A Biden administration push for states to pay low-income residents to get the Covid-19 shot is clashing with research findings that certain financial incentives are largely ineffective—leaving government officials on the line for new ways to bolster vaccination numbers.
States across the nation have offered up gift cards, lottery tickets, and other perks to nudge the vaccine hesitant to get the jab. The Medicare agency is encouraging states to do more, greenlighting funds to create incentives for recipients of the Medicaid and Children’s Health Insurance Programs. But research from academics at the University of Pennsylvania and the University of Chicago shows that states with and without incentives have similar vaccination trends.
“Many people who had already intended to get vaccinated had done so already,” said Harsha Thirumurthy, associate director of University of Pennsylvania’s Center for Health Incentives and Behavioral Economics who led the research. Now, the government is using rewards to try to “change the behavior” of those who distrust vaccines because of misinformation or other reasons, he said.
Health policy experts say the recent guidance by the Centers for Medicare & Medicaid Services fits into a broader pattern of immunization efforts already proven to fall short, ignoring the convictions of those avoiding immunization. They say the administration should instead focus on fighting misinformation, an approach that may require a broad marketing strategy leaning on professionals from various backgrounds.
Misinformation is one of the “biggest deterrents from solving the pandemic in America,” said Julie Swann, a North Carolina State University professor who led a government-backed team for supporting public health decision-making in the pandemic.
“We need to first make sure we’ve done what we can to address the root cause of the problem, because the cause of that problem is not that someone needs money,” she said.
The ‘Extremely Resistant’
Vaccination rates have largely trended upward since July, according to the Centers for Disease Control and Prevention. CDC data shows that at least 75% of American adults have received a dose.
Over the past year the share of adults opting to “wait and see” how others react to jabs has dwindled, shrinking from 39% of the public in December 2020 down to 10% in July, according to the Kaiser Family Foundation data. The number of people who have gotten the shot has significantly gone up in that same time frame. But the number of adults refusing vaccination has largely stagnated, hovering around 14% during the same period.
More than half of U.S. states have made efforts to persuade holdouts to get the jab, according to the National Governors Association. States like California, Colorado, and Illinois are entering vaccinated residents into contests for $1 million or more. Maine, Washington, West Virginia, and others have offered their citizens gift cards in exchange for immunization.
But some health policy experts say these efforts are likely to miss the mark.
“Given the evidence is starting to come in, that the early signs aren’t good, I would be dubious about thinking that that it’s going to be the entering wedge that’s going to be effective at this point,” said Keith Holyoak, a UCLA psychology professor who studied public perceptions on Covid-19.
Thirumurthy’s research found that between April and July, daily vaccine rates declined 8.9 per 100,000 individuals in the two weeks following the incentives introduced by 24 states. States without incentive programs showed similar results. Eighteen of those states only offered lotteries, while three more also featured a gift card or certificate, the research said.
“The probability of winning those prizes may have been so low that at the end of the day, it may have failed to motivate some of the people on the fence,” Thirumurthy said. He added that “incentives along the lines of $100 or substantial amounts of cash” could increase vaccination rates.
For the “extremely resistant, it could be it takes a lot to get them to go for a shot,” Thirumurthy said.
National Governors Association spokesman James Nash said in an email that his organization is “not aware of any definitive research” on incentive effectiveness given they’re recent and the lack of precedent, but that it has “heard anecdotally some of the incentives have helped to drive uptake in communities, particularly rural ones.”
Tackling ‘Root’ Causes
Transportation, difficulty getting time off work, distrust of the government, and other barriers remain in place for many people lower on the socioeconomic scale, health experts say. Vaccine misinformation across social media and other information outlets has also been prevalent throughout the pandemic.
The administration has failed to push for “a systematic deep solution” for fighting misinformation on social media and other channels, Swann said. The government has leaned too heavily on traditional messaging from the CDC and state health departments while leaving “the way information spreads across a network” mostly in the hands of companies like Facebook and Google to address, she said.
Resolving the issue will require “computer scientists, engineers, and technologists coming together,” Swann said, noting that the government should be at the helm of such an effort.
It will also require a “comprehensive marketing strategy " to persuade more unvaccinated individuals to get jabbed, Stanford professor of medicine Kevin Schulman said.
“If whatever the incentive du jour is doesn’t work, what’s next? That’s the issue—these incentives aren’t strategies, they’re tactics that we’re testing. If they work that’s fabulous, but what’s missing is the strategy,” he said.
Convincing vaccine holdouts to think of immunization as critical to their core identity is key, he said. Broader vaccination calls for messaging tailored for specific communities and delivered by trusted members “in a language that they use.”
From a psychology perspective, Holyoak said research indicates that “for an issue people view as moral, incentives don’t work well and backfire,” and that negotiating with people to get vaccinated using another issue they view as moral, like community benefit or keeping their kids healthy, is more likely to have an impact.
“‘Now it’s not, ‘You’re selling out for a bit of money,’ but you’re preserving your way of life,” Holyoak said. “That’s probably better than raising the anti on the lottery.”