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The influenza (‘flu’) vaccination is low cost and effective, typically reducing the likelihood of infection by 50–60%. It is recommended for nearly everyone older than 6 months of age; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success^{, –}. Of the attempts that are successful, most are expensive—limiting scalability—and have not been evaluated in the elderly. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to …