care ser­
vices. While these health insurance systems are theoretically based on
notions of social solidarity and affordable health care for all, it was
particularly people in precarious conditions, like Radko, who fell into
gaps of health insurance provision, pointing towards the fact that the
idea of solidarity at the basis of European health insurance systems was
not unconditional.
5. Solidarity with whom? Health insurance and normative ideas
of citizenship
When I asked Radko about health insurance, he usually shrugged and
said that he did not have any, because he was unable to obtain it. Unlike
Felicia, however, he did not question his lack of health insurance op­
tions. While he often complained about the German health care system,
he nevertheless took this situation for granted. His understanding of
health insurance stood in stark contrast to the aforementioned notion of
solidarity at the basis of German and other European health insurance
systems. In the consolidation of European welfare states, “national
health insurance and free or subsidized health care provided the kernel
of the social contract between the state and its citizens and have been a
cornerstone of citizens’ concepts of ‘the good society’” (Prince, 2017, p.
155). Yet, inherent in this idealized connection between states and cit­
izens through social insurance are also interrelated questions of who is
considered a citizen, who contributes to a collective health care system
and how, and who is deserving of subsidized health care (Holmes et al.,
2021; Willen, 2011), highlighting how health insurance systems are part
and expression of a larger moral economy of health (care) in Europe
(Fassin, 2005; Kehr et al., 2018).
This creates various explicit and implicit gaps in public health in­
surance systems, as access to public health insurance is strongly linked
to ideas of national belonging and contributing to a (national) collective.
Health and social insurance systems in EU countries are united in the
fact that legal citizenship and/or proof of belonging through permanent
residence in a country represent a basic requirement for accessing health
insurance systems or free health care services. Therefore, by design,
these systems exclude those who fall outside those definitions, such as
undocumented migrants (Huschke, 2013). Additionally, particularly
within employment-based social insurance systems prevalent in Ger­
many and eastern European countries, access to health insurance is also
closely connected to contributions to the (nation) state through taxation
and belonging to the work force (Esping-Andersen, 1990; Rechel and
McKee, 2009).
The increased mobilities of EU citizens pose a problem for these
systems, as for highly mobile populations, citizenship, place of resi­
dence, and location of employment are often no longer aligned. This
raises the question of where they can or have to be insured and subse­
quently what health care coverage they can access in which country. For
participants like Felicia and Radko this meant that despite having
Romanian and Bulgarian citizenship, they could not access the public
health insurance systems in their countries of origin, as they were
neither employed nor permanently living in these countries.
This also hindered their access to the European Health Insurance
Card (EHIC), which was introduced in 2004 as a solution to the problem
posed by increasing labor mobilities. Envisaged as an expansion of EU
social citizenship rights and an experiment in transnational health care
U. Probst
coverage, in practice the EHIC scheme increased inequalities and access
to social citizenship rights for some (Stan et al., 2020), as the precon­
dition for obtaining an EHIC was an existing public health insurance in
one of the participating member states. This reflects the conceptuali­
zation of the EU as an association of different nation states, which re­
inforces ethno-nationalistic ideas of belonging as a basis of EU
citizenship (Hansen, 2000; Keinz and Lewicki, 2019; Kinnvall, 2016;
Yıldız and De Genova, 2018, pp. 433–437), thus placing limitations on
the transnational idea of EU citizenship, as well as on health care
provision.
These limitations were also present in the everyday practices of
health insurance provision. Since the 1980s, the neoliberal governance
of health care (Maarse, 2006) has increasingly exacerbated the stratifi­
cation of health care systems in accordance with different sociocultural
hierarchies. As described by a social worker from a Berlin-based orga­
nization providing support to young migrant men like Radko who
engage in transactional sex with men, some of their clients were denied
access to public health insurance due to discrimination against ethnic
minorities: “We often see the situation that, for example, in Bulgaria and
Romania, Roma and Sinti are structurally and deliberately denied access
to public health insurance, sometimes through the vilest means. For
example, somebody has to travel 50 km to the next big town to register
for health insurance, only to be told to leave if they have trouble filling
out the necessary form and only to come back when they have learned to
do so.”
While Radko did not identify as a member of Roma or Sinti com­
munities, his accounts of his life in Bulgaria hinted at the fact that in
addition to racialization and ethnic discrimination, classist stereotypes
also came into play in interactions with public health insurance pro­
viders. Coming from an economically precarious background and hav­
ing been unemployed in Bulgaria, he had already experienced problems
in accessing social welfare services in his country of origin, which led
him to unquestioningly accept that such services were “not for him.”
Rather, through engaging in labor migration to Germany, he aimed to
obtain job training and a stable income, which would allow him to
become part of German society and make him eligible for services like
public health insurance. Considering the strong linkage between health
insurance provision and employment in Germany and other European
countries, his assumption was not only technically correct. It also
highlighted how, through the connection of health insurance provision
with normative ideas of European citizenship in combination with an
ongoing neoliberalization of health care systems, the notion of solidarity
inherent in European health care systems became understood less as
something provided, and rather as something that has to be earned by
embodying moralized ideals of neoliberal “Europeanness” (Keinz and
Lewicki, 2019; Lewicki, 2020). This shift facilitates the neoliberal
governance of health care, as it not only legitimizes further stratification
of health insurance systems. It also encourages the acceptance of not
being able to access health insurance systems, as expressed in Radko’s
case, as well as ambitions to adhere to racialized, sexualized and classist
norms of European citizenship.
6. Deserving victim or unwanted migrant? The curious case of
migrant sex workers from eastern Europe
“With this job [i.e. sex work], I pay my rent, I pay my taxes, I am self-
sufficient and I never had to rely on social welfare. So why am I treated
like this?” asked Felicia. In her attempt to defy the stigmatization of sex
work, Felicia reinforced the normative assumptions of independent
(hard) work as a basis for inclusion into public health insurance and
(national) collectives. Yet, at the same time her situation exemplified
that for migrants, employment is not enough to gain access to health
insurance and broader social welfare schemes in Germany. In recent
years, European migration panics have legitimized exclusions of mi­
grants and refugees from health care systems (Holmes and Castañeda,
2016; Lebano et al., 2020; Marques, 2012). This made it particularly
5
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difficult for her and other participants to access public health insurance
in Germany.
In Germany, the simplest way of integrating into the public social
insurance system is through a “sozialversicherungspflichtiges Anstellungs­
verhältnis.” This term refers to a contract-based employment relationship
(“Anstellungsverhältnis”) subject to social insurance contributions shared
between employer and employee (“sozialversicherungspflichtig”). This
type of employment contract gives employees access to the full range of
the social insurance system, i.e., not only public health insurance but
also unemployment insurance, sick pay, and other welfare benefits.
However, migrant as well as non-migrant sex workers mostly engage in
sex work in the form of self-employment, which does not constitute a
“sozialversicherungspflichtiges Anstellungsverhältnis.” Self-employed
workers have to pay the full amount of public health insurance fees,
and are largely excluded from other sectors of the public social insurance
system. Health insurance presents an exception, as it is statutory in
Germany. Therefore, public health insurance providers offer insurance
options for self-employed workers; yet, without cost sharing, the mini­
mum fees for self-employed workers were beyond the financial means of
many of the research participants.
Under certain conditions, i.e., eligibility for social welfare payments,
public health insurance is covered by the state, yet low-income self-
employed EU migrant workers often face the problem of not being
eligible for social welfare payments in the first place. Whereas German
citizens have the option of applying for unemployment benefits in
Germany regardless of their previous working and living arrangements,
non-national EU citizens cannot receive unemployment benefits – which
includes state-subsidized public health insurance – unless they have
been in a “sozialversicherungspflichtiges Anstellungsverhältnis” for some
time or can prove that they have been living in Germany for at least five
years.
Both can be difficult for migrants who are racialized as “eastern
European,” as they often experience discrimination on the job and
housing market. As Felicia described, she encountered difficulties
finding an apartment in Berlin because landlords were reluctant to rent
to her, after she had to provide identification documents which made it
clear that she was from Romania. Other participants recounted instances
when their job qualifications were not recognized, therefore leaving
them no other option than to enter precarious forms of self-employed
labor. Yet, even if migrants manage to fulfill these residence and/or
employment requirements, receiving unemployment benefits is pre­
conditioned on their willingness to actively search for a job, demon­
strating another instance of non-citizens having to conform to certain
norms of citizenship and deservingness to gain access to the social
welfare system.
Migrants from eastern European countries engaging in sex work in
Germany are by far not the only group affected by these different forms
of exclusion, as many migrants in the low-income care or agricultural
sectors face similar experiences with exclusion from public health in­
surance and social insurance systems. However, the stigmatization of
the source of their income in combination with ethno-racialized ste­
reotypes about “eastern Europe” (Lewicki, 2020) puts migrant sex
workers from eastern European countries in the spotlight of public
concern as an object of humanitarian concern (Mai et al., 2021).
By relying on stereotypical representations of both the profession
and “poor” migrants from eastern Europe (Hill and Bibbert, 2019),
German public debates around migrant sex workers’ health insurance
access make sex work and not health insurance legislation appear as the
main cause of insufficient access to the social insurance system (Balci,
2020; Hill and Bibbert, 2019; Meyer et al., 2013). While the inclusion of
sex workers in the social insurance system would require a thorough,
although not impossible reform of the social insurance system (Bern­
hardt, 2019), this framing built on and contributed to the continued
moralization of sex work and sex workers’ health care needs.
Felicia was outraged by this situation, as she strongly contested the
perception of migrants like her as naïve victims in need of rescue.
U. Probst
Nevertheless, she acknowledged that state-subsidized sexual health care
services for sex workers, which originated from the long standing
reduction of sex workers’ health care needs to matters of sexual health in
Germany (Probst, 2015), were useful in some regards, yet did not solve
the underlying issue of facing multiple barriers in accessing health in­
surance, which would allow her to access a broader variety of health
care services. Furthermore, she and other participants also experienced
problems in accessing these free services. Sometimes, administrative
staff exhibited an uncritical reliance on the universality of health care
coverage in the EU and assumed that they, as EU citizens, must be
insured and therefore were not deserving of free sexual health care
services.
These misconceptions must be interpreted as an expression of ten­
sions around European nation states’ involvement in the transnational
health care practices of marginalized populations. Reducing sex
workers’ health care needs to a question of sexual health enables gov­
ernments to position themselves as caring institutions supporting
vulnerable sex workers without having to subsidize broader health care
needs or change the relevant legal framework. Reinforcing assumptions
of universal health care coverage in the EU also allows the German state
to withdraw its responsibility for the health care needs of EU migrant sex
workers, since, within a supposed egalitarian and universal system, it is
the responsibility of their countries of origin to provide health insur­
ance. For the participants, who often also were excluded from public
health care in their countries of origin, this meant that the public health
care system was out of reach, making private insurance the only viable
option to fulfill the statutory health insurance requirements in Germany.
7. The importance of health insurance in becoming a good
neoliberal citizen
Ewa, a cis woman from Poland in her late twenties, had been
working as an escort in Berlin for a few years when we met in 2018. In
our conversation, she portrayed herself as a successful entrepreneur who
embodied neoliberal citizenship by running her escort career as a well-
calculated business, with the aim of accumulating enough capital to start
another business venture. Emphasizing success, wealth, and indepen­
dence as her life goals, she did not aim to access the public social in­
surance system, as she had little regard for public welfare systems and
dependence on them. Therefore, private insurance did not present a
problem, but rather an advantage to her.
“My [private] health insurance is in Poland. Here I would have to pay
300 euros or something for private insurance, this is too expensive
for me, therefore I am insured in Poland.”
Presenting an expression of consumer citizenship centered around
informed choices with regard to health insurance, Ewa’s reasoning for
obtaining private health insurance nevertheless had little to do with
choices about the best health care coverage for her needs. Rather, her
choice was informed by calculations to find the cheapest option avail­
able. Her chosen private insurance scheme would not allow direct
treatment payment through the insurance company, which meant that
she had to pay for treatments up front, only to be reimbursed later – of
which Ewa, however, did not make use: “I am paying everything in cash
here and never file for reimbursement. When you pay in cash, you get
treatment immediately, this is an advantage.”
In a few words, she summarized the current state of the German
health care system, where affluent, privately insured patients are
prioritized in treatment and care, while publicly insured patients often
face long wait times and fewer options (Buntenbach, 2012; Maarse,
2006). Just as she did not want the state to interfere with her business
ventures and only reluctantly paid taxes, she preferred to be in charge of
her health care herself without being bound to continuous payments for
public health insurance or (in her view) the limited options available in
the public health care system. Having sufficient financial means to pay
for treatments up front provided not only a way of accessing the health
6
Social Science & Medicine 319 (2023) 115190
care she desired, but also of representing herself to me and to health care
providers as an affluent citizen.
Ewa’s approach raises the question of why she had private health
insurance despite never using it for reimbursements. The reason for this
lies in the bureaucratic importance health insurance has acquired in
Germany and the EU through its links to employment and residence
status. Given the statutory health insurance scheme in Germany, Ewa
had to obtain some kind of health insurance. As she was not planning on
integrating into the German social insurance system for the reasons
mentioned, private insurance represented a suitable option which
allowed her to express normative ideas of neoliberal citizenship.
Furthermore, Ewa’s considerations highlight a detachment of health
insurance from its ideal purpose as a solidary system of affordable access
to health care towards an individualized interpretation of health insur­
ance as a financial and bureaucratic nuisance. This shows that the move
towards framing health insurance as a matter of consumer choice is not
only part and effect of the further privatization of health care, but also
contributes to the erosion of social solidarity under neoliberal health
care governance.
While these shifts towards neoliberal consumer citizenship repre­
sented an advantage to Ewa in her quest of representing herself as a
successful citizen, the option of fulfilling Germany’s statutory health
insurance requirements through (cheap) private health insurance often
increased the precarities of participants and other low-income self-
employed migrants. As mentioned above, transitioning from private to
public health insurance was only possible under certain conditions in
Germany, particularly complicating the integration into broader social
welfare schemes when people aimed to exit sex work without directly
changing to another job.
Considering these barriers to public health insurance in Germany,
participants like Monika, a cis woman from Hungary in her early
thirties, recounted overcoming these hurdles as an achievement in
integration: “I have German [public] health insurance; after 10 years,
this is the first year I have it. I am super proud of myself. It is like you
made it, you basically made it. It is fucking hard, I pay 118 [euros per
month] or something like that; to sweat this out is difficult sometimes.”
Monika had moved from Hungary to Germany roughly ten years prior to
our first meeting. As an artist with little formal education, she struggled
to make a living in a city in which living and housing became more
expensive each year. Moving from one precarious part-time job to the
next, she eventually started working in a strip club, through which we
became acquainted. During our meetings we often engaged in conver­
sations about German bureaucracy, as this presented a continuous
struggle for Monika.
In this context, she understood her successful integration in the
public health care sector less as giving her protection from high health
care costs and more as an expression of having “made it” as an EU
migrant in Germany. Earning enough money to pay her monthly in­
surance fees became a priority for her as a way of proving that she could
belong in Germany by contributing to what is expected of citizens and
residents who want to create long-term prospects in Germany. Monika
nevertheless retained her criticisms of German bureaucracy, but having
public health insurance facilitated her engagement with it. Even outside
the health care sector, migration or social welfare authorities likewise
interpret an active public health insurance as a symbol of “good” inte­
gration, which facilitates procedures such as naturalization.
Both Ewa’s and Monika’s case demonstrate that barriers to health
insurance created through the neoliberal fragmentation of health care
systems in Europe and the underlying moral economy of health care
provision serve not only as an exclusionary, but also a disciplinary
measure in creating the “good” (European) citizen (Mladovsky, 2020).
The claim of universality of these health insurance systems must be
understood less as a right, and rather as a promise to be fulfilled upon
adhering to racialized, classist, and gendered norms of neoliberal
“Europeanness.” In the case of migrant sex workers from eastern Europe
in Germany, the necessity of overcoming various gaps and
U. Probst
contradictions within health insurance systems therefore can be inter­
preted as both an expression of their marginalization and as a form of
governmentality which urges or allows them to prove their “Euro­
peanness” by obtaining public health insurance or embodying the
neoliberal consumer-citizen.
8. Conclusion
Eastern European migrants engaging in sex work in Germany or
other western European countries face various interrelated forms of
exclusion from both public and private health insurance systems. These
exclusions arise at the conjunction of the increasing privatization of
health care across Europe, the rise of consumer-citizenship as a basis for
accessing social citizenship rights, moralized interpretations of sex
workers’ health care needs, and uncritical reliance on the supposed
universality of health care coverage for EU migrants. These exclusions
also stem from public health care systems being built on moralized ideas
of “good” citizenship as a basis of health insurance provision. This makes
accessing health insurance a difficult endeavor for migrant sex workers
from eastern Europe and obscures the intricate underlying causes by
ignoring the fact that insurance choices are socioeconomically
embedded and limited in this system, particularly for low-income mo­
bile populations.
While the findings of this article relate to a particular constellation of
labor migration and insurance coverage in the EU, they nevertheless fall
in line with similar insights described in studies of recent development
in European health care systems and their effects on the health care
practices of intra-EU migrants (Buntenbach, 2012; Ewert, 2011; Holmes
and Castañeda, 2016; Maarse, 2006; O’Donnell et al., 2013; Pavolini and
Guillén, 2013; Stan, 2015; Stan et al., 2020). Therefore, the analysis
provided in this article offers another example of the importance of
health care reforms within Europe (Stan et al., 2020, p. 12), which need
to enable cost-sharing between differently positioned member states, as
well as provide options for registering which do not depend on access to
a particular national health care system.
Expanding these analyses, the article has highlighted the fact that
health care reforms also must critically engage with the moral un­
derpinnings of health insurance systems and the social meanings which
health insurance has acquired therein, particularly for marginalized
populations, but also for health insurance providers and legislators.
Because it is not only structural barriers enforced by neoliberal health
care reforms, which contribute to a stratification of health insurance
access, but also the meanings currently assigned to health insurance by
various actors. Understandings of health insurance as an expression of
privilege and success in conforming to neoliberal ideas of “good” Eu­
ropean citizenship not only undermine notions of solidarity as a basis of
public health insurance systems, but thereby also legitimize the further
erosion of solidary health insurance systems. If left unaddressed, these
developments will continue to produce unequal access to health care
even in the event of financial reforms, as for access to health care to
become universal in Europe, it cannot be limited only to citizens who
conform to sexualized, racialized, and classist ideas about the good,
hard-working citizen.
Credit author statement
Ursula Probst: Conceptualization, Methodology, Investigation,
Analysis, Writing – original draft, Writing – Reviewing and Editing,
Project administration, Funding acquisition.
Declaration of competing interest
None.
7
Social Science & Medicine 319 (2023) 115190
Acknowledgments
I want to thank Janina Kehr, Ruth Prince, Jacinta Victoria Syombua
Muinde for inviting me to be part of this special issue and providing a
space to discuss first ideas for this article. Furthermore, I want to express
my gratitude to the members of the working group Medical Anthro­
pology | Global Health at Freie Universität Berlin, as well as to the two
anonymous reviewers, for their careful engagement with and critical
comments on earlier versions of this article. The research for this article
has been funded by the Elsa-Neumann-Scholarship from 2017 to 2020.
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