The internet had a field day when Krispy Kreme in March offered free donuts to anyone who could prove they’d been vaccinated against COVID-19. But only a few weeks later, as vaccine supply begins to outpace demand in many places and daily vaccination rates tumble across the U.S., states, cities and counties are following the donut chain’s lead.
West Virginia is offering $100 savings bonds to 16- to 35-year-olds who get vaccinated. Maryland will pay fully vaccinated state employees $100. Breweries participating in New Jersey’s “Shot and a Beer” program are giving out free drinks to legal adults who gets vaccinated in May. Connecticut and Washington, D.C., are also running free-drink promotions for the inoculated. The New York Yankees and Mets will reportedly offer free tickets to fans who get vaccinated at ballparks before games. Lawmakers in Harris County, Tex., approved a $250,000 budget for vaccine perks like gift cards and freebies. Detroit is handing out $50 prepaid debit cards to pre-registered individuals who drive a neighbor to a vaccine clinic.
The subtext of these programs is clear: The lifesaving benefits of COVID-19 vaccination have not been enough to convince many people to get their shots. And now, if the U.S. wants to reach herd immunity, it may need to get creative.
But will a free drink or a $100 payment actually convince anyone to get vaccinated?
“It gets at the low-hanging fruit”—people who aren’t actively opposed to vaccination but may have been too busy or apathetic to make an appointment, says Eric Feigl-Ding, an epidemiologist and health economist at the Federation of American Scientists. “The hardcore denialists are not going to budge after being bribed with a beer or a $100 savings bond.”
Still, the “low-hanging fruit” population is a large one. More than half of the U.S. population has not yet received a single COVID-19 vaccine dose, even though they are now available to adults nationwide—but U.S. Census Bureau data show that less than 15% of U.S. adults identify as vaccine hesitant. A recent Axios-Harris poll found that 31% of unvaccinated Americans say they’ll either “get the vaccine whenever they get around to it” or “will wait awhile and see before getting the vaccine.” That suggests a significant number of people fall somewhere between eager for and opposed to vaccination. Incentives could help bring them in the door.
That’s not a new idea. Late last year, Robert Litan, a scholar at the Brookings Institution, argued that each person who gets vaccinated should be paid $200 up front, and another $800 once the country reaches herd immunity. Former Congressman John Delaney also called for $1,500 stimulus checks for those who get vaccinated. More recently, Norman Ornstein, an emeritus scholar at the American Enterprise Institute, proposed an even bolder plan: a $10 million lottery, into which each vaccinated adult would be entered once the country reaches 70% vaccine coverage.
Past studies have shown that financial incentives can get people to change their health behaviors. One 2019 research review found that monetary rewards can help motivate smokers to quit cigarettes. Other studies have found that incentives can encourage participation in employer-sponsored wellness and fitness programs, and convince people to eat fruits and vegetables.
When it comes to COVID-19, that pattern seems to hold. For example, in a recent University of California, Los Angeles survey, about a third of unvaccinated people said cash payments would make them more likely to get a COVID-19 shot. Democrats seemed especially swayed by the promise of a payout, the survey found, while Republicans tended to be more tempted by relaxed safety standards, like the ability to go maskless in public.
Uri Gneezy, a behavioral economist at the University of California, San Diego who studies incentives, cautions that many study participants don’t accurately predict how they would respond to an incentive in the real world—but there is some evidence to suggest cash payments are already encouraging COVID-19 vaccination.
West Virginia saw a wave of interest in vaccination after Governor Jim Justice announced the state’s savings bond program, says state COVID-19 Czar Dr. Clay Marsh. “We were encouraged that a lot of people were interested in receiving the incentive,” he says, adding that the state government is open to offering other rewards if this one continues to succeed. There were, however, unintended consequences: It has been so onerous to order and issue bonds one by one that the state may have to switch to direct payments of equivalent value, Marsh says.
That’s a tricky proposition, too. Gneezy says cash payments can unintentionally (and falsely, in the case of COVID-19 vaccines) signal that something is dangerous. Imagine if researchers asked you to participate in a medical trial and said they would cover meals and travel during the study period. Now imagine they’d offered a $100,000 payment. That hefty sum would likely set off more alarm bells than the reimbursement offer, Gneezy says. You don’t want people to think, “‘Why do they have to pay me to participate in this? It must be dangerous,’” he says.
Something like a free beer or a perk from local businesses might actually be more effective for encouraging COVID-19 vaccination, Gneezy says, because it doesn’t send that signal. Many people also feel positively toward their local businesses, which could add extra motivation. “Even if the government is paying for it, it’s a much better feeling if you get it from a restaurant,” Gneezy says.
For incentives to really work, Feigl-Ding says, they should go beyond a single perk. “The best incentives are when you encircle our society with enough benefits if people get vaccinated and enough hoops if they don’t,” he says.
The U.S. Centers for Disease Control and Prevention (CDC) has already done this, to some degree, with its guidance for fully vaccinated individuals. By saying vaccinated people can travel safely and go maskless outdoors and at private gatherings, the CDC has equated vaccination with things people want. Judging from the UCLA survey, that could be quite effective.
The problem is, those guidelines are largely unenforceable. To go even further, Feigl-Ding says, the U.S. would need a national system (beyond easily faked paper vaccine cards) that private businesses could use to verify their customers’ immunity. This would allow bars, restaurants and other venues to admit only vaccinated people, as some establishments in Hong Kong, for one, have done.
Tying freedoms to vaccination status is controversial, though. Immunity passports that allow vaccinated or naturally immune people to travel, dine indoors and attend events are already in use in countries including Israel, but they come with ethical concerns.
For one thing, it’s not clear how people who have legitimate medical reasons not to get vaccinated would fit into an immunity passport structure. Some experts also argue immunity passports could exacerbate disparities in places where COVID-19 vaccines are not yet universally available and lead to unintended discrimination. “By stratifying members of society into different tiers of risk of infection and contagiousness, an immunity certification programme may result in unequal treatment of individuals that is based on ethically irrelevant considerations of ethnicity, religion, socioeconomic status or similar differential traits,” a group of experts wrote in a recent Bulletin of the World Health Organization.
But there may be effective hybrid approaches. In a March BMJ Opinion article, medical student Nakisa Sadeghi and public-health expert Dr. Leana Wen raised possibilities like instituting vaccinated-only hours at private businesses, or requiring unvaccinated people to undergo COVID-19 tests before flying (while allowing vaccinated passengers to skip testing). Such policies could build up enough social pressure to make vaccination attractive, without completely excluding unvaccinated people from public life.
Trivial though they may sound, small perks for vaccinated people might help. A single free beer or donut (or groceries or marijuana or popcorn) may not be enough to convince a given individual to get vaccinated. But creating a culture in which vaccination is associated with benefits—beyond, of course, stopping the spread of a deadly virus that has shut down the world—could be enough to move the needle at a population level.
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Contributor: Jamie Ducharme