The once promising pace of Covid-19 vaccination in the United States has slowed from a peak of 3.38 million shots on April 13, 2021 to less than 2 million doses per day in May. Until recently, Americans competed for limited immunization windows – a situation that raised equity concerns – but now supply exceeds demand in much of the country, and mass immunization clinics are closing.

Yet the United States remains far from the herd immunity target of around 80%: around 47% of Americans have received at least one dose of the Covid-19 vaccine. What do we need to do to motivate millions more to participate?

Growing concerned that standard “information and education” approaches to encouraging vaccination are inadequate, some state governments and businesses are starting to pay people to get vaccinated. Incentives range from $ 100 savings vouchers or gift cards in West Virginia, to free beer and other beverages in New Jersey and Connecticut, to daily Krispy Kreme donuts nationwide. The biggest stakes are in New York City, which features a lottery with a $ 5 million grand prize, and Ohio, where five lotteries will each award $ 1 million to a vaccinated adult and a full scholarship. to a vaccinated child. Are these incentives a desirable way forward?

There is some logic in providing financial incentives, which can be used to offset the indirect costs of immunization – including time spent planning appointments, traveling or waiting; loss of income for hourly paid workers; or expenses such as child care. These costs disproportionately deter low-income people from getting vaccinated, and the payments could ensure that vaccination is effectively “free” for everyone.

In addition, economists generally recognize that government intervention has a role to play in addressing externalities – the effects of the actions of individuals on others. A classic negative externality is a factory polluting the air: in the absence of government sanctions, many factories would “overproduce” pollution because dirtier technology is cheaper. Vaccination confers a positive externality, protecting other people as well as the vaccinee. In a free market, people may underestimate the beneficial effect of their actions on others; goods with positive externalities may therefore end up being by-products. Subsidies and incentives are a logical policy approach in the presence of positive externalities.1

In addition, incentives are useful in situations where changes in behavior can reduce future health care costs.2 In the case of the Covid-19 vaccination, the positive return of incentives can be considerable: in the United States alone, the cumulative financial costs of the pandemic are estimated at more than $ 16 trillion.3

Finally, incentives can change even intractable health behaviors, such as smoking and physical inactivity, although people may revert to these behaviors when the incentives end. Incentives are therefore particularly effective in changing ad hoc behaviors – such as getting cancer screening and vaccination.4

Given declining vaccination rates and the societal imperative to end the pandemic, financial incentives are attractive, especially if an incentive-based program focused on groups with consistently low vaccination rates. Some people who are reluctant to be vaccinated may choose to be vaccinated “because of the push,” thereby overcoming inertia or resistance from their peer group.

Although the incentives may produce a short-term increase in immunization, several strategies will be needed to increase the immunity of the population. Campaigns should identify sources of resistance, including safety concerns (for example, for pregnant women), and communicate transparently to build public confidence. Immunization policies will also need to be coordinated with efforts to address the systemic racism that suppresses access and adoption in black and brown communities.

With more than 100 million Americans now fully vaccinated, rewarding “late adopters” with incentive payments may seem unfair – so an incentive program might have to compensate those already vaccinated. Suppose 60% of adults have been vaccinated and a program sets a goal of reaching 80% using a premium of $ 100 per person vaccinated. If incentives were offered to everyone, the program would cost $ 400 per additional person vaccinated. To manage costs, programs could be targeted at recalcitrant youth or people living in postal codes with low vaccination rates or high disease rates, but there are important trade-offs between the effectiveness of these offerings and the ‘equity.

Additionally, although many Americans clearly recognize the value of the Covid-19 vaccination and have freely practiced it, the vaccination inducements could be taken as signaling that the vaccine is somehow unwanted or dangerous, and could thus generate a backlash.5 And given the political divide in vaccine uptake, government-funded incentives could engender additional resistance.

It is important to consider that booster shots are likely to be needed down the line. Offering incentives now can set an expensive and unwanted precedent, causing people to wait – and wait – for an incentive next time.

Ultimately, although a well-designed incentive program can increase immunization rates in the short term, it is likely that the implementation will encounter a significant hiccup, and deliver flawlessly timely rewards. would be the key to the effectiveness and credibility of the program. We believe that three alternative strategies should be considered whenever possible, as they present more lasting solutions than incentives to boost immunization.

First, organizations that care for patients might require Covid vaccination for their employees, just as many of them have long demanded influenza vaccination. No intervention strategy is more effective than requiring vaccination,4 and our institution, Penn Medicine, recently announced that all employees in the health care system will need to be immunized. U.S. healthcare workers are refusing Covid-19 vaccination at alarming rates. In a nursing home, although 90% of residents were vaccinated, only half of the employees followed suit; one of the unvaccinated employees infected several residents, and one vaccinated and two unvaccinated residents died (https://nyti.ms/3w6bUvJ). These preventable breaches of safety should be unacceptable to anyone in the healthcare profession. Vaccination mandates in schools and workplaces – especially in high-contact settings such as meat packing plants and prisons – could dramatically reduce the future toll of Covid-19 in the United States.

Second, access to activities involving close person-to-person contact could only be granted to vaccinated persons. So far, among Americans, this approach has opened the doors to largely elitist activities, such as going live in the National Football League draft, summer trips to the European Union, or registering. at residential colleges and universities this fall. Some educational institutions have pointed out that by making full in-person participation in higher education conditional on vaccination, they will also reduce risks in the surrounding community. Recently, some restaurants, gymnasiums and sports stadiums have started either to restrict access to those who have been vaccinated or to create special seating sections.

Such contingent access is a social rather than a financial incentive, and the desire to “get back to normal” is likely to be a strong motivator. The wider the range of organizations that adopt such policies, the greater the proportion of the population that will opt for vaccination.

A third option is to increase health and life insurance premiums for people who forgo vaccination. This approach could redistribute the expected higher health care costs in a way that is equitable to people who have already been vaccinated.

Incentives alone are unlikely to give people the immunity that will end the pandemic. The million dollar jackpot series being rolled out in Ohio is an interesting alternative to test out, but it’s unclear if this will be a widely adopted approach. We need to go further by adopting a combination of behavioral policies that will protect our health and that of the economy for years to come.



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John R.

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