As the delta variant ran rampant this summer, Missouri officials pleaded with the federal government to allow a $100 gift card program to incentivize COVID-19 vaccines.
But months later, just 20 of the 115 eligible local health departments have opted into the vaccine incentive program, an investigation by The Missouri Independent and the has found.
Less than $1.8 million of the $11 million allocated for the initiative has been distributed.
And while the exact number of gift cards handed out is unclear, several of the departments that opted in say they鈥檝e only handed out a fraction of the upwards of 15,000 gift cards that could be purchased.
One additional department may participate in the program; their participation is pending as of Wednesday.
In Adair County, just 15 of the estimated 740 cards had been used as of mid-November. Less than a quarter of the 272 gift cards the Joplin City Health Department was approved for have been distributed.
And in the most visible success story, in hard-hit Springfield and Greene County, many of the nearly 1,000 gift cards issued went to children between the ages of 5 and 11 鈥� not the vaccine-skeptical adults the program was originally intended for.
Missouri鈥檚 experience with vaccine incentives is mirrored in dozens of other states that have experimented with cash lotteries: The programs鈥� net impact on vaccination rates have been low, experts say, and initiatives have been met with distrust from some communities who view the incentives as a form of government-sponsored bribery or worse.
In Carter County, in the Ozarks, opposition to the program was so fierce that a planned vaccination drive with the gift cards was canceled.
鈥淪o many parents and community members were upset, we were not allowed to hold the vaccination event at the school,鈥� said Michelle Walker, the county health center administrator, adding that they had successfully hosted three previous COVID-19 vaccine clinics with the school district.
Since Sept. 30, just 85 gift cards have been issued out of the 396 the county received funding to purchase.
The actual logistics of the incentive program, which was first announced in late July, fell to local public health agencies across the state.
About $752,200 has been issued to purchase the gift cards, along with over $990,000 to cover operational costs for the agencies, Lisa Cox, a spokeswoman for the state health department, said Wednesday.
State officials had high hopes for the gift card program.
Former acting Department of Health and Senior Services Director Robert Knodell wrote in a mid-July email, obtained through an open records request, that the program would 鈥渢ake a big swing at hesitancy.鈥� Missouri leaders urged federal officials cash program, rather than .
Now, prompt renewed calls for vaccination drives, the impact of the ongoing incentive program at a local level seems minimal 鈥� at best.
In a statement Wednesday, Cox said DHSS knows monetary incentives are not 鈥渢he silver bullet鈥� that will persuade every Missourian to get vaccinated, but it鈥檚 an available tool worth using.
鈥淔or those it is impacting, the vaccination may have saved their life or the life of a loved one. Every person vaccinated lessens the opportunity for the virus to spread further,鈥� Cox said. 鈥淲e will never truly know the full impact of incentives and other efforts to encourage widespread vaccination. It can鈥檛 hurt to try.鈥�
Representatives for the governor鈥檚 office and Centers for Disease Control and Prevention did not respond to requests for comment regarding the incentive program鈥檚 impact and whether efforts will be taken to boost participation.
鈥楢 complete nightmare鈥�
For dozens of health departments that didn鈥檛 opt into the program, officials said distributing the gift cards would have been an additional task that already-overwhelmed staffers simply couldn鈥檛 handle. It was a burden that some local health departments when they expressed early concerns with the program.
鈥淚f the state had made it an easier process for us at the local level, it would鈥檝e been great. But we were going to have to do all the purchasing of gift cards and the keeping track of everything, and it was just going to be a complete nightmare,鈥� said Kandra Counts, the administrator of the Shannon County Health Department in southern Missouri, later adding: 鈥淲e can barely keep up with COVID cases, let alone manage a program like that.鈥�
For some, it was simply an issue of timing. While the local incentive program , it didn鈥檛 get off the ground until after was finalized in August. From there, departments still had to have their plans approved by the state and receive the funds to purchase gift cards.
With funding for the incentive program ending Dec. 31, the time it would take to receive approval from both the state and the Columbia City Council would only allow about a month for the Columbia/Boone County Department of Public Health and Human Services to implement the program, said spokeswoman Sara Humm. Gift cards already received can still be issued past Dec. 31, local health departments said.
Others expressed skepticism about whether the cards could truly make a dent in Missouri鈥檚 stubbornly-low vaccination rate, which is just above 51% and ranks among the bottom 15 states in the country.
Nationwide, unvaccinated Americans are 鈥渄isproportionately Republican,鈥� according to surveys from the Kaiser Family Foundation and other research organizations, said Ashley Kirzinger, an associate director for the foundation's public opinion and survey research team. As a result, public health departments in conservative areas 鈥� such as rural Missouri 鈥� may believe vaccine incentive programs would have limited impact in their communities, she said.
鈥淧eople don't want to feel unfairly pressured to get a vaccine,鈥� she said. 鈥淪o a public health department trying to maintain credibility with its community may not want to feel like they are coming off as pushing something that a large segment of their immediate population thinks is unsafe.鈥�
Health agencies that chose not to participate in the gift card program echoed the concern.
鈥淐ounty taxpayers have expressed that that's not where they wanted their tax dollars to go,鈥� said a spokesperson from Jasper County鈥檚 health department. 鈥淪o we chose not to (opt in).鈥�
Perhaps even more problematic for the program is the perception that the gift cards could be viewed as a form of bribery.
In Knox County, in northeast Missouri, many of the doses administered this fall have been booster shots, said administrator Lori Moots-Clair, and just 156 gift cards have been distributed. On their own, the cards have not made a significant difference in motivating people to get vaccinated 鈥� and might have pushed some people away, Moots-Clair said.
鈥淚 can't say that people are spreading the word and coming in and saying, 鈥楬ey, I want that card,鈥欌�� she said. 鈥淚f anything, it made people appear angry when we first started giving them out.鈥�
In nearby Clark County, health department administrator Evelena Sutterfield鈥檚 desire to both increase her county鈥檚 vaccination rate and direct the funds locally outweighed the pushback from locals.
鈥淭here were a lot (of people) that felt it was a bribe, and people that have already been vaccinated that they weren't going to get it,鈥� Sutterfield said. 鈥淪o I have a lot of people in my community that were upset that we did this.鈥�
Mixed success
Among the 20 local health agencies that opted into the gift card program and have already received funding, some found that the incentives were, in fact, pushing people to get their COVID-19 shots 鈥� though confusion abounded about topics such as booster shots and eligibility for children.
Out of at least 1,700 gift cards that The Independent and Documenting COVID-19 project鈥檚 survey found were distributed, 991 were distributed by the Springfield-Greene County Health Department 鈥� many of them .
鈥淏ased on our experience, there's no question that this $50 is making a big difference and motivating people to get their vaccines now,鈥� Cara Erwin, communications and outreach manager at the Springfield-Greene County Health Department, said during an interview the Monday following the events.
Many Springfield residents vaccinated at the events were children in the 5 to 11 age range who had recently become eligible for Pfizer shots, Erwin said. But some parents and grandparents of those 5 to 11-year-olds who hadn鈥檛 received the shots also came in to get their first doses.
In addition to the gift cards, the department auctioned off $15,000 in prizes for newly vaccinated residents, donated by the Community Foundation of the Ozarks.
Like Springfield, in Adair County, the health department has paired its gift card program with a drawing for four winners to each receive $250 that was funded by private donation. For every 10 new participants in the incentive program, another drawing will be held. For Jim LeBaron, the administrator of the health department, it鈥檚 worth trying anything that could spur an uptick in vaccinations.
鈥淚f we get 10, 20, 25, 50 people that get vaccinated because of the incentive program, I think it's worth it,鈥� LeBaron said.
Health departments are permitted to give away $50 gift cards when county residents get their first or second COVID-19 shots, but not booster shots.
Washington County has distributed 267 gift cards to newly vaccinated residents as of Nov. 22. Department administrator Shawnee Douglas said the cards have been helpful, particularly in motivating younger residents. But she wishes she could also distribute the cards to people receiving their booster shots.
鈥淚t's just kind-of sour,鈥� Douglas said, of not being able to offer gift cards to those getting a booster. 鈥淎nd I get that. I don't like it either.鈥�
Vaccine incentives can serve as a form of stimulus payments for Americans, said Armando Meier, a research fellow at the University of Lausanne in Switzerland who contributed to a study for a Swedish population.
The payments both contribute to public health goals and promote spending in the local economy, he said. This was true for some of Missouri鈥檚 health agencies, which purchased gift cards from local businesses.
鈥淚t's not simply about avoiding hospitalizations and deaths,鈥� Meier said, 鈥渂ut actually that this money is useful for people anyway.鈥�
In Washington County, the health agency obtained gift cards through the local chamber of commerce. About 68% of cards were for local grocery stores and the remaining 32% were for local gas stations.
鈥淚'm hoping [the gift cards] will also help promote our local businesses and support them instead of just going into some big conglomerate like Walmart,鈥� Douglas said.
In Dent County, more than two thirds of students in some of its school districts were enrolled in free-and-reduced price lunch in 2020, according to state data. With food insecurity an issue facing the area, the health department decided to select a locally-owned grocery store, Country Mart, for its gift cards, said Zachary Moser, the department鈥檚 administrator.
Out of the 532 gift cards the department received funding for, about 110 gift cards have been given out as of Nov. 15, Moser said. He hasn鈥檛 heard anyone cite the gift card as the catalyst for getting vaccinated, but he thinks it helped tip the scale in that direction for some.
鈥淢ost of the time, people's concerns are not something that's going to be overcome by $100,鈥� Moser said. 鈥淏ut I do think that as a measure of mitigating the impact overall of COVID, I think it's a big deal. We had a lot of people lose income and all that from the pandemic, and so I think this will go a little ways to at least helping us recover from that as well.鈥�
Similarly, the Clinton County Health Department, which received enough funding for 250 gift cards, is at the 鈥渒itchen sink鈥� phase of their vaccine rollout, said department administrator Blair Shock. Shock and his colleagues are trying to do anything to convince people to take a shot. Of the more than 80 COVID-19 deaths in the county, all but one were among residents who weren鈥檛 fully vaccinated, he said.
鈥淲e're not pushing this because it's our job. We're not pushing this because we're toeing the line here. We're pushing this simply because this is our community,鈥� Shock said, 鈥渁nd we want to reduce the amount of suffering and the amount of death that we see within the community.鈥�
Missouri fits into national pattern
Ohio was the first state to implement a lottery for vaccinated residents, back in May. The 鈥淰ax-a-Million鈥� lottery appeared to drive an uptick in vaccinations, which was touted by state and national leaders.
But Ohio鈥檚 lottery was not as successful as it seemed, researchers found in a study .
Two days before the announcement of the new Ohio lottery, the Pfizer vaccine was approved for children ages 12 and 15 and the Ohio lottery鈥檚 perceived success was likely influenced 鈥渂y the nearly simultaneous release of the vaccine to adolescents,鈥� said Dr. Allan Walkey, an associate professor of medicine at Boston University and the lead author of the study.
The lottery, simply put, 鈥渄idn鈥檛 have a large effect on vaccine uptake,鈥� Walkey said in an interview.
Other states鈥� lotteries similarly have not had a substantial impact on vaccination. A study found that after governments announced new cash lottery programs, any increase in vaccination rate was 鈥渧ery small in magnitude and statistically indistinguishable from zero.鈥�
Though vaccinations increased during the summer in states like Missouri, Arkansas and Louisiana, it鈥檚 difficult for researchers to attribute these increases to vaccine incentive programs when the delta surge was devastating healthcare systems.
In late July, that the undervaccinated counties facing delta were most likely to see an uptick in people going to get their first doses.
鈥淭he increase in cases and concerns about filling ICUs, and knowing someone that got really sick, or perhaps died 鈥� all of those seem to have a much bigger impact on people's vaccine intentions鈥� compared to cash incentives, said Kirzinger, the Kaiser Family Foundation polling expert.
In its surveys, the foundation divides unvaccinated Americans into 鈥渨ait and see,鈥� 鈥渙nly if required,鈥� and 鈥渄efinitely not鈥� categories. Incentives may be a measure to help convince the 鈥渨ait and see鈥� and 鈥渙nly if required鈥� groups to get their shots, Kirzinger said, but the 鈥渄efinitely not鈥� group is less likely to come around 鈥� especially as vaccination becomes increasingly tied to political polarization.
While Gov. Mike Parson and DHSS Director Don Kauerauf have called successful, the program coincided with the delta surge, making it difficult to evaluate.
More than 656,200 Missouri residents entered to win the state鈥檚 vaccine lottery, which ended in October and offered $10,000 prizes. But of the nearly 617,000 adults that entered, only 9%, or 57,117, got vaccinated after the lottery had been announced, according to DHSS figures.
Those 57,117 Missourians represent less than 1% of the state population.
Just over half of the state鈥檚 population is fully vaccinated as of Dec. 1, according to the . It鈥檚 about 8% lower than the as a whole and it puts Missouri in the bottom quarter for vaccination rates nationwide.
With lower vaccination rates, Missouri will likely have a more difficult time beating back new variants, Kauerauf . He hopes to see Missouri鈥檚 vaccination rate rise to 75%.
鈥淧eople may laugh at me for thinking it鈥檚 even possible, but I hope so,鈥� Kauerauf said. 鈥淚 hope we can get there.鈥�
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, supported by Columbia University's Brown Institute for Media Innovation and MuckRock, collects and shares government documents related to the COVID-19 pandemic and works on investigative journalism projects with partner newsrooms.
