This year I got a pretty amazing birthday present: a public example of highly effective health gamification.
Namely, Ohio’s Vax a Million campaign, which is giving away $1M per week to residents that get vaccinated. Vaccinations jumped 28% total, with weekly vaccinations increasing by over 50% week over week, according to the state. Maryland and New York have followed suit, and several other states (and perhaps even the Federal government) are poised to follow suit.
Large scale social good gamification is not new, per se. And we’ve been talking about the importance of lotteries to incentivize good behavior for years, including in the fields of prize-linked savings and rescuing journalism. But with the COVID-19 pandemic looming large, and a sinking vaccination rate in the US, the idea has received some major new attention. So why do behavioral lotteries work so well, and how can we expand their use?
Behavioral Lotteries take advantage of several cognitive biases and psychological processes that are relevant for public health and social good:
Optimism Bias holds that people will underestimate their odds of avoiding negative outcomes, and overestimate their odds of encountering positive outcomes. This is important because the risk of the underlying problem (getting sick from COVID) is being underestimated in the target population. Tying that to an unreasonable belief in your odds of winning a lottery replaces the negative optimism with positive optimism towards the potential of winning.
This is particularly important in public health settings where optimism bias drives a large part of the “bad” behavior. For example, smokers famously underestimate their chances of getting lung cancer when asked. Distracted drivers also underestimate their chances of getting into an accident and executives lowball their risks of stress-related disorders.
Sometimes called the Monte Carlo fallacy, this bias causes people to believe that — after witnessing several draws in a row — the next instance of that draw will be the opposite of those seen previously. That is, if you see heads 4 times in a coin toss, you assume the next result will be tails.
This plays out positively in lotteries, but very negatively in areas of public health. For example, if your house is spared from flooding in the past 2 hurricanes, you may assume that the next hurricane will destroy it. And conversely, if you’ve been hit by an adverse weather event, you believe you might be spared in the future.
A behavioral lottery refocuses that energy on the odds of winning, encouraging the individual to take the action that is actually statistically more likely, versus betting it won’t happen to them.
When an individual sees someone else engaged in a behavior — positive or negative — they are more likely to want to do the same. The bandwagon effect can explain many phenomena, such as the rush to a particular table at a flea market while others sit empty, or the contagion of suicide.
In public health, the implications are quite stark. For example, if you are in a community of anti-vaxxers, you are significantly more likely to avoid vaccination. The best way to overcome this bandwagon effect is to replace it with someone people will want to join in on (e.g. a free-to-play lottery), and hopefully generate a new, more positive bandwagon for everyone to follow.
The other major consideration for the efficacy of behavioral lotteries is the cost. Ohio set its prize at $1M. The estimated cost of uninsured/out-of-network COVID treatment is close to $40,000 per person. Given that states bear the brunt of covering the costs of the uninsured, the “breakeven” point on this intervention is 25 high-risk people vaccinated per prize, or approximately 2500 people in the general population.
Obviously, $1M is life changing for individuals who might (or think they might) win. But for the lottery entity this is a very cheap intervention. This means that each dollar spent gets an exponential potential ROI purely from the gap in consumer and governmental expectational biases.
Gamified public health and civic innovations have a proven track record of success where governments and NGOs have been brave enough to try them. The country’s laws must change to enable this kind of widespread incentivization. Of particular note, a Federal law prohibits the use of incentives for voting. This law — and our public policy framework — should be revisited and amended, for the common good.