The Volokh Conspiracy
Mostly law professors | Sometimes contrarian | Often libertarian | Always independent
Brookings Institution economist Robert Litan has an insightful new article making the case for paying people to take a coronavirus vaccine, once one is approved and ready for distribution (as may well happen by sometime next year). I had been planning to write a piece making a similar argument. But Litan beat me to it, and he therefore deserves the credit for the idea. As he explains, this could save both lives and money, and is likely to be better than simply mandating vaccination:
When I was a child, doctors giving vaccine shots used to hand out candy or a little toy to take the sting and fear out of the shot. A similar idea could rescue the U.S. economy when one or more COVID vaccines are approved by the FDA and widely available for mass uptake.
Infectious disease experts, such as Minnesota's Michael Osterholm, tell us that "herd immunity" – or the point at which the virus will quit spreading like wildfire – will be reached when at least 60 percent of the population is immune. A truly effective vaccine… will avoid the tragedy of the million-plus deaths it otherwise could take for the country to reach herd immunity.
Provided enough people take the vaccine when they can. Since no vaccine will be perfectly effective – Dr. Fauci has said he could live with a vaccine that was 75 percent effective, which could be optimistic – that means that at least 80 percent of the U.S. population (60 percent divided by 75 percent) must be vaccinated if the virus is to be tamped down to the point where enough people will feel safe to patronize service establishments and travel so the country and the economy can return to some semblance of normal.
But now that seemingly everything about the virus – its severity and whether to wear masks in public, to take two examples – has become deeply politicized, is there any hope of reaching that 80 percent threshold?
Not according to a poll by NPR/PBS/Marist released on August 14, which reported that more than one third – 35 percent to be precise – of Americans won't take the vaccine when it is available, which means that the population take-up percentage would only be 65 percent, or well short of the 80 percent target. The take-up rates predictably differ by party, with 71 percent of Democrats saying they'll take the shot versus 48 percent for Republicans…
In principle, a President Biden could take executive actions or seek legislation – assuming Democrats control both the House and Senate and the filibuster rule is abandoned – penalizing those who don't take the shots (for example, by requiring vaccination certificates before entering most public spaces). But imposing any penalties on people who don't take the vaccine at the outset of his presidency – even if the penalties were both effective and constitutional, which is not at all clear it would be – would aggravate polarization, conceivably cause violence, and prevent any healing of the country that Biden has promised to usher in….
The "adult" version of the doctor handing out candy to children, fortunately, points toward a solution: pay people who get the shot (or shots, since more than one may be required).
How much? I know of no hard science that can answer that question, but my strong hunch is that anything less than $1,000 per person won't do the trick. At that level, a family of four would get $4,000 (ideally not subject to income tax) – 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.
As Litan explains, even if we end up "overpaying" to get people to take the vaccine, it would still be a massive savings of money on net. Every day without herd immunity is a day when many lives are lost, and the economy continues to stagnate - costing us far more than vaccine payments would.
I agree with most of Litan's analysis, and have a few points to add.
First, the poll he cites is far from the only one indicating many Americans will refuse to take a Covid vaccine. Other surveys paint a similar picture (see, e.g., here and here). It is possible that such attitudes will decline once a vaccine is actually available, and taking it holds out the promise of returning to normal life. Vaccination might also be incentivized by businesses requiring employers and/or customers to have vaccination certificates. But it's hard to say whether either of these will happen quickly enough or on a large enough scale. Even a few weeks or months delay in getting to vaccine-driven herd immunity is likely to be extremely costly.
Second, many will be tempted to reject the idea of paying people to get vaccinated because vaccination is a moral duty we must fulfill in order to protect others against the disease. We have mandatory vaccination against other contagious diseases. Why not this one?
In principle, I agree. Mandatory vaccination against deadly contagious diseases can even be justified on libertarian grounds, overcoming the strong presumption against coercion. Libertarian political philosopher Jason Brennan has a good explanation of the reasons why.
But that which is justifiable in principle isn't always the right approach in practice. Coercing tens of millions of unwilling people to get vaccinated is likely to be a huge and painful undertaking. It is far from clear that either the federal government or the states are up to the task. Currently, most mandatory vaccinations are imposed on children; parents can be relatively easily incentivized to permit them on threat that the children will otherwise be excluded from schools. Imposing mandatory vaccination on some 300 million (mostly adult) Americans is a far dicier proposition.
Moreover, using law enforcement to coerce so many people is likely to lead to serious abuses. If you believe (correctly) that police too often use excessive force, engage in racial profiling, and otherwise abuse their authority, imagine how often these things would happen in the process of forcing millions of people to take a vaccine.
It's worth emphasizing that African-Americans - the group with the worst relations with police - are also disproportionately likely to be suspicious of vaccines. If mandatory vaccination leads to high-profile incidents of violence between police and the black community, it could simultaneously set back race relations and undermine the vaccination campaign.
If you think federal law enforcement officers can take up the slack from local and state police, you should remember that there aren't nearly enough of the former to do the job. There are only about 100,000 federal law enforcement officers in the United States (compared to about 700,000 state and local ones), and most of them can't simply be turned into full-time vaccination enforcers. Many of the federal law enforcement agencies we do have are notorious for their brutality and disdain for due process and the kinds of abuses we recently saw when they were deployed in Portland. A federally-enforced vaccination mandate might lead to the repetition of such events on a massive scale. Paying people to take the vaccine is likely to be more effective, more humane, and less dangerous than coercion.
Financial incentives probably won't persuade hard-core anti-vaxxers or people with strong religious objections to vaccination. But these groups are likely only a tiny fraction of the population. The goal should be to win over the much larger group of people who are on the fence or simply prefer to avoid the annoyance and inconvenience of getting vaccinated.
I do have a few reservations about Litan's analysis. First, as he recognizes, we don't have a good way to gauge the right amount of payment to incentivize a sufficient number of people to take the vaccine. I tend to agree, however, that $1000 per person should be sufficient, perhaps even more than enough. To the extent that, as Litan notes, the incentive is stronger for the poor, that's a feature not a bug. For a number of reasons, poor people are more likely to get infected than the relatively affluent.
Finally, I am skeptical of Litan's idea that the government should only pay a small percentage of the money up front, and defer the rest until enough people have been vaccinated to reach herd immunity. Doing so might lead many people to hold off on getting vaccinated until it is clear that enough others have done so that herd immunity is likely to be reached. In order to incentivize the fastest and most widespread possible acceptance, it would be better to pay all or most of the money up front, as soon as the individual in question gets vaccinated.
There are likely to be aspects of this idea that need more detailed consideration, including angles that Litan and I may have overlooked. I hope experts in various relevant fields will begin to consider these issues. The sooner the better.
UPDATE: It's worth emphasizing that this is not the only way we can use financial incentives to speed up the vaccination process. In this post, I explained why it would also be right and just to pay volunteers to participate in "challenge trials" to speed up vaccine development.
UPDATE #2: I have made a few small additions to this post.