Imagine you are an older adult in your 60s or 70s, perhaps even your 80s. You’ve lived a long life of exquisite joy and sorrow. Today, you suffer from diabetes, heart disease, dementia, and a mental health problem like depression or anxiety.

Then, one day in the mail comes a blue envelope.

Inside is a notice written in jargon you can’t fathom, declaring that you’ve been enrolled in a new government program that will completely change your healthcare.

That’s how more than a million Californians are being introduced to the Cal MediConnect program for the state’s “dual eligible” population, so called because they are typically old, sick, disabled and poor – and thus receive benefits from both Medi-Cal and Medicare.

On Jan. 1 the largest number of Californians – about 125,000 – have been slated for enrollment in Cal MediConnect, which is being rolled out in stages within seven pilot counties. It’s the largest rollout month since the program began in April.

Patients are automatically enrolled in the controversial program, yet are given a choice to “opt out.” The state hopes to save $1 billion annually after it’s implemented statewide, and hopes that patients will get improved care as Medi-Cal and Medicare patients are managed under a single roof.

So far, the program has slogged through previous rollouts with a litany of complaints. Some patients never received blue envelopes. Some couldn’t understand the program. Some were told they couldn’t opt out. Orange County’s date slipped when CalOptima, the county program for Medi-Cal patients, suffered sanctions following an audit. Computer glitches ballooned.

And for these frail patients – perhaps a third with mental health problems – it was frequently hard to designate an authorized representative, thereby blocking friends and family members from making selections for them.

“Right now they’re being defaulted into the plan because their friends, caregivers or families can’t make a choice for them,” says Amber Cutler of the National Senior Citizens Law Center.

“It’s really hampered the process for those who have physical or mental disabilities,” adds Aileen Harper, executive director at the Center for Health Care Rights in Los Angeles.

Worst of all, patients have complained that once inside managed care, they have not only left their own trusted physician, but aren’t getting needed treatment.

Customer help phone banks have exploded, far surpassing expected volumes.

Supporters say Cal MediConnect is needed to provide managed care to this highly complex population, coordinating physical and mental health, along with some vision and travel allowances.

Others say the program – while necessary – was implemented hastily.

“This whole planning process started three years ago when the state was in dire financial straits,” says Harper.

Most importantly, critics say, one simple concept has been overlooked during the rollout. Yet it’s the clarion call for today’s brave new world of medicine: “Patient-centered healthcare.”

The astounding “new” discovery – that patients should be placed firmly in the center of the healthcare system – has many wondering why it has taken the health care industry so long to figure this out, 2,500 years after the Hippocratic Oath counseled physicians that their visits should be “for the convenience and advantage of the patient.”

Despite good intentions, the state has routinely overlooked this simple phrase when dealing with a vulnerable population with little understanding of health insurance options.

“If it’s so hard for all of us, you can imagine what it’s like for a dual eligible beneficiary, many of them who have never dealt with managed care,” says Cutler.

Harper cites an 87 year-old woman who never heard of Cal MediConnect until her doctor’s office mentioned it. Would it be a problem?

“Well, you may not be able to come back to us if you’re going to be in a managed care plan,” she was told.

Skeptics say the state doesn’t speak “patient centered healthcare.”

“It’s not consumer driven, it’s plan driven,” says Randy Hicks, who chairs the legislative committee of Californians for Disability Rights.

Meanwhile, some plans have fumbled the transition.

In fact, many have sub-contracted out patients to Independent Practice Associations – or IPAs – in effect outsourcing care.

“Which means you get further and further from coordinated care,” says Cutler.

Further confusion is added since a patient’s primary care physician may be part of an IPA, while a specialist is not.

Stories like this have induced a huge number of dual eligibles to “opt out” of the program and keep their existing providers.

Statewide the number of duals to opt out is about half. As of December 1st, only about 59,000 patients have actually enrolled in Cal MediConnect.

The program has spawned unique outreach efforts like one in Los Angeles County by Advocates for African American Elders.

To address the complex program – with phrases like DSNPs and Medicare Advantage – the organization hosted both a game show and talk show in an effort to explain the program.

In other words, they transformed a combative and bureaucratic nightmare into something fun.

“It really allows people to connect,” says Bryan Gaines of USC’s School of Social Work, whose Institute on Aging supports the elder advocacy group. “We wanted to create this atmosphere where each one can talk to the people involved and ask personal questions.”

The game show outreach contrasts starkly to a recent phone call hosted by state contractor Harbage Consulting that included those affected by the change, including advocacy groups. Callers who shared intimate and painful stories of astounding frustration and denied care were told “We’ll look into that” with a disdain far from the concern and compassion one might expect for such a vulnerable population.

Optimistic observers note that improvements are slowly being made. Doctors offices are beginning to understand that they don’t need to contract with Medi-Cal to service their new Cal MediConnect clientele, nor will they need to obtain prior authorizations.

And health plans are finally sitting down with community groups in this new model of coordinated care. Some patients are even getting housing vouchers, energy assistance or other social supports they sorely need.

And lead consultant Harbage Consulting brought on outreach staff a year ago to improve access to an organization that speaks for the state’s Department of Health Care Services.

Around the country the stakes are similarly high, with other states looking westward to see how California’s effort fares.

“Both the states and the feds have said ‘This is the way for Medi-Cal and Medicare to work together,” says Harper. “It’s taking the managed care concept a step further.”

What is certain today – and almost every day in the world of healthcare – is that Cal MediConnect pits two opposing forces against one another.

On one side: Bureaucratic jungles. Policymakers completely separate from the people they are making policy for. Cost savings. And balance sheets.

On the other side: The poor, the sick, the lonely, depressed and forgotten. 1.1 million of them.

This is the world of patient centered health care.