Rutschman A, Wiemken T. The case against monetary behavioral incentives in the context of COVID-19 vaccination. Harvard Public Health Review. 2021; 27.
Here, we examine and critique current proposals to offer monetary incentives for vaccination against COVID-19 in the United States. As the U.S. Food and Drug Administration authorized the first COVID-19 vaccines, these proposals gained traction among commentators and policymakers as a response to emerging data indicating that a significant percentage of the U.S. populations was unwilling to be vaccinated against COVID-19. We note that the proposed monetary behavioral incentives lack in evidentiary support and argue that their implementation would lead to both short-term and long-term detrimental effects. Monetary incentives can easily be instrumentalized in vaccine-questioning discourses to question the safety and public health value of COVID-19 vaccination. Moreover, they tap into existing socioeconomic and racial disparities, exploring the economic disadvantages experiences by disadvantaged individuals, who are asked to adopt a particular health-related behavior, while wealthier individuals are likely left largely unaffected by the proposed behavioral incentive.
Multiple COVID-19 vaccines have gained regulatory approval or authorization across the world. Emerging data suggesting low rates of confidence in COVID-19 vaccines authorized by the FDA in the United States have triggered concerns over the possibility of sub-optimal immune coverage once COVID-19 vaccination becomes widely available to indicated populations. In response to these concerns, some commentators have proposed a monetary incentive for COVID-19 vaccination. In this manuscript we trace the conceptual development of this incentive mechanism, survey existing proposals to implement it, and then examine the merits of these proposals. We conclude that their adoption is ill-advised, in agreement with others (Largent & Miller, 2021). First, as currently proposed, COVID-19 vaccination incentives lack in evidentiary support. Second, offering monetary compensation in exchange for COVID-19 vaccination is likely to be instrumentalized in vaccine-questioning discourses to question the safety and public health value of COVID-19 vaccination, thus compromising both short- and long-term trust in vaccines. And third, implementing monetary incentives in the context of COVID-19 vaccination would tap into existing socioeconomic and racial disparities, putting disadvantaged individuals in a position in which they are asked to adopt a particular health-related behavior, while wealthier individuals are likely left largely unaffected by the proposed behavioral incentive.
Initial studies conducted in mid- to late 2020 showed that the number of people willing to be vaccinated against COVID-19 in the United States was much lower than desirable from a public health perspective. According to a Pew Research Center survey published in mid-September, only 51% of Americans indicated they were inclined to (Pew Research Center, 2020b) get a COVID-19 vaccine. (Pew Research Center, 2020b) Even though the most recent studies now put that number at 60%,(Pew Research Center, 2020a) America still faces a widespread problem of trust in emerging COVID-19, vaccines, particularly among racial minorities. (Artiga & Kates, 2020)
The idea of making payment available upon proof of COVID-19 vaccination originated against this backdrop, in an attempt to influence the behavior of vaccine-hesitant individuals during the pandemic. (Litan, 2020) In August 2020, Robert Litan suggested that each American who received an FDA-authorized COVID-19 vaccine should be paid $1,000. He characterized this idea as the “adult version of the doctor handing out candy to children”. (Litan, 2020) According to Litan’s proposal, this amount would help incentivize individuals to overcome hesitancy or lack of trust in available COVID-19 vaccines. Since then, the proposal has been endorsed repeatedly in public fora, including by economist N. Gregory Mankiw (Mankiw, 2020) and politician John Delaney, who proposed raising the award to $1,500. (Delaney, 2o2o)
Monetary incentives designed to influence health-related behaviors are not new. They have been studied in multiple areas, from smoke cessation to the screening of sexually transmitted infections. (Vlaev, King, Darzi, & Dolan, 2019) Their study in the field of vaccination, however, is very limited. (Savulescu, 2020) And no study to date has examined the implications of a governmental intervention that would make payment available as a “reward” for vaccination in the specific context of the COVID-19 pandemic, during which vaccine-related discourses have been highly polarized and politicized, and levels of government mistrust have increased. (Rainie, Keeter, & Perrin, 2019)
The lack of data and literature support undergirding current proposals for the creation of monetary incentives for COVID-19 vaccination is clear. Litan explicitly stated in his essay that his suggestion of setting the payment at $1,000 was based on a “hunch” (Litan, 2020). His proposed framework referenced no survey, study or scholarly work in any field of science or the humanities, other than data exploring the varying herd immunity threshold for COVID-19 across the United States. Mankiw’s endorsement of Litan’s proposal rests of general principles of economic analysis, which the Author summarizes as “people respond to incentives” and then pairs with the idea that vaccination triggers positive externalities, (Mankiw, 2020) suggesting that incentivizing a positive behavior (vaccination) is worth committing governmental resources to in the subsidy-like form proposed by Litan. There is no exploration of the specificities of vaccine-related behaviors, nor of any strand of the literature on the multifactorial roots of vaccine hesitancy and appropriate interventions to curb hesitancy.
In addition to the current lack of empirical and theoretical support, establishing a monetary incentive for COVID-19 vaccination would likely be problematic on other fronts. Here we argue that paying individuals in exchange for vaccination in the context of the ongoing pandemic could both intensify vaccine-questioning discourses and potentially affect overall levels of trust in vaccines. Moreover, payment for vaccination – especially as envisaged in current proposals – accentuates socioeconomic and racial disparities by treating minority and economically vulnerable populations in paternalistic, non-data-driven ways. (Bhopal, 1998)
As correctly pointed out by Mankiw, the incentive mechanism as proposed by Litan would take the form of a federal subsidy. (Mankiw, 2020) A monetary award stemming from the federal government, however, may in practice foster hesitancy towards vaccination within certain segments of the population who experience profound distrust of the government, or the government’s response to the COVID-19 pandemic. (Devine, Gaskell, Jennings, & Stoker, 2020) Moreover, for individuals or communities already experiencing vaccine hesitancy or mistrust, the association between vaccination and the availability of a monetary payment may further intensify doubts about vaccines and vaccination. Some of the debate surrounding the federal program providing monetary compensation in the relatively rare cases in which administration of a covered vaccine results in serious injury – the National Vaccine Injury Compensation provides – is often misconstrued in vaccine-questioning discourses, particularly in connection with claims alleging vaccine-induced autism.(SafeMinds, 2011) Although originating from within relatively small activist communities, these misconstructions are amplified by media able to attract large followings, as well as through social media. (Hamblin, 2019) And while this federal program is different from a monetary incentive in scope and design, the potential for misconstruction of payment for COVID-19 vaccination because of its association with the actions of the federal government remains unstudied and a potential problem.
At yet another level, a monetary incentive may also feed into strategies to increase the circulation of vaccine-specific disinformation. Recent studies have documented the growth in circulation of vaccine disinformation in the online environment, including through the use of automated programs deployed by foreign entities seeking to increase overall divisiveness in American debates. (Broniatowski et al., 2018) A monetary incentive offered by the government may thus be easily instrumentalized by promoters of vaccine disinformation and invoked in online discourses linking heterogenous forms of government support for vaccination to conspiracy theories. (Bertin, Nera, & Delouvee, 2020) This, in turn, would magnify the noise surrounding vaccine information available to the public in an area that is already extremely polarized.
Finally, the problems posed by a monetary incentive for COVID-19 vaccination extend beyond their impact on vaccine sentiments and their potential manipulation in the informational arena. They embody and perpetuate approaches to public health policy that reinforce paternalism towards racial minorities and economically disadvantaged individuals. Existing proposals target individuals who are conceptualized as responsive to $1,000-1,500. (Delaney, 2o2o; Litan, 2020) Litan specifically contemplates the case of a family of four receiving $4,000, stating that the amount constitutes “a lot of money to a lot of families in these difficult times, and thus enough to assure that the country crosses the 80 percent vaccination threshold”. (Litan, 2020) The proposal therefore rests on the implicit assumption that this amount will lead to individual – and possibly familial – behavioral changes irrespective of initial vaccine- or government-related beliefs, ease of accessing vaccination services or other factors that may play a role in the response to a monetary incentive. (Vlaev et al., 2019) Moreover, it specifically targets individuals or families who would perceive the amount offered as sufficient to nudge them towards receiving the vaccine, either overcoming inertia, doubt or distrust about a COVID-19 vaccine or vaccines in general. At the same time, the incentive would benefit individuals who would otherwise elect to receive the vaccine but are now able to reap a financial reward. This would lead to significant waste of resources against the backdrop of a pandemic that triggered an economic recession in the United States and that is expected to leave a long-lasting imprint in the budgetary and financial health of the country.
The proposed incentive scheme is thus designed in a way that is hypothesized to be attractive to individuals or families who would switch behaviors for $1,000-1,500. Lower-income populations are hypothesized to adopt a particular health behavior in exchange for money, while wealthier individuals are less likely to face a moral or economic choice between a monetary reward and adherence to their beliefs. Given the fact that a substantial percentage of low-income Americans belong to a racial minority, monetary incentives to vaccination indirectly differentiate between individuals and communities based on their race, assuming that economically vulnerable minorities will behave in a certain way, whereas wealthier individuals are left free to ignore the incentive if they so desire. This logic compounds historical approaches to biomedical innovation – including the development of vaccines – that have long been discriminatory against racial minorities. (Washington, 2006) Offering monetary incentives under the model proposed by Litan and others risks accentuating sentiments of distrust towards emerging vaccines. Already during the COVID-19 pandemic, the National Medical Association announced the creation of a task force composed of Black doctors to review COVID-19 vaccines and drugs, citing mistrust of government-led processes of review and authorization of COVID-19 products. (National Medical Association, 2020)
Overall, the lack of data supporting a monetary incentive for COVID-19 vaccination, the potential for instrumentalization of the incentive in vaccine-questioning circles, and the dubious socioeconomic assumptions on which the proposed incentive scheme rests combine to suggest that legislators and policymakers should not yield current calls to make payment available as a quid pro quo for COVID-19 vaccination.
Dr. Ana Santos Rutschman is assistant professor of health law and intellectual property at Saint Louis University, where she is also a researcher at the Center for Health Law Studies and the Institute for Vaccine Science and Policy.
Dr. Timothy Wiemken is an Associate Professor in the Saint Louis University School of Medicine Division of Infectious Diseases, Allergy, and Immunology. Dr. Wiemken has a doctorate in Public Health from the University of Louisville, a master’s degree in Epidemiology from Saint Louis University, and has a bachelor’s degree in microbiology and molecular biology from Southern Illinois University. His research currently focuses on pneumonia, influenza, emerging respiratory pathogens, vaccinology, data science in healthcare, and healthcare-associated infections.