Companies, including many A-list brands, have been encouraging the public to receive COVID-19 vaccination by dangling everything from beer to donuts as incentives. Get a shot through a state or county health department and you could score everything from an Amazon gift card to complimentary baseball tickets or a fishing license.

Indeed, using tchotchkes, rewards and other behavioral strategies to influence healthy habits has a long history in health marketing. But what of large cash payments? 

With COVID-19 vaccination rates ebbing, states are promising to give away millions of dollars and other rewards to residents who opt to get the shot. For instance, adults who participate in New York’s “Vax & Scratch” program, which runs this week, will receive a scratch-off ticket for the New York Lottery. 

Prizes range from $20 up to $5 million, and the tickets have a one-in-nine chance of being a winner. The incentive is open to those who get vaccinated at one of 10 state-run sites. “If you were undecided about getting a vaccine or dubious about getting a vaccine, now you have an added bonus,” explained Gov. Andrew Cuomo.

It follows Ohio’s own “Vax-a-Million” lottery drawings, offering adults five $1 million prizes and those aged 12 to 17 five full-ride college scholarships to any of the state’s colleges or universities. Last week the Ohio Department of Health announced that the program had helped drive an increase in COVID-19 vaccination rates among Ohioans 16 and older by more than 28% (among those 20 to 49, rates have risen 55%). The Ohio Lottery is running the drawings, with prize money coming from federal coronavirus relief funds.

Ohio Gov. Mike DeWine (Getty Images)

Then there’s Maryland’s VaxCash promotion. Starting this week, the state will award $40,000 to a new vaccinated winner every day through July 3; a grand prize of $400,000 will be handed out to one Marylander on Independence Day. It’s open to those 18 and older.

And in Kentucky, adults who get their first or second COVID-19 shot at Kroger or Walmart will receive a coupon for a state lottery ticket. About 225,000 coupons are available through May 21 for the Kentucky Cash Ball, with a top prize of $225,000.

Achieving vaccine equity is expected to be a long, hard road. Even the term “hesitancy” risks oversimplifying the problem, as people have all sorts of reasons for delaying. Government officials, not unlike pharma execs, can and should try a range of incentives. 

Back in 2014, I led a roundtable during which proponents of behavioral science argued for applying these insights to the issue of drug adherence. Behavioral theory, their argument went, could provide a framework for understanding what’s behind medication non-compliance. That, in turn, would lead to better interventions. 

Industry recognized that unhealthy behavior can stem from a range of causes. It shifted away from a historic reliance on reminders, which assume that forgetfulness or an inability to plan is the root of the problem.

That realization – that a one-size-fits-all approach was failing – has led to more of an openness to trying behavioral techniques, like increasing empathy among doctors or addressing patients’ attitudes about managing their condition. It’s been exciting to observe the uptick in pharma campaigns incorporating such insights.

And what of the panoply of behavioral strategies being tried in public health? Partnerships between lotteries and state departments of health are just the latest. 

Meeting people where they are and making vaccination conveniently available from trusted sources has been one method suggested by behavioral scientists. Removing friction from the process makes it more likely the patient will take the medically desired path – assuming he or she is motivated by public health to get themselves or their families vaccinated. 

A lottery, on the other hand, reframes the choice, from public good and protecting oneself and one’s family to an “opportunistic behavior,” as another public-health expert explained. In other words, that “added bonus” approach might be an incentive for some people. “Go out and get vaccinated to protect yourself, your family, your friends, and your fellow Marylanders. And if you need one more good reason, then go out and get vaccinated for your chance to win a share of this $2 million,” as Maryland Gov. Larry Hogan put it.

Governors sound a little like game show hosts when making these pitches. But people are responding: 2.7 million vaccinated Ohioans registered for the state’s first lottery, and 104,000 vaccinated youngsters signed up for the scholarship giveaway. 

Those numbers got the attention of the White House. “People do care about getting vaccinated, but it turns out they have other things they care about, too,” Andy Slavitt, senior adviser on the national COVID-19 response, said at a media briefing on Tuesday. “Some of those things might encourage people to think about what might otherwise be a lower priority.”

Washington has now given its blessing for states to use their coronavirus relief dollars in this way. On Tuesday the Treasury Department updated its guidance for how states and local governments can spend federal aid monies, saying lotteries, cash payments or other incentive programs are allowed as long as they are “reasonably expected” to increase vaccinations and the costs are “reasonably proportional” to the expected public health benefit.

Behavioral scientists advised in a December JAMA article on COVID-19 vaccination strategies that “financial incentives are likely to discourage vaccination (particularly among those most concerned about adverse effects); instead, contingent nonfinancial incentives” are preferred. One of the authors of the JAMA article, Alison Buttenheim, PhD, who’s on faculty at the University of Pennsylvania School of Nursing, said vaccination lotteries are “contingent, probabilistic, financial incentives.”

A flaw? Perhaps. Yet, to the extent sweepstakes schemes make non-vaccination a less attractive alternative, that’s a good thing, even if they are a bit unorthodox. “It’s unusual,” admitted Ohio Gov. Mike DeWine, “but these are unusual times.” 

Look for vaccination incentives to continue to intensify, and to grow ever more creative.