As COVID-19 vaccines trickle into the Philadelphia region, some are concerned that even when doses become available to the general public, not everyone will want to take it. For some vaccine skeptics, the problem is misinformation, while for others, including Black communities impacted by racism in medicine, it’s the result of distrust. To encourage everyone to get vaccinated, some experts have suggested the incentive of direct payments. But critics say such measures could threaten trust among the most vaccine-hesitant groups.
To debate this issue, The Inquirer asked economists and health researchers: Are financial incentives for the vaccine a good idea?
By Erin Todd Bronchetti and Ellen B. Magenheim
We show that when it comes to vaccinations, money talks. In a randomized controlled trial including over 10,000 college students, we find that a small financial reward — $30 — nearly doubles influenza vaccination rates. Of course, college students may be especially sensitive to small rewards, and the flu vaccine is familiar and regarded as safe. A much larger reward, along the lines of the $1,000 suggested by economists Bob Litan and Greg Mankiw, may be required to achieve similar results with the COVID-19 vaccine.
Perhaps more importantly, our research sheds light on why paying people works and many other approaches don’t. People fail to undertake preventive health measures, like vaccinations, for varied reasons. Some miss information about how or when to get the vaccine. Some are afraid of shots or do not believe they are at risk of serious illness. And some intend to get vaccinated but don’t follow through.
Whereas many low-cost behavioral nudges address just one of these barriers, the small financial reward changed behavior at each stage of the decision-making process. Compared with people in the control group, those randomly selected to be eligible for the $30 paid more attention to information about how to get the vaccine. Strikingly, they were 56% more likely to answer “yes” to whether they planned to get vaccinated, suggesting the incentive changed some people’s minds. And among those who intended to get vaccinated, the rate of follow-through was 36% higher in the incentive group than in the control group.
These are exactly the barriers that must be tackled to get the COVID-19 vaccine to enough people. The pandemic’s economic toll has many people worried about keeping their jobs, paying the bills, and having enough food to feed their families, perhaps more so than about getting the vaccine. The prospect of a substantial incentive can cut through the noise and direct attention to the safe public health measure at their disposal.
Once individuals decide to get the vaccine, encouraging them to follow through will be crucial. Unlike the flu vaccine, COVID-19 vaccination requires two doses, yet another reason for a larger reward than the $30 our study provided. Carefully designed incentives can increase the odds that individuals come back for the second shot.
We are far less optimistic that lower-cost nudges, alone, will be sufficient to achieve vaccination rates necessary for herd immunity. In our study, the low-cost behavioral interventions we tested to increase attention to vaccine information or help people focus on the benefits of vaccination had exactly zero impact on uptake.
That is not to say that nudges can’t be useful coupled with financial reward. As suggested by Nobel laureate Richard Thaler, making it easy to get the vaccine, scheduling the second dose right when the patient receives the first, and encouraging follow-through with reminders will be critical. Endorsements of the vaccine from political leaders and trusted sources may help counteract concerns about its safety or any additional distrust people may feel because they are being paid to get it. The right solution is likely to be a both/and approach.
But the bottom line, at least according to our own work, is that the best way to give a shot in the arm to vaccination efforts is by putting cash in the pocket.
Erin Todd Bronchetti and Ellen B. Magenheim are economics professors at Swarthmore College.
By Harald Schmidt and Alison Buttenheim
While everyone hopes that vaccines can help end the pandemic, not everyone is keen to be vaccinated. Offering financial incentives is a tempting solution to vaccine hesitancy, but one we should avoid. Instead, we should focus efforts on making it as easy as possible to receive a vaccine in trusted settings. Incentives may have a role in a broader strategy, and in ensuring that people return for their second dose.
We see four main reasons not to offer pay:
First, such incentives are unlikely to work for the most vaccine-hesitant individuals, who may account for around 10% of the population. Behavioral scientists typically deploy financial incentives to change behavior when the benefits of that behavior accrue in the future, involve some chance, and are intangible (vaccination ticks all three boxes) — but the “costs” (time, hassle, pain) are immediate. Incentives work well when the problem is follow-through or procrastination, as the incentives overcome our “here and now” focus on immediate costs. They don’t necessarily work well for changing beliefs or intentions.
Second, a major component of COVID-19 vaccine hesitancy is rooted in distrust of health-care researchers and providers, especially in government-run initiatives. This is particularly true for Black and brown communities. We are already seeing stark racial and ethnic disparities in COVID-19 vaccine acceptance. A recent survey found that 40% of Black respondents, compared with 60% of white respondents, would take a vaccine as soon as it is available. Distrust is not addressed by waving money — in fact, offering incentives may undermine trust. Rebuilding trust requires removing political influence, being transparent about the scientific process, and planning responsive outreach and delivery strategies.
Third, offering incentives can signal that the incentivized behavior is unpleasant, risky, or difficult. While the COVID-19 vaccine Phase 3 studies were large, we’re still learning about reactions and side effects as vaccines are taken on a larger scale. Expected but severe adverse events experienced by possibly hesitant individuals who received an incentive is a recipe for a politicized social media misinformation disaster, which could do considerable short- and long-term harm to rollout efforts.
Finally, universal incentives for vaccination are an inefficient use of limited resources. Consider a $25 incentive (a common amount for a one-off behavior): Even at that scale, we would pay billions to the large segment of the population that doesn’t need an incentive to get vaccinated (likely about 40%-60%). It’s hard to justify this expense when state and local health departments have insufficient resources for effective vaccine rollout.
If incentives are offered in a targeted instead of a universal way, then considerable care is needed to ensure that incentives aren’t seen as stigmatizing. Plans to offer incentives at a much larger scale, comparable to COVID-19 relief checks, are similarly impractical.
A better use of scarce public health funds is to develop and implement effective outreach and delivery strategies that “meet people where they are,” physically and psychologically. These efforts should focus on groups who bear the greatest burden of disadvantage and historic racism in health care, as well as the greatest COVID-19 disease burden. If incentives are going to be part of the vaccine rollout toolkit, they should be tied to accessing evidence-based resources to support a vaccine decision, or to completing the vaccine series with the second dose.
Many innovative approaches have been proposed to ensure a swift, transparent, and equitable vaccine rollout. Incentives are not the best or wisest option we have.
Harald Schmidt is an assistant professor in medical ethics and health policy at the University of Pennsylvania’s Perelman School of Medicine. Alison Buttenheim is an associate professor of nursing and health policy at the University of Pennsylvania’s School of Nursing.