You may be familiar with the TV show “Who Wants To Be A Millionaire?” Colorado has launched its own version, and all residents who are vaccinated against COVID-19 are eligible to win. The state announced it will give away $1 million weekly between June 4 and July 7, using federal CARES Act money that would have gone to vaccine advertising. But how well vaccine incentives actually work remains a bit of an open question.
“Colorado, every vaccine works incredibly well,” Gov. Jared Polis said during the Tuesday press conference where he announced the sweepstakes. He pointed to the Pfizer/BioNTech vaccine’s 95% effectiveness in keeping people from getting the virus. “But it's really even more effective than that because the 5% that still get it get much more minor cases of COVID, much lower level of hospitalization.”
Polis said that was enough for him to get vaccinated. And more than 53% of the state has joined him in getting at least one dose. But uptake of the vaccines in the state has slowed recently, putting Colorado in 20th place nationally, according to the Centers for Disease Control.
The state is hoping big sweepstakes, where people who get at least one dose of a COVID vaccine are automatically enrolled for five chances to win $1 million, will move the needle (into the arms of people who have been hesitating to get their shots.) Anyone over the age of 18 who has received a dose by Friday will automatically be eligible for all five drawings.
“All of the information will remain confidential. The only information that will be provided to the lottery will be the winner, the one winner,” Polis said, ensuring security for the personal information of those who get the vaccine. “All of the others will be anonymized with a randomly assigned number.”
The first winner will be announced on June 4. More winners will be announced in the five weeks that follow.
That’s not the only way Coloradans can make money off of vaccination. Some employers are offering employee bonuses ranging from $25to $500if they get inoculated.
“There's really two reasons why people get vaccines, right?” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. “They're either getting the vaccine to protect themselves or they're getting the vaccine to protect others.”
Some are unconvinced by those personal or “external” benefits and may need money to feel their time, effort and whatever side effects they might experience are worth it, he said. Severe side effects from the vaccines are rare, according to the CDC — much less common than hospitalizations withCOVID-19 across age groups.
“That's what these incentives are intended to do, is to internalize an external benefit, to turn this external benefit into something that benefits you personally,” Dr. Wynia said. “We like to get people to think more about how their actions either harm or benefit other people. And (incentives are) a way to do that. It's a very direct way to do that.”
Dr. Wynia points out money alone doesn't solve the access problems many face, like living in a remote area or getting time off of work to get a shot.
“To the extent that a monetary incentive internalizes a positive externality, it is good public policy,” he said.
Do incentives work?
Other smaller, health incentive programs, such as offering cash to get people to quit smoking, have shown a degree of success. But using these kinds of cash incentives in a vaccination drive of this scale is unique.
“There's so much that we don't know in life, and especially in medical care delivery, that having just a little bit of a better sense of, ‘hey, this works, this doesn't work’ is really important,” Dr. Daniel Lee said.
Dr. Lee is an assistant professor of urologic oncology in the department of surgery at the University of Pennsylvania Perelman School of Medicine. He also studies health incentives in partnership with the university’s Center for Health Incentives and Behavioral Economics.
Several other states began offering multi-million-dollar vaccine sweepstakes before Colorado. Ohio was the first. They saw a 53% increase in vaccinations just in the first week after the “Vax-A-Million” sweepstakes were announced, according to the state’s health department.
“People buy into it because we're all a little bit irrational in that way, right? We're willing to chip in for that chance at a really large reward,” Dr. Lee said.
But with the new, massive scale of these sweepstakes and employer bonuses for vaccination, there is room for uncertainty and concern.
“How long they work tends to reach a kind of a plateau of some form,” he said, noting people might eventually stop being convinced by cash offerings.
“Can we do that again if we need a booster? I don't know,” Dr. Lee said. “Maybe, maybe not.”
This plays out in a 2006 study of multiple sweepstakes-style incentives to get people to quit smoking. As time goes on, the percent of people who still don’t smoke after the contest tends to drop (but it's still higher than the percent who quit without any money incentive.) This is one of several studies on this particular kind of health incentive.
Dr. Lee notes it might affect people in an opposite extreme, making them hold off on doing something unless they know they’re going to make money for it. And for some, the money offer might backfire, he said, increasing existing distrust of the vaccines.
He’s not the first to raise those concerns. Several publichealth,economic and legalexperts have pointed out similar potential issues as vaccination incentives began gaining traction earlier this year.
“It's not a one solution for everybody,” he said. “And there's so many different varieties for why people don't want vaccines.”
Experts say incentives can't replace efforts to increase access, social pressure or culturally and individually relevant education.
“I think about like even my African American patients versus like my Asian parents,” Dr. Lee said. “Of the fears that they have and the things that I have to try and talk them through, like they're they're quite distinct and different, but still very powerful. And I think that those are things that all of us are trying to work through.”
But overall, Dr. Lee sees these monetary incentives as a good step forward.
“We do know that when there are such big striking disparities in care that we need to advocate for health equity, we need to be able to bring everybody kind of up and provide that equal access and care and stuff like that,” he said. “I would say that this could be a way to help improve some of the rates among a group that's truly disadvantaged and at risk.”
“Incentives are thus particularly effective in changing one-time behaviors — such as obtaining cancer screening and vaccinations,” University of Pennsylvania Center for Health Incentives and Behavioral Economics Director Dr. Kevin Vlopp and social epidemiologist Carolyn Cannuscio wrote in the New England Journal of Medicine. “Even if incentives can produce a short-term bump in vaccination, however, multiple strategies will be necessary to increase population immunity.”
Who are these money incentives targeting?
“Typically, it's people who do not have strong objections to the vaccine,” Dr. Wynia said. “They just never got around to doing it.”
People who think vaccines do more harm than good probably won’t be convinced by money, he said. Polis recognized that on Tuesday.
“We think that most Coloradans want to do the right thing and get vaccinated,” he said. “Our research shows there's probably only 10 or 15% that don't want to get vaccinated.”
That percentage aligns with a May poll of Colorado voters about the vaccines, by Keating Research, OnSight Public Affairs and Mike Melanson, where 15% of respondents said they don’t plan to get vaccinated.
The hope is the roughly 35% of people between those who already have gotten a dose and those that definitely don’t want to will be convinced by extra cash to roll up their sleeves for a potentially life-saving poke.
