Cases of COVID-19 are higher than ever in America, and the steps to decrease viral spread are simple: masks, social distancing, and staying home from holiday gatherings. But the main approaches to improve behaviors, thus far, have been either ineffective or unsustainable, involving mandates (which make many Americans feel resentful), shaming, and theatrics.
The truth is that following public health recommendations day after day, month after month, is exhausting—even for experts like us, an infectious disease physician and an epidemiologist, who have spent the pandemic in the weeds of public health. Keeping up with these practices is difficult and, frankly, depressing. Even with a vaccine on the horizon, we’re going to be following strict protocols—or breaking them, to the peril of our communities—for the next several months, at least. To follow public health guidance, Americans need a lot more support than anyone has so far given them. This isn’t just about making sure people have crystal-clear public health guidance (regular briefings from the Centers for Disease Control and Prevention, for example). People need comprehensive health programs, like paid sick leave. They also need clear incentives—sometimes, prizes—for doing what’s best for public health.
The concept of incentivizing positive behavior is well-established from the field of behavioral economics. The idea isn’t one born from socialist ideas nor is it one that has lingered in dusty academic tomes. It is the subject of bestselling books such as Nudge, by Nobel Prize winner Richard Thaler and Harvard Law professor Cass Sunstein, and Thinking, Fast and Slow, by another Nobel Prize winning economist and psychologist, Daniel Kahneman. The basic premise will be familiar to anyone who has set up a sticker chart to encourage a toilet-training toddler, or gotten through a tough work project by thinking about a year-end bonus: giving people or organizations tangible rewards to promote or reinforce desirable behaviors and discourage unhealthy ones will lead to sustained behavior change. “If you want to get somebody to do something, make it easy,” Thaler said in a 2011 interview in McKinsey Quarterly. “If you want to get people to eat healthier foods, then put healthier foods in the cafeteria, and make them easier to find, and make them taste better.”
Incentives lower the cost of entry or engagement—they make it so you don’t have to do as much to get on board with better behavior. Sometimes this looks like disincentivizing the negative behavior, like automatically enrolling citizens in a pension plan who might otherwise defer saving for a rainy day, or signing up driver’s license holders for organ donation programs, when many people don’t ordinarily dwell on the usefulness of their own mortality to others. Not participating in the program takes a little bit of thought and work, even if it’s just checking a box. Sometimes this looks like a gift or freebie for doing the right thing, like paying people to quit smoking, or providing a tax break to homeowners who install solar panels.
That incentives haven’t been a sustained part of our government’s COVID-19 response belies a clear lack of both leadership and imagination. The Coronavirus Aid, Relief, and Economic Security Act and the Paycheck Protection Program provided financial incentives for people to remain home instead of searching for work and for businesses to keep employees on the books, respectively. But these short-lived policies are mere table scraps compared with the comprehensive support programs enacted by several European countries. The Biden administration can change this and set America off on the right path. In addition to reestablishing and expanding financial support for businesses—especially businesses like restaurants where close contacts, particularly indoors, puts people in risky situations—the new administration should support individual Americans in taking up and sticking to healthy behavior in smaller ways.
Take masks. The evidence is clear that they save lives. But they also cost money. A box of 40 blue surgical masks retails for nearly $10, which translates to $120 for a year. Sturdy, quality masks that feel good to wear can run $30 for a three-pack, meaning you’d need $70 worth of masks to wear a fresh one each day and do laundry once a week. That might not sound like much, but consider that many Americans are unemployed, pay through the nose for private child care, and/or are already extremely unhappy at the prospect of wearing a mask. The government should make masks freely available and easily accessible. It’s not a strange proposition: In the 1980s and 1990s, condoms flowed like water from health departments and AIDS organizations, as well as bars, which often had bowls of them free for the taking. Today, there should be mask dispensers on every bus and train and in front of every grocery store.
Masks, of course, aren’t the only thing we need to think about: Everyone in America, including hourly workers should have access to paid sick days and adequate child care—it’s necessary to public health for people to stay home from work, even if they think they have just a mild cold. These are incentives too. There should be vouchers for grocery delivery available so that sick people are not tempted to go to the store and potentially infect others. (There should also be hazard pay for food delivery workers who are at increased risk for infection, and compensation for lost wage and the costs of isolation and care should they get sick.) Much like tax credits for installing solar panels, congregate settings such as homeless shelters, residential substance use treatment programs, schools, and prisons should be given tax credits for improving their air quality and ventilation.
Incentives should go beyond the purely practical—they might even look a little like bribes. For an incentive to work, the perceived gain must be greater than the perceived loss. For example, if someone feels like they have to give up not just $10, but personal autonomy, to wear a mask, the incentive to wear one will need to be pretty high. Because attitudes around masking vary by geographic location and political affiliation, incentives must be community- and context-specific. In grade schools and high schools, the incentive could be extra credit (as some teachers are already trying) or additional recess time to students in exchange for consistent mask wearing. Colleges and universities could incentivize mask wearing by providing vouchers for books, meal cards, or tuition remission for those who wear them consistently to class. Businesses could provide discounts on products to customers who wear masks while shopping. Even in cities where there are mandates, this could boost morale. Cash payments of $100 could encourage Americans to download a contact tracing app, as Johns Hopkins University’s Jemima A. Frimpong and Stephane Helleringer have suggested. When a vaccine is available, as economist Robert Litan has suggested, the government could pay people $1,000 to take it.
In the meantime, incentives could encourage safe celebrations and socializing. Instead of punishing and shaming people for hosting indoor parties, college presidents and mayors should offer outdoor space where people can gather and, yes, drink alcohol and smoke pot. New York and other cities have already done this by offering restaurants sidewalk space and parking spots in which to set up tables. In suburban areas, empty parking lots could be converted into movie theaters or beer gardens, perhaps with government-subsidized drink or dessert vouchers for people who show up to socialize safely, and spend their money helping local businesses. When people must stay home, as we’re all being advised to do for the holidays, there should be a tangible reward, beyond not getting sick or potentially spreading the virus. Entertainment companies like Netflix, Hulu, and HBO could offer a free one-month login for people who pledge to stay home for Thanksgiving. Local governments could provide stipends to couples and wedding venues to help with the cost of postponing and rescheduling nuptials.
What all Americans are being asked to do is not fun—it’s isolating, depressing, and restrictive. Adhering to public health advice in a pandemic comes with real sacrifices, which need to be addressed head-on. Politicians, at their best, have taken an unempathetic approach by telling citizens to “be smart” and, at their worst, have promoted conspiracy theories and anti-science rhetoric to dissuade people from healthier choices. Our political leaders need to know that there are alternatives to their abstinence only, “just say no” to social gatherings, “ask what you can do for your country” approaches, which are not working well enough, and also are not sustainable. They should know there is a special political incentive in giving Americans rewards for adhering to public health measures: The sooner the pandemic abates, the sooner Americans can resume activities that make the economy thrive and get us truly back on the road to recovery.