The Letter, the Birthday, and the System That Explains Nothing

The letter arrives on a Tuesday.

A woman in Sacramento, almost sixty-five, picks it out of the mail. Standard envelope, state seal in the corner, with her name typed cleanly across the front, the kind of address you see on documents you’re not supposed to ignore.

Inside, a few paragraphs in English. Every word, taken alone, makes sense. Together, they don’t add up to anything. “Initial Enrollment Period.” “Part B.” “Penalty for late enrollment.”

She reads it. Then reads it again. Then sets it on the pile by the kitchen counter.

Not because it doesn’t matter. Because it’s not clear what exactly she’s supposed to do with it. Three days later she’ll come back to it, run her finger along the lines, and at some point ask out loud, to no one in particular:

“People come in after they’ve already received the information. But information and understanding are completely different things.”
~ Liliana Keth

“I’m turning sixty-five soon. Do I have to sign up for something, or does it just happen automatically?”

A question you hear, if you listen for it, in apartments all over California. From people with different education, different backgrounds, different numbers of years in this country. But the words are always the same.

Liliana Keth hears this question every day.

She’s a licensed Medicare advisor and a board director at the Council for Cross Cultural Affairs in Sacramento. People come to her when they can’t put the letter off anymore. When deadlines are breathing down their necks. When the neighbor said one thing, the brother in Florida said another, and the internet said something else entirely.

“They come after they’ve already gotten the information,” she says. “But information and understanding? Completely different things.”

She keeps a folder of letters like this. Dozens of them. She pulls one out, runs her finger along a line that reads “You may be eligible for…”

“Right here,” she says. ” ‘You may be eligible.’ For someone who doesn’t live inside this system, that means nothing. ‘May’ – is that a yes? Is that a no? Do I sign up now or do I wait? People are putting together a puzzle from scraps. From what someone told them on the phone. From a flyer they got in the mail. From something that flashed across the news.”

And more often than not, she says, they put it together wrong.

“Letters are written in a language that makes sense to the people who created them, not to the people who receive them.”
~ Alisa Yurchenko

Alisa Yurchenko hears the same story from a different angle.

She’s the executive director of the Council for Cross Cultural Affairs, a 501(c)(3) nonprofit. Her job isn’t one-on-one. It’s community-wide. A few years ago she started running educational workshops on health insurance, after hearing the same phrase dozens of times: “If I’d only known sooner…”

“The problem isn’t that people don’t want to understand,” Alisa says. “The problem is the system is set up in a way that explanations aren’t necessary. It just sends notices. And you’re supposed to figure out the rest on your own.”

She gives an example. The one she sees most often.

Someone has been on Medi-Cal for years. Then their income shifts a little or the rules change, or a notice arrives saying coverage is ending. The person thinks, “I’ll deal with it later. Later comes. The insurance stops. They find out at the pharmacy, when the clerk tells them their medication isn’t covered anymore.

“This isn’t about irresponsibility,” Alisa says. “It’s about letters written in a language that makes sense to the people who wrote them, not the people who receive them.”

“People think they’re the only ones who are confused, when in reality most people are.”
~ Alisa Yurchenko

The scenarios, the experts say, aren’t that many. But they repeat themselves with exhausting regularity.

One: age. Someone turns sixty-five and genuinely believes Medicare just kicks in, like a birthday present from the government. Sometimes it does. Sometimes it doesn’t. And even when it does, it’s not necessarily the thing they need. What comes automatically is Original Medicare. After that, you’re supposed to make choices: add a drug plan, switch to Medicare Advantage, leave things as they are. There’s always a choice. And not choosing? That’s a choice too. Just an unconscious one. With consequences.

Two: losing Medi-Cal. Programs change. Rules get reviewed. People fall out of the system without realizing it. Or they notice but don’t understand they’ve lost coverage. Or they do understand, but think, “I’ll be on Medicare soon anyway, I’ll just wait. And between losing one insurance and getting another, a gap opens up. Could be months. And what if, during that time, you need to see a doctor?

Three: the names. Medicare. Medi-Cal. They sound alike. To someone who’s never dealt with either, they’re just two long words starting with M. That the difference isn’t just letters who pays, how they pay, what they pay for you figure out later. After the fact.

Four: the letters. The ones that arrive, spook you with their language, and end up in stacks on kitchen counters.

“People aren’t stupid,” Liliana says. “It’s just that the system expects you to live inside it to understand it. And if you show up at sixty-four? You’re in a foreign country with no map and no GPS.”

“He didn’t make a mistake in his calculations. He just didn’t know he had a choice.”
~ Liliana Keth

The Council has been running workshops for a few years now. People come for different reasons. Some sign up themselves. Some are brought by their kids. Some show up with a neighbor just for company, and then at the end ask the sharpest questions.

Alisa remembers one session. A woman in her seventies raised her hand and asked, “Why did nobody tell me I didn’t have to pay for Part B while I was still working? I paid extra for three years. For nothing.” They explained it to her. She nodded. Then, after a pause: “So it’s not just me.”

“That’s the thing we hear most often,” Alisa says. ” ‘It’s not just me.’ People think they’re the only ones who got lost. But the lost ones? They’re the majority.”

Liliana remembers one case. A man, sixty-seven, came in with questions about his bills. Turned out he’d spent two years thinking he had Medicare Advantage. What he actually had was Original Medicare with no additional plan to cover prescription drugs. He’d been paying for his medications out of pocket. Thought that’s just how it worked.

For two years, it worked. Then his medications got expensive.

“The system demands decisions but offers no instructions.”
~ Liliana Keth

He came to ask about Part D prescription drug coverage. And that’s when he found out: he’d missed the enrollment window. Now every month he went without a plan will count against him as a penalty. Lifetime. Forever.

“He wasn’t bad with numbers,” Liliana says. “He just didn’t know what he was supposed to do. Didn’t know he had to make a choice. And that choices have deadlines.”

And that, maybe, is the most common loss. Not even the money. Just the feeling that you didn’t know: you had a choice. And you were supposed to choose. Letters come, dates pass, and you’re left thinking: the system runs itself, and me? I’m somewhere off to the side.

The system doesn’t change. The letters still come with the same language, and people still set them on the edge of the kitchen counter. But one thing can change: the number of people who know where to look and what to ask.

“You have to explain more than once,” Alisa says. “Not when the deadline’s already breathing down their neck. Earlier. Calmly. In human language. So when the letter comes, they read it and think not ‘what does this even mean,’ but ‘oh, I know what this is, and I know what to do next.’ “

In an ideal world, that’s how it would work. In the real one, at least you need to know: don’t put the letter off.

“If you enter the system at 64, it feels like you’re in a foreign country without a map or navigation.”
~ Liliana Keth

Toward the end of the conversation, Liliana goes back to the letter. The one we started with.

“Right here,” she says, pointing to a paragraph at the bottom of the page. Smallest print on the sheet. “This is about late penalties. “But who reads all the way to the end? People read the first three lines, don’t understand them, and close it.”

She shuts the folder.

“If someone asked me to explain the problem in one sentence,” she says, “I’d say: the system demands decisions, but doesn’t provide instructions.”

In a month, the woman in Sacramento will get another letter. Maybe she’ll open it right away. Maybe she’ll let it sit for a couple of days. But this time, maybe, she’ll already know what to look for.