How to Boost Vaccine Uptake
Cash payments—including to those already vaccinated—should be on the table.
My attitude toward vaccine reluctance has gone through something like Elisabeth Kübler-Ross’s five stages of grief: denial (“They’ll come around”), bewilderment (“How could people believe so much nonsense?”), frustration (“Seriously, what are these people thinking?”), anger (“It’s an epidemic of idiocy!”), and finally, acceptance (“Calm down, take a breath, this is complicated”).
Acceptance does not mean moral acceptance. Nothing in this column suggests that people who choose to endanger themselves, their families, and their communities are doing something admirable. In a sober, sane, science-minded, non-polarized, high-trust, data-driven country, everyone without a compelling medical or religious reason would be rushing to take the jab. In that country, herd immunity—when resistance is so prevalent that the virus can’t spread—would now be in view, or even reached already.
But that is not the country we inhabit. The percentage of eligible Americans who are vaccinated, after the initial surge in the spring, is creeping upward painfully slowly, with only a bare majority of the total population fully protected. That puts the U.S. in the lower half of countries in the Organization for Economic Cooperation and Development and well short of ending the pandemic.
Instead, the country we inhabit is a complicated place, where all kinds of people have all kinds of reasons to duck the jab. Yes, some are anti-vaxxers and MAGA ideologues, people who see vaccines as poisonous injections of political correctness. That group would include the man who, from his hospital bed in a COVID-19 ward, told a reporter that if he could do it over again and avoid severe pneumonia, he would still reject the vaccine to defend his freedom.
Many others, though, are members of hard-to-reach communities. Or have trouble arranging time off work. Or have families or bosses who disapprove. Or remember how marginalized communities have been abused in the name of public health. Or believe they are too young to get seriously ill. Or still aren’t convinced of the vaccine’s safety. Or just haven’t gotten around to it. “Acceptance” means meeting these people where they are and figuring out what works.
The FDA’s full approval of the Pfizer vaccine seems likely to help. A growing number of mandates by employers, universities, and government agencies will also help. Yet, unaccountably, one potent arrow remains in the quiver.
Time to use it. Pay people to get vaccinated.
Not half-heartedly, whimsically, or inanely, with a lottery ticket (in various places), or a $50 prepaid shopping card “while supplies last” (North Carolina), or $20 credit toward a hunting license (Arkansas), or—with no disrespect to Thin Mints—a box of Girl Scout cookies (Indiana). Do it generously, in a way that shows serious social appreciation and respect. Do it universally, including people who already got themselves vaccinated because it was the right thing to do. And do it smartly, incentivizing people to recruit friends and family to the cause.
Last year, in August, my Brookings colleague Robert Litan, a distinguished economist and lawyer who served in the Clinton administration, proposed just such a plan. It was generous. It was universal. It was smart. It was unheeded.
Litan proposed a plan with three interlocking elements. First, he suggested an attention-getting, head-turning amount: $1,000—an order of magnitude larger than the $100 that President Joe Biden suggested in July. That kind of money would break through any number of excuses and doubts. (But more about that in a moment.)
Second, pay not just latecomers but everyone who has been vaccinated, regardless of when. That is self-evidently fairer than stiffing people who got the shot early for all the right reasons. It also avoids perverse incentives to delay getting vaccinated in future pandemics. Biden didn’t endorse universal payments. But creating resentment and perverse incentives is a false economy.
Third, cleverly, Litan proposed withholding part of the payment until a certain percentage of other people have also been vaccinated. You might get half your payment up front and the rest when your state or community reaches, say, an eligible vaccination rate of 80 percent. That gives individuals a personal stake in recruiting others and reaching herd immunity. In economists’ jargon, it incentivizes the production of a social good.
Litan guesstimated his plan’s cost at about $275 billion. A large amount, surely, but small compared to the cost of the continued pandemic, and well in line with other pandemic relief measures.
So why not? Two kinds of objections come up.
One is practical. In the public-health world, a worry is that an offer of compensation might backfire by implying that the vaccine might be dangerous, or by putting vaccination on the footing of a financial transaction rather than a civic duty. According to Jessica Fishman of the University of Pennsylvania’s Message Effects Lab, there have been no controlled trials using actual dollars. Recent research, however, suggests that paying people to get jabbed does have a meaningful effect on their intentions. In March, a study found that compensation increased self-reported vaccination intentions by about 8 percentage points, with the highest gains—16 percentage points—among blacks.
New research by Fishman, Litan, and three other colleagues is even more impressive: When offered compensation, unvaccinated people’s self-reported intention to take the jab rose by 20 to 25 percentage points. Moreover, $200 was enough to produce that effect. “It looks like a lot of people who haven’t been vaccinated aren’t diehards; they’re just apathetic and aren’t strongly opposed and just haven’t gotten around to it,” Fishman said. “For them, the financial reward is appealing and can increase their motivation.” In fact, the positive effect was even more pronounced among younger people and people with less education and lower incomes: exactly the populations policymakers have had trouble reaching with civic appeals.
Still, resistance persists, partly because of moral qualms. Isn’t getting vaccinated a civic duty, something people should do voluntarily for the community? Do we really want to transactionalize the obligations of citizenship? And isn’t it sad that, in America in 2021, we might even need to?
I see the objection, but America is what it is, and what it is includes its prickly and sometimes irrational Jacksonian streak. Americans’ cultural libertarianism and suspicion of authority are deep in our national DNA. Although they are unhelpful in a pandemic, they can be advantages in other contexts, and in any case we cannot wish them away.
Nor should we brush aside the concerns of those who believe that, as Sen. Ron Johnson, Republican of Wisconsin, put it, refusing medical treatment is a fundamental right. However misguidedly in current circumstances, many people experience being injected with a drug as a profound intrusion, something no one should be coerced to do. The harder they are pushed, the more indignant they will feel. The offer of a substantial payment alters that calculus. It is not merely a cash transaction but also a gesture of respect: a public acknowledgment of the social benefit individuals provide by receiving the vaccine.
Payment will help vaccination mandates go down easier—and it has become clear that mandates are necessary to break the epidemic. It is true that mandates are nothing new. But it’s also true that using sticks without carrots—as President Biden did in yesterday’s exasperated announcement of new mandates (“Our patience is wearing thin”)—is bound to stimulate resentment and resistance. Incentivizing compliance can increase uptake and reduce friction as mandates come into force.
Congress is about to move a giant reconciliation bill with perhaps $3.5 trillion in new spending. It ought to include federal money and incentives to pilot serious compensation programs—preferably starting with Litan’s version—and then rapidly expand the ones that work. The country should have done this over a year ago. But it’s not too late.
Jonathan Rauch is a columnist at Persuasion and the author of The Constitution of Knowledge: A Defense of Truth.