Incentives vs Mandates: Encouraging People to Get the Covid-19 Vaccine

A year after the first vaccines for COVID-19 were administered, the United States is still struggling to reach herd immunity, which scientists estimate to occur when 70% of the population is vaccinated (Robertson et al, 2021). The main challenge in reaching herd immunity has been vaccine hesitancy. People have refused to get the vaccine because they are concerned about its safety, they don’t think the vaccines do enough to protect them from COVID-19 and are therefore not worth the risk, or they simply don’t trust the people who make the vaccines.

However, the United States needs to increase vaccination rates. It is in everyone’s best interest to limit the number of people who get COVID-19. Not only do those infected pose a risk to those around them, but if large numbers of people contract the disease simultaneously, they could overburden health systems and prevent others from accessing healthcare. This has already happened—hospitals have run out of ICU beds throughout the pandemic, preventing people with other medical emergencies from getting immediate treatment.

Across the United States, governments, schools, and employers have tried different methods to increase vaccination rates. These methods fall into two categories: incentives, such as Ohio’s vaccine lottery, and mandates, which lead to penalties for those who don’t get the vaccine, such as loss of employment. With the surge of the Omicron variant, it is important to evaluate which vaccine policies are most effective for increasing vaccination rates.

Incentives respect individual choice; Savulescu and Wilkinson argue the least-restrictive alternative (the option with the fewest constraints on liberty) should be employed (2021). On a feasibility level, if the United States implemented incentives as part of a broader stimulus plan (such as by making tax relief conditional on getting the vaccine), then the budgetary impact of the policy could be zero (Robertson et al. 2021). However, Savulescu and Wilkinson (2021) also argue incentives are an undue inducement, as people’s judgment may be compromised depending on the size of the incentive. Paying people to get the vaccine could signal the vaccine is particularly risky based on past occurrences of human subjects being paid to participate in research studies (Robertson et al, 2021).

Robertson et.al. (2021) analyzed the efficacy of financial incentives with a randomized survey of 1,000 individuals. Participants were asked if they would get vaccinated for $2,000, $1,500, $1,000, or $0. Overall, the survey found that 59% of participants would elect to be vaccinated. Financial incentives only increase that number by 8%, though the size of those incentives did not considerably affect vaccine uptake rates. Results also varied dramatically by demographic group. Republicans were less responsive to the incentives than the general population, and large financial incentives proved counterproductive when presented to Black and Latino Americans. Notably, lower-income participants did not respond more acutely to the financial incentives than those of a higher income, implying people were largely unmoved by financial incentives.

These results are consistent with another study which found there was no evidence Ohio’s vaccine-incentivizing lottery, which enrolled newly vaccinated participants in a lottery where they could win up to $1 million, increased rates of adult vaccination against COVID-19 (Savulescu and Wilkinson 2021).

Mandates are more widely implemented policies. There are many forms a mandate could take, such as the withholding of benefits, imposition of fines, or loss of employment or privileges if a person chooses not to be vaccinated. Another major form that mandates have taken in the age of the coronavirus has been the ‘vaccine passport’—needing the vaccine in order to enter restaurants, travel, or participate in other aspects of society.

There is precedent for vaccine mandates: in the United States, children have long been required to get certain vaccines before starting school, and there are Supreme Court decisions upholding that precedent. A recent study by Kuznetsova et al. analyzed the effect of mandatory childhood vaccines on morbidity for vaccine-preventable diseases in Italy, Germany, France, Latvia, Serbia, Moldova, and Ukraine. They found the introduction of vaccine mandates did not have negative effects on vaccine coverage and incidence (except in Serbia, briefly). In fact, after the introduction of the mandates, vaccine coverage improved and morbidity was reduced. Another study, which focused on the effects of school vaccination mandates in California found that a vaccine requirement had a substantial effect on vaccination rates (Averhoff et al. 2004).

Despite legal precedence and evidence of efficacy, mandates remain ethically complicated. The Supreme Court case, Jacobson v. Massachusetts (1905), challenged a Massachusetts law which gave cities the authority to implement smallpox vaccine mandates. The Court ruled such a law was a legitimate use of the state’s authority to protect the public health of its citizens. Based on their theory of the least-restrictive alternative, Savulescu and Wilkinson (2021) argue that in most cases, mandatory vaccination is not appropriate. Furthermore, Robertson et al. (2021) argue mandates would be disproportionately coercive to lower-income people who have stronger preferences against vaccination.

Vaccine policy is a complicated business. Mandates have been shown to be effective—unlike incentives. However, the ethics behind both policies are shaky, specifically in terms of costs versus benefits, and the balance between protecting public health versus promoting personal liberties. Despite the discomfort discussions of a mandate have proved to be for both vaccine supporters and non-supporters, it must be delved into. We, as a society, must raise our vaccination rate. If we don’t reach herd immunity, we will have to deal with even more variants. As we start into our third year with COVID-19, it is important to make informed decisions on how to effectively achieve herd immunity through policy.

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Averhoff, Francisco, Leslie Linton, K. Michael Peddecord, Christine Edwards, Wendy Wang, and Daniel Fishbein. “A middle school immunization law rapidly and substantially increases immunization coverage among adolescents.” American journal of public health 94, no. 6 (2004): 978-984.

Kuznetsova, Lidia, Giorgio Cortassa, and Antoni Trilla. 2021. “Effectiveness of Mandatory and Incentive-Based Routine Childhood Immunization Programs in Europe: A Systematic Review of the Literature” Vaccines 9, no. 10: 1173. https://doi.org/10.3390/vaccines9101173

Robertson, Christopher, Daniel Scheitrum, Aleks Schaefer, Trey Malone, Brandon R McFadden, Kent D Messer, Paul J Ferraro, Paying Americans to take the vaccine—would it help or backfire?, Journal of Law and the Biosciences, Volume 8, Issue 2, July-December 2021, lsab027, https://doi.org/10.1093/jlb/lsab027

Savulescu, J., Pugh, J. & Wilkinson, D. Balancing incentives and disincentives for vaccination in a pandemic. Nat Med 27, 1500–1503 (2021). https://doi.org/10.1038/s41591-021-01466-8