Health

House Lawmakers Eager to Boost Vaccine Uptake, Quash Hesitancy

Implementing so-called “regret lotteries,” launching school vaccination clinics, and targeting “microherds” were among the strategies proposed by expert witnesses to address vaccine hesitancy, during a hearing of the House Select Subcommittee on the Coronavirus Crisis on Thursday.

“Nearly all of the more than 8,500 Americans who died from COVID-19 last month were unvaccinated,” said Chairman James Clyburn (D-S.C).

Too many Americans remain vulnerable to the coronavirus due to vaccine hesitancy, which not only allows the virus to spread, but increases the risk of vaccine-resistant variants. Up to one in five American adults say they are “strongly opposed” to getting a COVID vaccine, he noted. (Currently, about two-thirds of U.S. adults have received at least one shot, according to the CDC.)

Joshua Garza, of Sugar Land, Texas, was one of those Americans reluctant to get vaccinated. While eligible in January because of a pre-existing illness, he opted not to be vaccinated.

Instead, the 43-year-old later became so ill with the virus that he was hospitalized for several months and needed a double lung transplant. He pleaded with Americans on the fence to think of their families and communities and get the vaccine.

“I have a second chance at life, and I intend to share my story as much as I can,” said Garza, explaining that his experience has compelled him to become a vaccine advocate.

America needs a “shoe-leather public-health” approach to address vaccine hesitancy, one focused on vulnerable communities, especially those of color, said Georges Benjamin, MD, executive director of the American Public Health Association and Maryland’s former Secretary of Health.

The four-point plan he prescribed entails using data to identify communities with lower than expected vaccination rates, uncovering people’s reasons for not getting vaccinated, engaging local community-based stakeholders to design solutions, and then monitoring whatever actions are taken. Then it’s rinse and repeat, until an adequate number of people are vaccinated, he said.

Katy Milkman, PhD, a behavioral scientist at the Wharton School of the University of Pennsylvania in Philadelphia, explored the strengths and weaknesses of financial incentives to improve vaccine uptake.

One study found that 34% of unvaccinated Americans said they would be more likely to get a vaccine if they were paid $100.

Another, a study of unvaccinated Medicaid recipients, found that cash payments increased vaccination, but only among those already planning to get immunized. There was also a wrinkle in the study findings: small payments of $20, compared to a $100 vaccine incentive, actually reduced people’s interest in getting vaccinated. Possibly, she said, due to the thought that some people may believe they are getting paid “to offset a risk.”

Lotteries, however, have proven successful in increasing vaccine uptake, at least in the short term. A week after Ohio’s Vax-a-Million lottery was announced the state’s vaccination rate shot up 28% for those over 16, for example. Between 50,000 to 80,000 additional Ohioans may have gotten their vaccine, in the 2 weeks after the announcement, according to some estimates, Milkman said.

This incentive is effective due to people’s natural tendency “to overestimate the chances of low probability events,” she said.

‘Regret Lottery’ and Pre-Scheduled Appointments

Milkman and collaborators recently designed a “regret lottery” in Philadelphia, where names of winners are drawn from a residential database. The catch? Winners must have proof of previous vaccination. As any city resident is automatically entered into the lottery, those unvaccinated will receive notification that they would have won a cash prize had it not been for their hesitancy.

Research has found that imagining the regret a person would feel if they got a call but couldn’t receive the prize can be even more motivating than a typical lottery.

Another strategy for reaching unvaccinated Americans involves prearranging vaccination appointments. Research on pre-scheduling flu shots and ensuring that re-scheduling is easy led to a 36% increase in flu vaccination, compared to just telling people how to get vaccinated, she said.

In two studies that included over 700,000 Americans, Milkman said she and colleagues found that reminder messages telling people that a vaccine was “reserved” for them increased vaccine uptake in pharmacies and doctors’ offices by 7% to 10%.

One possible reason this strategy works, Milkman said, is that having a healthcare provider remind people to claim a vaccine that’s set aside specifically for them conveys that vaccination is recommended and that it will be easy. Plus, people “strongly dislike giving up things that have been allocated” to them, she said.

Target ‘Microherds’

Former Surgeon General Jerome Adams, MD, said the U.S. may never achieve COVID vaccination rates of 70% nationwide, but advocated for “defining microherds” and taking pains to reach “overall containment” within smaller groups such as churches and sport teams.

“The more these smaller herds achieve 70% U.S. vaccination rates within their groups, the less likely the virus and variants will find quarter to spread within the larger population,” he said.

Adams also called on lawmakers to direct the Department of Education to support school-based vaccination clinics for COVID and other immunizations students missed during the pandemic.

He also urged members of the subcommittee to “stop talking about vaccine hesitancy in political terms, for goodness’ sake.”

“I’ve heard plenty of people say, ‘I won’t get vaccinated, because I don’t trust the government, I don’t trust the healthcare system,'” he said. But nobody has told him they aren’t getting a shot because they’re a Republican, he said.

“When we focus on this mistrust versus focusing on political ideology, we win people over.”

  • Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow

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