I relish the intersection of public health policy informed by behavioral economics.
It's a joy akin to matchmaking your two best friends and then witnessing as their relationship proceeds to marriage. It leaves me giddy and breathless and proud of the clever public health strategist who is able to leverage human psychology to improve population-level health.
My wife relayed a radio piece she heard on NPR that blew my mind. Through an interview with Dr. Katy Milkman, a behavioral economist at Wharton, it explored different financially based vaccine incentives in practice across the US.
There's the cash is king approach: Kroger is paying $100 to employees who get vaccinated. Target is offering employees $25 for each of the two shot series.
There's also the lottery approach: Ohio created a Vax-A-Million lottery, with two prize options for any resident who has received at least one dose of an approved COVID vaccine.
The prize for adults is a million dollars. The prize for kids is a 529 account in their name opened with sufficient funds to pay the cost of the highest Ohio state university tuition, room and board.
The initial results are impressive: a 33% increase in the number of residents who registered to get the vaccine in the week after the lottery was announced, with copycat lotteries inspired in New York and Maryland.
As Milkman explained, human psychology tends to vastly overestimate the chances of winning a life-changing lottery prize. Creating a media sensation based on a significant monetary prize also generates plenty of free press that extends the reach of a program that might otherwise not receive coverage.
Interestingly, the research shows that you don't need a single huge prize to lure people to enter. Smaller prizes with better odds of winning can be perceived as realistic enough to increase the overall numbers that enroll. So giving away ten Hondas may be more effective that one Lamborghini.
There was an interesting approach based on the endowment effect, which is where humans irrationally over-value something they already own compared with what they'd pay for that same item in the marketplace.
People would receive phone calls informing them that a dose of vaccine had already been reserved especially for them, and asking when they'd like to come in to receive their dose. By framing a vaccine as a possession they already owned, those who received the calls were likelier to follow up in receiving vaccination.
My hands down favorite approach was the regret lottery. In this model, every state resident is initially eligible for the drawing to win a million dollars. The name is picked, the individual is called, and then they must answer the key question: "Have you received your first dose of vaccine?"
If the answer is yes, you've just won a million dollars.
If the answer is no, you win nothing, but you (and everyone else) will know you would have won the million dollars if you'd only made a different decision.
This cuts right to the heart of loss aversion - it will hurt far more to lose a million dollars you ought to have won than to skip out on a lottery you were never eligible for in the first place.
Given that estimates of those who are adamantly opposed to receiving the COVID vaccine range from 5-15%, the regret lottery could change behavior in a significant portion of those folks on the fence about whether or not to get the vaccine.
That's the beauty of public health informed by behavioral economics.
Comments 11
Very cool psychological/behavioral concepts being employed here.
Would be devastating particularly being unlucky in the regret lottery
Author
As a public health tool that leverages behavioral economics, it’s hard to top this conceptually! Have yet to see it in practice.
Thanks for stopping by, Xray.
Fondly,
CD
A more robust question than how to incent people to satisfy your policy agenda, is why do people resist? People don’t normally act contrary to their best interest and people are not stupid.
Author
Less about my particular policy agenda than an interesting way to apply behavioral economics principles to achieve a public health intervention.
I don’t think people are stupid, but at times they can act irrationally. Kahneman, Tversky and Ariely (among others) have demonstrated circumstances under which humans behave in irrational ways that can run contrary to their economic self-interest. Some suggest these might be based on the way we are hardwired evolutionarily.
I’d make the distinction that this is a validated observation and not a judgement; any inability to convey the distinction in my post is a shortcoming of my abilities as a writer, and I’ll strive to make this more clear in the future.
Not a criticism of you or your writing. I think the resistance comes from lack of trust in the social compact. Too much fake science, too much hyperbole, too much politicization, too much dishonesty, too much illusion of control. 6ft “social distancing” when a cough or singing can propel a virion 30 feet is pretend. Where did the 6ft recommendation come from? It was made up and then codified in stone. Too much obvious manipulation of freedom. Plexi-glass screens = zero % effective for example. I’ve seen studies showing masks 95% effective AND studies showing 5% effective, yet people come to blows over masks. The pretend solutions erodes any trust in something really effective like vaccines. mRNA viruses are complex and don’t particularly fit the 10th grade science model. Is immunity permanent? Unlikely. 80% of the cases are “mild” 20% are significant meaning 80% don’t really need to be vaxed. The vax doesn’t protect against getting COVID it reduces death in the 20% cohort by 90% When the next pandemic comes should we all wait for the lotto?
Pandemics take typically 2 years to run their course, yet the weekly breathless prediction of resolution causes public policy to be incorrectly administered. You can’t wish away a pandemic no matter how blow dried you are. Does then “incenting” further erode trust in the social compact or does it increase cynicism and even incent rebellion? It is true we are hard wired towards making avoidance decisions 4:1 and the avoidance is STRONGLY sub cortical meaning the cortex (rationality) has nearly no effect. The white matter reaching the cortex FROM the mid brain is robust. The white matter reaching from the cortex to the mid brain is sparse. If your eye catches sight of a snake the mid brain and below acts LONG before the cortex even registers a threat. In fact there is evidence a premonitory “action” in prefrontal cortex is necessary for a thought to even form cortically.
Acting irrational is giving children a trail vaccine for a virus they have a 99.99% of surviving…
I would gladly forfeit 1 million $ against having to be injected against my will.
Remember Nuremberg.
Let’s say no to medical/biological apartheid.
Well, whatever objections people have given them enough incentive and the objections fade away.
I heard that NPR story as well about the phrasing can make a difference. I’ve actually tried to use this when calling patients on the vaccine waiting list to come in for our extra doses.
It reminds me a lot of the technique to use motivational interviewing skills to help patients get to the right solution by getting them to think they came up with the idea.
I have not heard the regret lottery but man oh man, could you imagine. It’s hard for me, as a healthcare worker, to understand why eligible adults refuse to get this vaccine or any vaccine really. I actually took training to do volunteer vaccine canvassing with the Medical Reserve Corps to try to see their point of view. Now I need to just sign up for a slot and get out there.
There point of view is they will most likely survive covid so why risk a vaccine that was created within months? I survived covid so why do I need a vaccine? I can still get it again and still transfer it the vaccine would lesson what little symptoms I had.
Author
It’s interesting how much difference the framing of a question can make.
I was reminded of this when I took a family member to an appointment for an opinion about whether or not they’d be a candidate for an invasive procedure. They received a call a couple of days later informing them, “You have a slot for the procedure reserved next week – just confirming you will be there.”
My loved one was distressed until I explained this was a marketing tactic to increase the likelihood of their following through.
The words we choose matter!
Thanks for the hard work you are doing out there in healthcare, Jenni.
CD