Problems With Paying People to Be Vaccinated Against COVID-19

The US Food and Drug Administration has issued Emergency Use Authorization for 2 vaccines for the prevention of coronavirus disease 2019 (COVID-19). This impressive scientific achievement paves the way to ending the pandemic, provided that vaccine uptake is sufficient. While the exact proportion is uncertain, it is likely that more than 75% of the US population will need to be vaccinated for the country to obtain herd immunity.¹ Yet surveys have repeatedly shown that many members of the US public are reluctant to be vaccinated, although this may change in the coming months.² As a result, vaccine uptake may fall short of necessary levels.

Numerous proposals to improve voluntary uptake of COVID-19 vaccines have been advanced. These proposals are often focused on fostering public trust in the vaccine approval process, removing practical barriers to vaccination, and promoting vaccine acceptance through community engagement, identification of trusted leaders, and public health messaging.³ Recently, however, several individuals from across the political spectrum have proposed paying cash incentives for COVID-19 vaccination.

In this Viewpoint, we describe features of 2 payment-for-vaccination proposals that have garnered attention from academics and politicians, outline several important objections, and maintain that payment for vaccination is morally suspect, likely unnecessary, and may be counterproductive.

Robert Litan, a nonresident senior fellow at the Brookings Institution who served in the Clinton administration, has advanced the most robust plan by suggesting paying people $1000 for vaccination, ideally not subject to taxes.⁴ Litan acknowledges that there is no evidence for his $1000 figure but argues anything less is unlikely to suffice. To avoid holdouts, he recommends the government commit up front to not increasing payment. To ensure that enough people are vaccinated, Litan suggests paying $200 initially when the individual accepts vaccination while conditioning payment of the remaining $800 on reaching a national vaccine uptake threshold.⁵ The intent of withholding the balance is to generate social pressure; those eager to be paid will encourage friends and family to be immunized. The estimated cost for this proposal would be approximately $275 billion, which Litan describes as a “bargain” compared with the economic effects of the pandemic lingering.⁴ Litan’s proposal has been endorsed by Greg Mankiw, former chairman of the Council of Economic Advisors under President George W. Bush, as well as Nobel Prize winner Paul Romer, economist Steven Levitt, and Wall Street Journal editorialist Jason Riley.^6-8

John Delaney, a former congressman from Maryland and 2020 Democratic presidential candidate, has suggested paying every individual in the US who provides proof of vaccination $1500 via check or direct deposit.⁹ If every adult took advantage of this program, the estimated cost would be approximately $383 billion. Delaney contends that his plan is “worth the cost” because it would save lives, provide “relief to struggling Americans [and]…accelerate the reopening of the economy.” Another 2020 presidential hopeful, Andrew Yang, tweeted his approval of Delaney’s plan.

Paying people to get vaccinated against COVID-19 might be a reasonable policy if it were necessary to achieve herd immunity. Yet payment-for-vaccination proposals are not only unnecessary, but problematic.

First, people have a moral duty to be vaccinated, including a duty to promote their own health, a duty to others to promote the community benefit of vaccination, and a duty to society for individuals to do their fair share in putting a stop to the pandemic. Being vaccinated in order to receive a $1000 or $1500 incentive robs the act of moral significance. However, it is morally appropriate to offer payment to people who are vaccinated to reimburse reasonable vaccine-related expenses or as a form of compensation for the time and effort expended to become vaccinated, analogous to the modest payment offered to citizens summoned for jury duty. Such payments may even be morally imperative if they are necessary to overcome barriers to vaccination.

Second, paying a substantial sum as an incentive to overcome vaccine hesitancy and to promote vaccine uptake is not a prudent investment. It is likely that a majority of the population will be eager to get vaccinated as soon as possible in view of the extremely high and increasing number of SARS-CoV-2 infections and COVID-19–related hospitalizations and deaths. Moreover, some of the documented reluctance may naturally dissipate as individuals observe others—trusted figures such as Anthony Fauci, MD, nationally prominent politicians, and even their own clinicians—being vaccinated without adverse health effects and as reports of vaccine-related adverse effects remain quite rare. Accordingly, it would be a substantial waste to pay $1000 or more to the millions of individuals in the US who are already highly motivated to receive the vaccine without expecting or seeking an incentive payment and also to those who require only reassurance. There are opportunity costs associated with using money for cash incentives. Some of the proposals for paying people to get vaccinated would come with high costs, possibly requiring many billions of dollars; the money would be more efficiently spent addressing the pandemic in other ways.

Third, some might feel that a substantial monetary incentive for vaccination is coercive. While this is a misconception that confuses an offer with a threat, there is a genuine ethical concern about the influence of such an incentive on decision-making.¹⁰ Offering payment as an incentive for COVID-19 vaccination may be seen as unfairly taking advantage of those US residents who have lost jobs, experienced food and housing insecurity, or slipped into poverty during the pandemic. COVID-19 has shone a spotlight on the substantial inadequacies of the social safety net in the US. As individuals and families struggle, some people might feel they must accept a vaccine in order to, for example, purchase food or pay rent. They might feel they have no choice but to be vaccinated for cash. It is deeply problematic that the government would offer cash incentives to promote vaccination when it has failed, in numerous instances throughout this pandemic, to offer money or other supports needed to ensure that the basic needs of many people are being met. This concern may be particularly pronounced in Black and Brown communities, which have been disproportionately affected by both the health and economic consequences of the pandemic. Although these communities would be expected to benefit from high levels of vaccination, other methods are more appropriate to promote this end than trading on financial insecurity.

Fourth, COVID-19 vaccine hesitancy is rooted in concerns such as the warp speed development and approval of vaccines, politicization of the broader pandemic response, and even denial that the pandemic is real. It is unclear that offering incentive payments can or will overcome apprehensions like these. Rather, cash incentives might reasonably be expected to heighten these apprehensions or raise new ones, as offers of payment are often understood to signal that a behavior is undesirable or risky.³ In a climate characterized by widespread distrust of government and propensity to endorse conspiracy theories, those who are already COVID-19 vaccine hesitant might perceive that the government would not be willing to pay people to get vaccinated if the available vaccines were truly safe and effective. Incentive payments might also stoke new fears and, perversely, increase resistance to vaccination.

A policy of paying people for COVID-19 vaccination should be adopted only as a last resort if voluntary vaccine uptake proves insufficient to promote herd immunity within a reasonable period of time. Public funds would be better spent advancing other evidence-based proposals to increase voluntary vaccine uptake.

Corresponding Author: Emily A. Largent, JD, PhD, RN, Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, 423 Guardian Dr, Blockley Hall, Room 1403, Philadelphia, PA 19104 (elargent@pennmedicine.upenn.edu).

Published Online: January 6, 2021. doi:10.1001/jama.2020.27121

Conflict of Interest Disclosures: None reported.