On Wednesday, May 12th, in what sounded more like a pitch from a used car salesman than the introduction of a major public health initiative, Ohio Governor Mike DeWine announced the launch of a $1 million lottery for vaccinated residents of the state. “Now, I know that some of you are shaking your head and saying, ‘That Mike DeWine, he’s crazy! This million-dollar drawing idea of yours is a waste of money,’” the governor said in a televised address. “But truly, the real waste at this point in the pandemic — when the vaccine is readily available to anyone who wants it — is a life lost to Covid-19.”
Technically, there will be five “Ohio Vax-a-Million” drawings, making it a $5 million idea from DeWine and the Ohio Department of Health, the sponsor of the initiative. The state is also giving away five full college scholarships to vaccinated students between the ages of 12 and 17. Other states have recently introduced their own programs to incentivize residents to get vaccinated against Covid-19, though none of them involve the spectacle of a statewide lottery — not yet, at least.
Offering people rewards for getting vaccinated isn’t something new. Large retail chains like CVS, Target, and Walgreens have offered perks like this for years — usually in the form of a gift card or coupon for customers who get a flu shot. Other businesses have gotten in on the giveaways during the Covid-19 vaccine rollout, offering everything from free doughnuts and beer to weed and amusement park tickets, with proof of vaccination.
Now, states like Ohio are attempting to use this strategy to increase Covid-19 vaccination rates, which, according to data from the Centers for Disease Control and Prevention (CDC) have been declining steadily on a national level for the past six weeks. On April 1st — the busiest day of the rollout so far — nearly 4.3 million new doses of vaccine were administered, and it has been downhill from there. Between April 11th and May 11th, the average number of weekly vaccinations dropped from approximately 3.3 million to 1.7 million — or a decrease of nearly 50 percent.
Each state takes their own approach when offering incentives. For example, Maine residents who get their first shot by May 31st can choose from a free park pass, hunting or fishing license, or a $20 gift card to L.L. Bean. Meanwhile, the Alabama Department of Health recently gave residents the opportunity to drive two laps in their own vehicle on the Talladega Superspeedway after getting a drive-through Covid test or vaccine at the racetrack. Other offers include free beer in New Jersey (though Gov. Phil Murphy hasn’t ruled out paying people to get vaccinated), MetroCards or tickets to various cultural attractions in New York City, and a complimentary beverage (with or without alcohol) in Connecticut.
Though Ohio is the only state to offer a dedicated lottery for vaccinated residents, people in Kentucky who get the Covid vaccine at participating Walmart and Kroger locations will receive a free lottery ticket for a statewide nightly drawing of $225,000. West Virginia is going a different direction, giving a $100 savings bond to anyone between the ages of 16 to 35 who receives, or has already received, a Covid-19 vaccine. At this point, it’s too early to determine which — if any — of these incentives will have a significant impact on a state’s vaccination rate.
Will these vaccine incentives work?
It’s been less than a week since DeWine first announced the Vax-a-Millions program, but there are some early indications that it might be working. During a May 17th press conference, Ohio Health Director Stephanie McCloud said that the state has already seen a six percent increase in vaccination rates among people between the ages of 30 and 74. This was coming off three weeks of a steady decline (specifically, 24 percent week-over-week decreases) in rates for that age group.
But will a trip around a racetrack in Alabama be as effective as the chance of winning $1 million in Ohio? Right now, we don’t know. Because these types of state-sponsored vaccine incentives haven’t been offered before on this scale, there is no existing data pointing to which rewards (i.e. a free beer vs. a lottery ticket vs. amusement park tickets) are more effective at increasing vaccination rates than others. Even after the Covid-19 vaccine rollout concludes and we do have that state-level data, several other factors come into play — including personal preferences and geographic differences — that may make it difficult to identify specific strategies that would be the most successful on a national level.
The exception to this is cash. Thanks to the UCLA Covid-19 Health and Politics Project, which has surveyed more than 75,000 people in the last 10 months, we have some indication of how effective monetary incentives might be. According to data published in the New York Times, approximately one-third of the unvaccinated people surveyed said that a cash payment of $25 to $100 would make them more likely to get immunized.
Another factor to consider when determining whether vaccine incentives work is who these initiatives are meant to target. “Incentive programs are best for the people who are on the fence about getting the vaccine, and what is being given away is enough to encourage them to get it,” says Dr. Keisha Ray, assistant professor with the McGovern Center for Humanities & Ethics at UTHealth in Houston. “With incentive programs, the concern is always that they will only reach people who were already going to get the vaccine and now just have some motivation to get the vaccine sooner than later.”
But Dr. Howard P. Forman, professor of radiology and public health, as well as director of the health care management program at the Yale School of Public Health, says that these incentive programs are aimed at people who fall into that category. “I’m in the camp that believes that there’s still a large group of individuals that are motivated by inertia, so to speak; that they actually do want to get vaccinated, but they’re not rushing to get vaccinated,” he tells Rolling Stone. This includes younger, relatively healthy people who have every intention of getting the Covid vaccine, but haven’t made it a priority.
There is one group that’s unlikely to be swayed by a free park pass or transit pass. “Incentive programs rarely encourage people who are against vaccines to get vaccinated,” Ray tells Rolling Stone. “They are not going to push hardcore anti-vaxers to get vaccinated.” According to the most recent data from the Kaiser Family Foundation’s Vaccine Monitor, approximately 13 percent of Americans say they will “definitely not” get the vaccine — a figure that has remained the same since January. And the current state-sponsored vaccine incentive programs aren’t aimed at them.
Dr. Emily Largent, assistant professor of medical ethics and health policy at the University of Pennsylvania agrees that these incentives won’t sway those who never plan to get the vaccine, but says there are other situations where offering a relatively modest monetary incentive can make a difference to people. “West Virginia is a good example, where it’s $100 that’s aimed at younger adults,” she notes. “The incentive can take benefits that maybe feel remote and abstract, and actually make them immediate and concrete.”
At the same time, states have to make sure that any vaccine incentives they offer aren’t generous to the point of compelling people to make decisions they otherwise wouldn’t consider. “The problem with incentive programs is that they can target people who have low incomes or who are economically and socially vulnerable in other ways,” Ray explains. In those situations, people may not feel as though they are in a position to pass up perks like significant sums of money, or free healthcare — making what’s supposed to be a choice into something that limits their agency.
However, Ray doesn’t see that happening with Covid vaccine incentives. “In the case of Covid vaccines, I don’t worry about people being taken advantage of, or people being coerced into getting the vaccine because of the great benefits to the individual getting vaccinated,” she explains.
Forman agrees, noting that using “behavioral nudges” is not an unusual public health strategy. “We use them all the time, in terms of getting people to do things that are in their self-interest,” he says. “You don’t have to accept a lottery ticket that has an expected value of $10 or $100. No one’s forcing you to do that, nor is that a particularly coercive thing for people.”
Is this the best use of public funds?
In an article published in the Journal of the American Medical Association in January 2021, Largent and a colleague argue that Covid vaccine incentive programs should only be adopted “as a last resort,” noting that “public funds would be better spent advancing other evidence-based proposals to increase voluntary vaccine uptake.” Five months later, she says we’ve reached that point. “Sadly, we’re seeing lagging demands now, and definitely are far short of ideal levels of vaccination,” Largent says. “So it’s time to get creative.”
As far as where, exactly, the money is coming from, both Ohio and West Virginia are using federal funds distributed through the CARES Act, which is seemingly permitted under the open-ended federal spending guidelines. Last week Governor DeWine told reporters that he believes the Vax-a-Millions program falls under the category of vaccine promotion, the Columbus Dispatch reports. “We have spent a lot of money fighting this virus in a lot of different ways,” he said in a press conference. “We have always felt it was worth it because we know the huge human cost of this virus.”
Are there other potential downsides?
While the chance at a $1 million may not be coercive, Largent says that vaccine incentive programs can come with some other undesirable side effects — including giving the impression that the Covid-19 is risky enough to warrant compensating people to get it.
“There’s good evidence from behavioral economics that offering money can make something seem riskier or more burdensome, and I’m worried that we signal to people that the vaccines — contrary to evidence — are not safe or not effective,” Largent explains. One example is a frequently cited 2006 behavioral economics study entitled “Tom Sawyer and the Construction of Value,” which found that when people are on the fence about something, finding out that they’d be compensated for their participation can cause them to view it in a negative light.
So while the chance of winning $1 million might motivate some people, Largent says that it may reinforce the suspicions others already have about the vaccine, or even create new resistance in them “because they worry about the strings being attached.”
Additionally, Largent is concerned that offering incentives for getting the Covid vaccine could set an unsustainable precedent for future vaccine rollouts. “There’s always a risk that we’re going to habituate people to thinking that there should be an incentive attached to the vaccine,” she says. “We’re already talking about the need, potentially, for booster shots for the Covid vaccines, and we don’t want to get ourselves into a loop where we constantly have to lure people into clinics with offers of benefits.”
Ultimately, while Largent sees the necessity of finding innovative ways to increase Covid-19 vaccination rates at this stage of the rollout, she says that states shouldn’t prioritize incentive programs over public health education. “People have a lot of different reasons for not being vaccinated right now,” she explains. “Some of these have to do with misinformation, some of them have to do with personal preferences, or political beliefs and ideology. And when we offer incentive payments of any sort, we’re not really targeting their reasons, meeting people where they’re at.”
Instead, Largent says that listening to people’s concerns and coming up with tailored responses is going to be essential. “We have disparities right now in access to vaccines,” she notes. “We have people who would like to be vaccinated, who maybe don’t understand that the vaccines are free, or who worry about being able to take time off of work if they have any side effects. These are all things that really have to be addressed. They’re less fun and less flashy [than a $1 million lottery], but foundational to how we continue to address the sluggish uptake of vaccines.”