When you were a kid, did your pediatrician give you a lollipop when your parents dragged you in to get your shots? This common approach is based on the idea that we sometimes need to be incentivized to do the things that are good for us but may make us nervous.
The same idea is now driving some economists and political figures — including two former 2020 Democratic presidential candidates — to argue that the government should pay everyone $1,000 or more to take the Covid-19 vaccine. That’s much better than a lollipop!
Although the US is still a few months away from the widespread availability of vaccines like Pfizer’s and Moderna’s, experts are already thinking about the challenges the country will face as the doses come in.
The goal will be to reach herd immunity, where enough people are protected against infection that the virus can’t keep sparking new outbreaks. It’s unclear exactly what proportion of the population needs to be vaccinated to make that happen, but National Institutes of Health official Anthony Fauci said last week that social distancing should continue until 75-80 percent of Americans are immunized.
Yet around 40 percent of Americans still say they would not want to get the shot; a recent Gallup survey shows Republicans, non-white adults, and 45-to-64-year-olds are the least willing. (An ABC News poll this week showed a higher rate of acceptance.)
A wave of anti-science, anti-vaccine, and anti-expertise sentiment has fueled this reticence. And while President Trump’s politicization of Covid-19 has shaped views on the right, it’s also caused some on the left to worry about potential political interference in the race to develop a vaccine. Meanwhile, some non-white people are skittish because of how the medical system has long experimented on people of color.
The result of all this is a worryingly high level of vaccine hesitancy, which could delay herd immunity and consign us to a longer pandemic purgatory where we’re unable to fully return to normal.
Given the chance to get $1,000, though, some skeptics may change their minds. The pandemic ground the economy to a halt, and many Americans are desperate for cash. While a stimulus kept millions afloat for a time, that support has all but dried up — and congressional gridlock might prevent any more relief from passing. In other words, people could benefit from a “vaccine stimulus” that simultaneously boosts individuals’ financial security and improves society’s prospects of reaching herd immunity.
So say some economists from across the political spectrum, like Robert Litan, a non-resident senior fellow at the Brookings Institution who served in the Clinton administration, and N. Gregory Mankiw, who was a top economic advisor to George W. Bush. The Nobel Prize winner Paul Romer is also in favor, as is Freakonomics co-author Steven Levitt. And when John Delaney, whom you might remember from the Democratic primaries, recently proposed paying Americans $1,500 to get the jab, his fellow former candidate Andrew Yang said he’s on board, too.
But some ethicists and epidemiologists think paying people to get the Covid-19 vaccine is a bad idea. They worry that it could backfire. Even if it doesn’t, it could create coercive incentives for disadvantaged people to get vaccinated. So let’s break down some of the potential risks of this proposal, and see whether they can be mitigated.
The potential pitfalls of paying people to get the Covid-19 vaccine
The biggest risk with paying people to take the Covid-19 vaccine is that it could make some people even more hesitant to get the vaccine than they were before. As previous research indicates, they might think: If the government has to pay me to take this vaccine, there must be something wrong with it!
Seema Shah, a bioethicist at Lurie Children’s Hospital of Chicago and Northwestern University, was clear about this pitfall. “It might make people think vaccines are riskier than they are,” she said. “For example, when people are paid for research participation, money acts to signal that the activity is risky.”
There’s another concern about tying stimulus to a vaccine: The people who would be likeliest to sign up are the people who already have trust in the medical establishment. People who are more mistrustful of the health system would, in effect, be penalized. That would be pretty tragic because, statistically, they’re also the people who need the cash and the vaccine the most.
Non-white adults currently lag behind white adults in their willingness to be vaccinated. Their mistrust is well founded. The American medical system has a history of experimenting on Black people without their consent. The most famous example is the 1932-1972 Tuskegee experiment, in which Black men were left to suffer and die from syphilis even though a viable treatment — penicillin — was available.
A more recent example concerns researchers who were studying aggression in the 1990s. They subjected Black and Latino boys to a drug called fenfluramine, which later turned out to damage the heart, without properly informing their parents.
So it should come as no surprise that some people of color are hesitant to get the vaccine. And it seems particularly unjust if they miss out on a stimulus as a result, because the pandemic has disproportionately affected both their health and their finances. According to a September poll, 66 percent of Black households with kids and 86 percent of Latino households with kids reported major financial problems during the pandemic — like depleted savings and inability to afford medical care — compared to 51 percent of white households with kids.
Because of the desperation for financial relief, Shah said, “If stimulus payments were tied to vaccination rather than being freely given, that could be coercive.” But she added that if payments for getting vaccinated were to be given in addition to separate stimulus payments, that wouldn’t necessarily be coercive.
Many governments and charities use such payment schemes to good effect. Some 130 countries, like Mexico and Brazil, have instituted conditional cash transfers, which may require recipients to go for health checkups or get shots. Some charities do this, too; for example, New Incentives, a top-rated nonprofit aiming to increase uptake of routine immunizations, offers cash to families in Nigeria conditional on childhood vaccinations.
Kirsten Bibbins-Domingo, an epidemiology and biostatistics professor at the University of California San Francisco who specializes in health disparities, said the problem in this case is the context. “The context of a pandemic where arguably the lowest-income communities that are most likely to have mistrust, and for whom we have not invested in strategies that could allow them to protect themselves, like sufficient testing and sufficient sick leave — it generally makes this much more of a problematic and perverse incentive,” she told me.
Litan, an economist who in August proposed paying Americans to get vaccinated, acknowledged that “that’s a very good argument,” and it’s one reason why he’s only in favor of paying people as a Plan B. Although his initial proposal left this fuzzy, he’s clear now that the government should only pay people if other methods like public service announcements fail to motivate vaccine uptake.
“This plan is a ‘break the glass’ option that’s behind the cabinet in case we need it,” he told me. “It’s good to know it’s there.”
Another reason to keep payments in reserve as a Plan B: For the first few months, there won’t be enough vaccine doses for everyone who wants the shot anyway, so we might as well wait and see how many people are willing to get it while supply is limited.
Litan also suggests that the government shouldn’t give each person the whole $1,000 as soon as they get vaccinated. It should hold back a big chunk — say, $800 — until herd immunity has been reached (at the national, and possibly also state, level). People would then have a stronger incentive to convince their family members and friends to get the vaccine, so they can collect the rest of their money.
What are the alternatives to paying people?
Bibbins-Domingo and Shah both said that getting trusted leaders to engage their communities at the local level would likely be more effective than handing out cash.
From sports players to church ministers, individuals can do a lot to sway those in their orbit. Community organizations like YMCAs, schools, or neighborhood pharmacies can be influencers, too.
“Trust is everything,” Georges Benjamin, the executive director of the American Public Health Association, previously told me. “You have to have messengers that people trust. That might mean people who look like them, who have similar life experiences. Or it could be sports figures and music figures.”
If deploying trusted messengers doesn’t work well enough, another possibility would be to dish out negative incentives: not carrots (or lollipops), but sticks. States have the authority to mandate that people not be permitted to enter certain public places — movie theaters, say — unless they’ve got a certificate proving they’ve been vaccinated. This could conceivably increase people’s motivation to get the shot. That said, a state mandate would likely spark a backlash. And it likely wouldn’t be that effective, because people travel from state to state and can bring the virus with them.
“If PSAs don’t work, and a mandate is at best a checkerboard, then we’ve only got one other choice,” Litan said. “We’ve got to pay people!”
But Bibbins-Domingo says there’s another way: Rather than assume the US will need to pay hesitant communities to get vaccinated, she’d rather the government take that same amount of money (Litan puts the price tag on his plan at about $275 billion) and use it now to get those communities better access to the life-saving resources, like testing, that have been in short supply. Actually helping people through the next few months would be the best way to convince them that the vaccine, when it becomes widely available, is also an effort to help them.
In other words, if you want people to trust you, give them a reason to believe you actually care about their wellbeing.
“Saying we’re going to give people money to take the vaccination is sort of a cynical way to short-circuit the work that needs to be done,” she said.
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