The Case Against Monetary Behavioral Incentives in the Context of COVID-19 Vaccination

In addition to the current lack of empirical and theoretical support, establishing a monetary incentive for COVID-19 vaccination would likely be problematic on other fronts. Here we argue that paying individuals in exchange for vaccination in the context of the ongoing pandemic could both intensify vaccine-questioning discourses and potentially affect overall levels of trust in vaccines. Moreover, payment for vaccination – especially as envisaged in current proposals – accentuates socioeconomic and racial disparities by treating minority and economically vulnerable populations in paternalistic, non-data-driven ways. (Bhopal, 1998)

As correctly pointed out by Mankiw, the incentive mechanism as proposed by Litan would take the form of a federal subsidy. (Mankiw, 2020) A monetary award stemming from the federal government, however, may in practice foster hesitancy towards vaccination within certain segments of the population who experience profound distrust of the government, or the government’s response to the COVID-19 pandemic. (Devine, Gaskell, Jennings, & Stoker, 2020) Moreover, for individuals or communities already experiencing vaccine hesitancy or mistrust, the association between vaccination and the availability of a monetary payment may further intensify doubts about vaccines and vaccination. Some of the debate surrounding the federal program providing monetary compensation in the relatively rare cases in which administration of a covered vaccine results in serious injury – the National Vaccine Injury Compensation provides – is often misconstrued in vaccine-questioning discourses, particularly in connection with claims alleging vaccine-induced autism.(SafeMinds, 2011) Although originating from within relatively small activist communities, these misconstructions are amplified by media able to attract large followings, as well as through social media. (Hamblin, 2019) And while this federal program is different from a monetary incentive in scope and design, the potential for misconstruction of payment for COVID-19 vaccination because of its association with the actions of the federal government remains unstudied and a potential problem.

At yet another level, a monetary incentive may also feed into strategies to increase the circulation of vaccine-specific disinformation. Recent studies have documented the growth in circulation of vaccine disinformation in the online environment, including through the use of automated programs deployed by foreign entities seeking to increase overall divisiveness in American debates. (Broniatowski et al., 2018) A monetary incentive offered by the government may thus be easily instrumentalized by promoters of vaccine disinformation and invoked in online discourses linking heterogenous forms of government support for vaccination to conspiracy theories. (Bertin, Nera, & Delouvee, 2020) This, in turn, would magnify the noise surrounding vaccine information available to the public in an area that is already extremely polarized.

Finally, the problems posed by a monetary incentive for COVID-19 vaccination extend beyond their impact on vaccine sentiments and their potential manipulation in the informational arena. They embody and perpetuate approaches to public health policy that reinforce paternalism towards racial minorities and economically disadvantaged individuals. Existing proposals target individuals who are conceptualized as responsive to $1,000-1,500. (Delaney, 2o2o; Litan, 2020) Litan specifically contemplates the case of a family of four receiving $4,000, stating that the amount constitutes “a lot of money to a lot of families in these difficult times, and thus enough to assure that the country crosses the 80 percent vaccination threshold”. (Litan, 2020) The proposal therefore rests on the implicit assumption that this amount will lead to individual – and possibly familial – behavioral changes irrespective of initial vaccine- or government-related beliefs, ease of accessing vaccination services or other factors that may play a role in the response to a monetary incentive. (Vlaev et al., 2019) Moreover, it specifically targets individuals or families who would perceive the amount offered as sufficient to nudge them towards receiving the vaccine, either overcoming inertia, doubt or distrust about a COVID-19 vaccine or vaccines in general. At the same time, the incentive would benefit individuals who would otherwise elect to receive the vaccine but are now able to reap a financial reward. This would lead to significant waste of resources against the backdrop of a pandemic that triggered an economic recession in the United States and that is expected to leave a long-lasting imprint in the budgetary and financial health of the country.

The proposed incentive scheme is thus designed in a way that is hypothesized to be attractive to individuals or families who would switch behaviors for $1,000-1,500. Lower-income populations are hypothesized to adopt a particular health behavior in exchange for money, while wealthier individuals are less likely to face a moral or economic choice between a monetary reward and adherence to their beliefs. Given the fact that a substantial percentage of low-income Americans belong to a racial minority, monetary incentives to vaccination indirectly differentiate between individuals and communities based on their race, assuming that economically vulnerable minorities will behave in a certain way, whereas wealthier individuals are left free to ignore the incentive if they so desire. This logic compounds historical approaches to biomedical innovation – including the development of vaccines – that have long been discriminatory against racial minorities. (Washington, 2006) Offering monetary incentives under the model proposed by Litan and others risks accentuating sentiments of distrust towards emerging vaccines. Already during the COVID-19 pandemic, the National Medical Association announced the creation of a task force composed of Black doctors to review COVID-19 vaccines and drugs, citing mistrust of government-led processes of review and authorization of COVID-19 products. (National Medical Association, 2020)

Overall, the lack of data supporting a monetary incentive for COVID-19 vaccination, the potential for instrumentalization of the incentive in vaccine-questioning circles, and the dubious socioeconomic assumptions on which the proposed incentive scheme rests combine to suggest that legislators and policymakers should not yield current calls to make payment available as a quid pro quo for COVID-19 vaccination.