Financial Incentives Won’t Buy Herd Immunity
Exactly one year ago today, I walked six miles from my office in Manhattan across the Brooklyn Bridge to my apartment. I called my mom during the long walk and explained that the Mayor of New York City had strongly suggested that people not take the subway for their evening commute. I haven’t taken the subway or been back to my office in Manhattan since March 9, 2020 and I no longer live in Brooklyn. While I eagerly await my turn to get the COVID-19 vaccine, I am often asked why I want to get vaccinated. For me, it’s because of my perspective of the benefit-risk profile of the vaccine….not because my employer wants me to return to the office.
Over the past year, we have been literally and figuratively holding our breath waiting for a way out of this pandemic. Now that a path to normalcy is becoming clearer due to the availability of COVID-19 vaccines, not everyone is as eager to be vaccinated as public health officials had hoped. Vaccine hesitancy is complex and multifaceted. A majority of the hesitancy is attributed to concerns about the long term safety and efficacy of the available vaccines. There is also a minority that question the seriousness and validity of the virus. Regardless of the reason for vaccine hesitancy, the vaccine is seen as the only way to end the loss of life associated with COVID-19 and as essential for the general public to return to normalcy.
For many of us, normalcy includes meeting friends for a meal without a mask, being able to visit our grandparents without fear of infecting them, or traveling internationally. For business owners, normalcy includes providing safe environments for employees and customers while earning a profit. To resume business as usual, business owners have started to provide financial incentives for employees to get vaccinated. Amtrak is offering two hours of pay for employees who get the vaccine and 48 hours of paid time off in case employees experience side effects. Target and Marriott are offering four hours of extra pay while Kroger is paying employees an extra $100. Despite these well-intended attempts, it is unlikely to be enough.
Research suggests that financial incentives are effective at encouraging health-promoting behaviors including smoking cessation, vaccinations and screenings. However, there is a limit on the impact of financial incentives, with evidence indicating that effectiveness decreases as the value of the incentive increases. When people are offered a large amount of money to encourage healthy behavior, they become more skeptical of the motive. Research also indicates that financial incentives may be more enticing for individuals that are economically disadvantaged, potentially creating significant health inequity if the vaccine does have long-term safety concerns. Lastly, these incentives shift the conversation away from addressing the underlying reasons for vaccine hesitancy to a mere financial transaction. Providing financial incentives may be an effective strategy to increase uptake of COVID-19 vaccinations but behavioral economics suggests that “nudging” people to get the vaccine could be a more effective strategy.
Behavioral economists study how individuals make decisions, and have found that individuals are not always rational nor do they always act in their own best interests. Research suggests that our decision-making is influenced by impulsiveness, social norms and the overall context in which we are making decisions. Therefore, “nudging” people to do the right thing can be a very effective public health strategy. Examples of these “nudges” in public health include making an apple the default as a side instead of french fries for school lunches, making organ donation the default so people have to opt-out rather than opt-in and having higher taxes on cigarettes.
For seasonal flu vaccines, researchers concluded that people were 36% more likely to get the vaccine if they were sent the date, time and location of their vaccination appointment. The reason that this is effective is because people are less likely to opt-out. Therefore, making the desired decision the default is an effective public health strategy.
Israel has received considerable attention lately due to its impressively high rates of vaccination and the associated nudging tactics that have led people to conform to a social norm of being vaccinated. The government has rolled out a “green badge system” that limits access to entertainment venues to only those that have been vaccinated. This strategy is very similar to the strategy implemented in the US that requires children to get vaccinated before attending public schools.
Over the past year, wearing masks and social distancing have become second nature for us yet we still lost 525,000 lives in the US and 2.6 million lives globally due to COVID-19. While all of us are eager to return to life as normal, people are understandably hesitant to get the vaccine. Private companies are hopeful that paying their employees to get vaccinated will help us return to business as usual. However, financial incentives may not be the answer because there is a limit to how much money people will accept before becoming skeptical. Additional “nudges” are more likely to increase vaccination rates, including providing scheduled appointments that people will have to opt-out of and limiting access to entertainment venues to only those that are vaccinated. There are just some things money can’t buy and herd immunity against coronavirus might be one of them.
Disclaimer: The opinions expressed in this article are the author’s own.
