County health officials, wary of ‘anger mongrels,’ clash with Missouri on vaccine prizes

Northern Missouri’s Shelby County has just 37.6% of its residents fully vaccinated against COVID-19 as the virus surges through the state. The number of hospitalized patients in the area has tripled since May and the county has just 6,400 residents.

But the idea of offering $100 to those who have refused the shot — an incentive Missouri has asked the Centers for Disease Control and Prevention to approve — is a nonstarter for county health administrator Audrey Gough, who called it burdensome and risky.

“I cannot imagine how we are suppose to manage $100 gift card incentives for those folks who have been public enemy #1 in the vaccination world,” she wrote to a state health official last week. “Many of us are just getting out from under the anger mongrels and now you want to set us up for another beating.”

Gough is one of at least five local health officials across Missouri pushing back on the proposed reward program to boost lagging vaccination rates as the delta variant advances.

They said their staff are already stretched to the limit and worried such a giveaway would send a message of rewarding “bad behavior” to vaccine-resistant communities, according to interviews and internal emails obtained as part of a collaboration between The Kansas City Star and the Documenting COVID-19 project at Columbia University’s Brown Institute for Media Innovation.

The state’s director of Community and Public Health, Adam Crumbliss, quickly responded that burdening local departments was not the intention. On a follow-up conference call last week, he acknowledged the program announcement was not as “DHSS would have preferred,” according to minutes of the meeting. He told local health departments that they wanted a “simple way” to get the “influx of dollars” into Missouri.

A spokeswoman for the Department of Health and Senior Services said the department would “assist LPHAs (local public health agencies) with the rollout if they choose to opt-in.”

But the program DHSS is proposing — grants to local health departments for small-dollar incentives — still requires CDC approval. Many local health departments say they’ve not yet decided if they will participate.

The tension between local and state health officials illustrates Missouri’s struggle to grow vaccination rates among a large population of the hesitant and resistant.

Wayne County, in the Ozarks foothills of southeast Missouri, has had just 26% of residents receive both doses of the COVID-19 vaccine. COVID hospitalizations have increased by 90% in the last two weeks, and the ICU at nearby Poplar Bluff Regional Medical Center is near capacity.

Wayne County Health Center Administrator Rhonda Eads said she was sure $100 would prompt some to take the vaccine, but she worried it would ultimately do more harm than good.

“If they decide to do it the cash way, we’re going to opt out of it,” Eads said. “I’m not putting $100 cash in someone’s pocket. We have a big enough drug problem in this area. We live in such a rural area that meth and opioids are crazy around here.”

She said she would only consider the program if the incentive is in a gift card form.

‘I and many others can’t take on anymore’

Gov. Mike Parson and DHSS first announced the program in July as a cash-per-shot option for local health departments.

Paired with the state’s higher-profile $10,000 vaccination lottery, the local initiatives were intended as a simple, customizable incentive that departments could introduce as soon as possible.

Local departments “often take the brunt of the frontlines of criticism and concern from citizens,” Crumbliss told reporters. The goal was to give them money to give away on their own terms, with few strings attached.

But, less than an hour before a public announcement of the new program, the CDC rejected Missouri’s original proposal for an incentive program that went above $25, saying the only allowable incentives above that threshold would be generic gift cards or transportation costs, not cash.

Parson blasted the CDC, calling the rejection “just totally ridiculous,” and DHSS appealed, saying $25 wouldn’t go far enough to entice the vaccine-hesitant.

Weeks later, in late July, DHSS was about to accept local agencies’ applications to participate in a smaller the $25 program when President Joe Biden said he wanted states and cities to pay people $100 to get the shot. Several states, including Arkansas, Colorado, Ohio, Minnesota and Nebraska, immediately started their own $100 incentive programs using federal funds; others, such as Iowa, Oklahoma and Tennessee, said they would not; and still others like Illinois, Indiana and Kansas are undecided.

After Biden’s announcement, Crumbliss wrote to local departments, saying at the state would seek approval for the $100 incentive.

That’s when Gough wrote to voice her opposition. In an email to Crumbliss and other local departments last Tuesday, she said the program would set local departments up “for a huge failure in our communities.”

Gough, who declined to comment, wrote that it would send the wrong message by rewarding those who have so far chosen not to get a vaccine.

“The people who do the right thing and got their vaccine when (we) asked them to get absolutely nothing. We again reward bad behavior,” she wrote.

She suggested that the state or federal government administer the program on their own.

“That keeps all the LPHA’s out of the mess,” she wrote. “I and many others can’t take on anymore.”

Four other rural health department administrators, including Eads, agreed.

“I would have to agree that handing out prizes will take much time away from our already exhausted staff who stay plenty busy with not only everything COVID related but everything else,” Carroll County Health Department administrator Jennifer Link wrote. “Please do NOT lay this burden on LPHA’s.”

Mary Young, interim administrator of Johnson County Community Health Services, said she was concerned about being targeted for theft if she announces the availability of cash or gift cards. Reached by phone, Sullivan County Health Department administrator Deborah Taylor, who also replied to the emails to Crumbliss in agreement, said local departments are “run over” with other public health work.

Crumbliss responded that counties are free to not offer the incentives.

“The objective remains the same: increase vaccination rates across Missouri and reduce the transmission of COVID-19 among our residents,” he wrote. “The objective is NOT to simply give you another program to administer without resources to do it. It’s been a more difficult path for us to get to that point than I would have hoped CDC would have authorized.”

Federal public health officials acknowledged concerns that some local departments face a lack of trust over vaccinations in their communities. But they said the Biden administration has reached the point of needing to try various new strategies to reach different segments of the vaccine holdout population.

“At a certain point, it takes different approaches to reach people,” one public health official said. “As you continue to move through different groups with different concerns, and more and more get vaccinated, the ones that remain will take different messaging and strategies to reach.”

Is $100 enough?

Incentive programs are not new to public health, experts said.

Expectant mothers have been offered car seats or strollers for completing smoking cessation programs. But Dr. Bridget Calhoun, associate dean of Duquesne University’s School of Health Sciences, acknowledged an ethical concern that an incentive could border on coercion.

“I can totally understand why health departments, despite being public health entities, are saying, ‘No we don’t like the idea of you giving money away for this public health initiative,’ because they’re using public money for that,” Calhoun said. “If you have someone who’s homeless and in the depths of an addiction, $100 is a lot for them. It may not be equally much for me and you, but certainly $100 may be coercive.”

Others say the monetary incentive is not coercive and may not even be enough to make a difference.

“I don’t think the $100 will do it,” said Dr. Arthur Caplan, professor of bioethics and the founding head of New York University School of Medicine’s medical ethics division. “We’ve seen a lot of attempts to try free meals, free drinks, small rewards, close to $100, but it didn’t move the needle very much. In general, the financial carrots don’t seem to be all that effective.”

The interest from other departments across Missouri is mixed.

In Camden County in the Lake of the Ozarks area, where state officials issued a COVID hotspot advisory last month, health administrator Stephanie Dake said her department “will not be participating in the program.”

“We do not have the staff nor time to do it,” she said.

In Springfield, epicenter of the recent surge, officials have been supportive of vaccine incentives. But asked if the Springfield-Greene County Health Department would participate in the local program, spokesman Aaron Schekorra said the department must “prioritize administering vaccine” and wouldn’t commit to offering the incentives..

“We are still looking at the details of the vaccine incentive program to determine if we are going to be able to implement it in Greene County,” Schekorra said.

Several said they have not yet decided if they will participate, including Shannon County, where health department administrator Kandra Counts said officials want to “know what we are getting into.”

“We are hoping to participate, but we shall see,” she said.

Columbia-Boone County Public Health plans to opt in, spokeswoman Sara Humm said, having experience providing gift cards for past public health incentive programs. As does Newton County Health Department in southwest Missouri, where administrator Larry Bergner said he already planned on using county funds to hold drawings for $100 gift cards for the vaccinated.

“If it’s that easy, if (state officials) send a certain amount of money set aside for vaccination, we’ll simply use the money to purchase gift cards,” he said. “I don’t have a problem with doing it, if it’s that easy.”

Michael Wilner contributed reporting from McClatchy’s Washington bureau.