The United States has missed President Biden’s July 4 goal of vaccinating 70 percent of eligible Americans against COVID-19. This is no surprise. Vaccination rates have been declining for months. With the spread of the highly transmissible and deadly Delta variant, the situation is worrisome.
To counter this decline in vaccinations, Governor Mike DeWine of Ohio announced, on May 12, a weekly $1 million lottery for people who got the vaccine. That day Ohio was administering about 15,000 COVID-19 vaccines daily. Two days later, the rate was nearly double, at 33,000 per day. This lottery-style incentive was celebrated as a huge success. NPR ran a podcast titled “Ohio’s Vaccine Lottery Proves an Effective Incentive.” Even President Biden described it as “creative” and highlighted other state lottery programs.
More than half of all states, including Massachusetts, are currently offering lottery programs to incentivize COVID-19 vaccinations. Prizes range from $1 million cash to college tuition to vacations and even firearms.
Despite the hoopla, this copycat behavior is misguided. If the United States is going to vaccinate 70 percent of the population, lottery-style financial incentives will not work. Instead, states need to introduce more salient incentives, deploy mandates, improve access, and alter social norms.
After the increase in vaccinations in the two days following DeWine’s announcement, the vaccination rate steadily declined. Just a week after the announcement, Ohio vaccinations were back to May 12 levels. Today, Ohio is administering just 5,000 vaccines per day — about one-third the rate the day of DeWine’s initial announcement. A similar pattern has occurred in almost every state that has mimicked Ohio, including North Carolina, which experienced a downward trend the week following its lottery announcement. States with lottery programs are not doing any better compared to states without such initiatives. For instance, New Jersey and Washington, D.C., lack lotteries and have also seen 50 percent declines since early May — except that they have fully vaccinated nearly 67 percent and 61 percent of residents, respectively, compared to Ohio’s 54 percent and North Carolina’s 48 percent.
So how can states get vaccination rates up?
States could mail every adult a $25 gift card with the catch that it can be activated only after receiving a vaccine. Behavioral economics teaches us that motivation can be more effectively generated through a guaranteed reward rather than by an uncertain gain by lottery. In a study incentivizing screening for sexually transmitted infections, only 1.5 percent of the control group was screened. With a lottery, 2.8 percent were screened, but with a gift card-like voucher, 22.8 percent underwent screening. Gift cards may also be more effective at sustaining motivation over time. Over a two-year period, they were shown to improve regular clinic attendance, adherence to drug treatment, and viral suppression among HIV-positive patients.
Voluntary incentives are appealing, yet sometimes mandates are necessary — and vaccine mandates are legal, ethical, and effective. Houston Methodist Hospital required all workers to be vaccinated against COVID-19. Over 99 percent of its 26,000 employees complied. Several large long-term care companies are also requiring COVID-19 vaccinations for staff. These companies have over 95 percent compliance, compared to an industry norm of about 40 to 50 percent. Many other employers have instituted similar mandates. Court rulings have confirmed COVID-19 vaccine mandates are legal.
Everyone deserves easy access to vaccines without financial worry. Employers need to do their part so their workers can schedule appointments during work hours and take time off if they experience side effects. The federal government allows tax credits to small and medium-sized employers to cover their workers’ paid time off around vaccine appointments. State governments, employers, and community leaders can also invest in low-cost solutions, such as mobile vaccine vans or pop-up clinics at grocery stores, to ensure that nobody is unable to get a vaccine due to lack of transportation or childcare.
The real long-term solution to addressing COVID-19 vaccination rates — and future pandemics — is to cultivate a sense of duty, so that individuals get vaccinated because it’s the right thing to do to protect themselves and their communities. We all look to what others are doing to shape our own behavior. Research shows that social norming is a highly effective tool for changing behaviors, including when it comes to health.
Recently, a study of college students found that if students perceived getting vaccinated was of high importance to their peers, their own intentions to get vaccinated increased. With young adults reportedly less eager to get vaccinated than older adults, leveraging social norms in public health messaging may be especially important for reaching this population and achieving vaccination goals.
Clearly, Ohio’s COVID-19 vaccine lottery has failed, and COVID-19 will be a long-term public health challenge. Leaders must focus on long-term solutions and messages to address COVID-19 vaccine hesitancy rather than put more time and capital into incentive programs that make fleeting gains. Making vaccination the social norm requires greater effort than lottery incentives, but would be more durable and effective — and save lives.
Dr. Ezekiel J. Emanuel is vice provost for Global Initiatives and codirector of the Healthcare Transformation Institute Perelman School of Medicine and the Wharton School at the University of Pennsylvania. Patricia Hong and Matthew Guido are researchers in the Department of Medical Ethics and Health Policy at the Perelman School of Medicine.