Carrots and sticks: How to compel Americans to get vaccinated

Our fastest ticket to “normal” in the United States depends on roughly 100 million Americans receiving a COVID-19 vaccine. Many of these Americans are under the age of 40, tend to be members of BIPOC communities, and some are anti-vaxxers, as well as white males who are political conservatives or supporters of former President Trump.  But all are essential to a world without masks, 6-feet markers, death and disease. Like many aspects of COVID-19, there is no easy answer but here are three approaches that build off of behavioral psychology and prior precedent — each with their own risks and benefits. And unlike the vaccines, the benefits simply do not always outweigh the risks. 

Vaccine mandate and requirements:

These are straightforward with very little uncertainty — as a condition of employment or enrollment in schools or other settings, individuals are required to show proof of vaccination. No intervention is more effective than a mandate or requirement.

Health care institutions such as the University of Pennsylvania Health System mandate all staff demonstrate immunization and many other employers are following suit. Some are extending existing mandates, including Delta Airlines, which already announced it will use vaccination as a mechanism to screen applicants. This approach will likely prompt other employers to do the same, particularly those trying to win consumer confidence — including retail, restaurants, fitness centers, etc.  The disadvantages can loom large including a sense of breaching individual autonomy, ethical dilemma of mandating a vaccine under emergency authorization, but it is likely that with time, mandates will become more commonplace.

Financial incentives:

Paying people to get vaccinated — currently, incentives range from $40 for Amazon employees, $100 savings bonds or gift cards in West Virginia, to free alcoholic beverages in New Jersey and Louisiana, to daily Krispy Kreme donuts nationwide. Lotteries with millions of dollars at stake are now offered by over a dozen states, with odds of winning 1 in millions. Incentives, especially lotteries seem to be working — Ohio reports a 47 percent increase in vaccination amongst adults.  

These incentives are effective because they provide a tangible immediate return, but these payments, could also generate a backlash and be seen as signaling that the vaccine is somehow undesirable or unsafe. In addition, once the financial incentives have been promoted, there might be an expectation that those incentives will continue for any potential boosters or regular COVID-19 vaccines — all valid points that could set an undesirable or unsustainable precedent. If an employer pays $50 for COVID Vaccine Series No. 1, how much should they pay for a booster? Or for the seasonal flu shot?

Social incentives: 

Limiting access to leisurely activities that people desperately want to return to — sports, concerts, travel, dining — provide another tangible incentive to increase vaccination.  Summer travel to the European Union will require proof of vaccination, as well as anyone who wants to attend the National Football League Draft. 

In essence, the desire to return back to “normal” might be the most powerful motivator. So, the broader the range of settings and organizations that use a social incentive, the bigger the response may be, in this case, more vaccinated individuals. So far, this approach seems to be limited to more elite settings and circumstances, where people have much more disposable income, illustrating a drawback — such limitations are more likely to widen racial, ethnic and gender disparities.  

The role of vaccinations in public health is to protect individuals as well as their communities. The concept of “herd immunity” where one vaccinated individual can protect strangers in their community is an old one, but is much more self-evident with COVID-19. Achieving such protection requires a level of social trust and a sense of individual responsibility. But our social trust and sense of responsibility has been eroded, threatened and challenged at multiple levels. Misinformation, politicization of science and even the emotions associated with masks have made each one of us skeptical in the honor system or our ability to trust our unmasked neighbors.  

In the absence of social trust, we must employ any and all techniques to vaccinate quickly, efficiently and with minimum friction to avoid unnecessary COVID-19 cases, hospitalizations and preventable deaths.

We’ve already lost nearly 600,000 Americans to COVID-19 — enough preventable deaths to last a lifetime, we can’t afford anymore. If that takes a combination of nudges, carrots or sticks, we should use any means necessary. 

Kavita K. Patel is a physician at Mary’s Center, a federally qualified health center in Washington D.C. and a nonresident fellow at the Brookings Institution. She was a director of policy in the Obama administration.