COVID vaccine lotteries are working — let’s apply the model to other diseases

Public lotteries that convince people to receive COVID-19 vaccines raise two fascinating questions: Why does an irrational reward like a lottery ticket work to get people to do the rational thing for their health? And can we — should we? — use this approach to address other intractable healthcare challenges that have resisted traditional public education initiatives?

COVID-19 vaccines offer individuals an almost 100 percent chance of not dying of an easily contractible, ubiquitous disease. The message from public health officials is simple: without the vaccine you face a significant chance of getting very sick or dying. By contrast, the opportunity presented by lottery operators is to get your vaccination and stand an extremely tiny chance of becoming rich.

While the first argument is more rational, it has in many cases failed to convince people. Meanwhile, the lottery argument has been staggeringly successful.

After the first COVID-19 lottery was launched in Ohio this spring, participation in vaccination programs jumped 45 percent in the state. Then the idea spread across the nation, from New York to California, and even to private companies like United Airlines.

California credits its vaccine lottery with a 22 percent increase in vaccinations, including vaccinations in hard-to-reach communities. And the lotteries are motivating positive behavior in people who might not be responsive to other incentives, such as free rides to vaccine appointments and vaccines given in convenient locations like train stations and stadiums.  

In addition, lotteries offer a huge bang for the buck for states. A few $1 million prizes is cheaper than paying $50 a person per vaccine, as some states have tried. In addition, lotteries get tons of free media coverage, saving money on paid ads promoting vaccination. 

As a person of science who has dedicated my life to bettering the health of the community, I have to ask myself — why does this approach work so well?

Behavioral economists have studied this phenomenon for years. Part of the answer is that many people have a hard time integrating a statistical argument into the reality of their lives. To many, life seems more random than that. Deciding on whether to get the COVID-19 vaccine is not a process of carefully computing odds. To them, it is a matter of good fortune or bad luck. 

Another part of the answer is that it feels much better to imagine something pleasant than something scary. Who wants to think about dying when you can think about becoming a millionaire?  

Whatever the reason for the successes of the COVID-19 vaccine lotteries, they provide suggestions for other initiatives in public health that might change irrational behaviors with irrational enticements. This is particularly compelling where standard health education initiatives have failed. 

There are a broad range of diseases we might target, including diabetes, heart disease, and cancer. But one idea for a lottery is particularly close to my heart. 

Before I was a hospital administrator, I was a neonatal intensive care unit nurse. I cannot help but imagine the good that might be achieved for mothers and young babies if governments or philanthropic foundations tried enticing pregnant women to get adequate prenatal care with dramatic lottery prizes. 

After all, the United States, with the world’s most expensive healthcare system, has terribly high rates of both infant and maternal mortality compared to other industrialized nations. Much of that tragedy could be prevented if we could convince more prospective mothers — too many of whom forgo vital prenatal care — to make regular visits to obstetricians. We would be enticing them with the vision of a better life for their families. 

A state-sponsored lottery could offer a ticket for each regular visit and could offer prizes that include tuition-free college educations at state universities, “baby bonds” that mature when the child reaches adulthood, or large cash prizes. 

Does it make sense that we need to offer lottery tickets to encourage people to engage in behaviors that they should rationally choose on their own? No. But it just might work. 

Kathleen Silard is president & chief executive officer of Stamford Health, a hospital and health system in Stamford, Ct.