Problems With Paying People to Be Vaccinated Against COVID-19 | Law and Medicine | JAMA | JAMA Network
[Skip to Navigation]
Sign In
Viewpoint
January 6, 2021

Problems With Paying People to Be Vaccinated Against COVID-19

Author Affiliations
  • 1Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Weill Cornell Medical College, New York, New York
JAMA. 2021;325(6):534-535. doi:10.1001/jama.2020.27121

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.

Back to top
Article Information

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.

References
1.
Omer  SB, Yildirim  I, Forman  HP.  Herd immunity and implications for SARS-CoV-2 control.   JAMA. 2020;324(20):2095-2096. doi:10.1001/jama.2020.20892 PubMedGoogle ScholarCrossref
2.
Szilagyi  PG, Thomas  K, Shah  MD,  et al.  National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020.   JAMA. Published online December 29, 2020. doi:10.1001/jama.2020.26419 PubMedGoogle Scholar
3.
Volpp  KG, Loewenstein  G, Buttenheim  AM.  Behaviorally informed strategies for a national COVID-19 vaccine promotion program.   JAMA. Published online December 14, 2020. doi:10.1001/jama.2020.24036 PubMedGoogle Scholar
4.
Litan  RE. Want herd immunity? Pay people to take the vaccine. Brookings. Published August 18, 2020. Accessed December 2, 2020. https://www.brookings.edu/opinions/want-herd-immunity-pay-people-to-take-the-vaccine/
5.
Litan  RE. If necessary, the U.S. should pay people to get a COVID-19 vaccine. Brookings. Published December 17, 2020. Accessed December 22, 2020. https://www.brookings.edu/blog/fixgov/2020/12/17/if-necessary-the-u-s-should-pay-people-to-get-a-covid-19-vaccine/
6.
Riley  JL. The best herd immunity money can buy. Wall Street Journal. Published December 8, 2020. Accessed December 29, 2020. https://www.wsj.com/articles/the-best-herd-immunity-money-can-buy-11607469746
7.
Mankiw  NG. Pay people to get vaccinated. New York Times. Published September 9, 2020. Accessed December 29, 2020. https://www.nytimes.com/2020/09/09/business/pay-people-vaccine-coronavirus.html
8.
Samuel  S. What if the US just pays everyone $1,000 to take the Covid-19 vaccine? Vox. Published December 14, 2020. Accessed December 29, 2020. https://www.vox.com/future-perfect/22160174/pay-people-covid-19-vaccine-stimulus
9.
Delaney  JK. Pay Americans to take a coronavirus vaccine. The Washington Post. Published November 23, 2020. Accessed December 2, 2020. https://www.washingtonpost.com/opinions/2020/11/23/pay-americans-coronavirus-vaccine-john-delaney/
10.
Wertheimer  A, Miller  FG.  Payment for research participation: a coercive offer?   J Med Ethics. 2008;34(5):389-392. doi:10.1136/jme.2007.021857 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    4 Comments for this article
    EXPAND ALL
    Payment for Vaccine Uptake
    Ron Knight, MA MB BChir FRCP | Swansea University
    Would it focus the minds of anti-vax believers if a passport was given to those vaccinated preventing those unprotected from going on public transport, visiting cinemas and shopping malls, and so on?
    CONFLICT OF INTEREST: None Reported
    Would You Pay Someone to Take Them to Dinner?
    Donald Champagne, PhD, Econ. and Statistics | Independent genomics researcher; formerly part-time research faculty at the Johns Hopkins School of Medicine for ten years
    Paying someone to accept a benefit is fundamentally wrongheaded. Actions do and must have consequences in a free society. The immunization itself is ample compensation. To pay what is essentially a bribe has no social benefit. 
    CONFLICT OF INTEREST: None Reported
    Public Funds Can be Saved by Making Payments Contingent on Vaccination
    Christopher Robertson, JD, PhD | BU
    The closing sentence that "public funds would be better spent advancing other evidence-based proposals to increase voluntary vaccine uptake" seems to presume a baseline of no expenditure of public funds. But if the government is considering a stimulus or other payment as the baseline, making it contingent on vaccination would actually save public funds (by those who decline the payment + vaccination package).

    Second, in a world where we already mandate other vaccinations, it also seems odd to suggest that payments are wrong for undermining choice.
    CONFLICT OF INTEREST: None Reported
    Cash Payments Can Work
    Jeremy Penn, Ph.D., M.P.H. | University of Iowa
    I appreciate the concerns identified in this article. Yet unfortunately it is now April and it appears, unless drastic steps are taken, that the U.S. will fall far short of the goal of vaccinating 75% of adults (right now we are at 40% of adults with at least one dose, but the number of people actively pursuing vaccine appointments is quickly slowing, particularly in some communities).

    There is some evidence that paying cash for vaccination does work, and increases the likelihood of completing a vaccine series (1). Therefore, cash payments should at least be considered as an important tool
    in the toolbox of responding to vaccine hesitancy.

    I would also point out there is a simple strategy to use to avoid cash payments being coercive. The strategy is to offer payment for either: 1) documented completion of a vaccine series for COVID, or 2) documentation of a vaccine waiver that is signed by a physician that states that the patient is either medically unable to receive a vaccine (such as the immunocompromised) or has discussed the benefits and risks of the vaccine with the physician and decided to decline the vaccine after the conversation. Trust is a critical factor in vaccine completion and by encouraging those who are vaccine-hesitant to discuss it with their physician, presumably a very trustworthy person, and incentivizing this action, could go a long way toward achieving herd immunity in the U.S.

    Reference

    1. Caskey R, Sherman EG, Beskin K, Rapport R, Xia Y, Schwartz A. A Behavioral Economic Approach to Improving Human Papillomavirus Vaccination. J Adolesc Health. 2017 Dec;61(6):755-760
    CONFLICT OF INTEREST: None Reported
    READ MORE
    ×