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“Pay or Die” Enrages but Enlightens

Written by: Matt Patti | November 13th, 2023

Film poster: “Pay or Die”

Pay or Die (Rachael Dyer/Scott Alexander Ruderman, 2023) 4 out of 4 stars.

The cost of insulin has long plagued Type 1 diabetics in the United States. The substance vital to their survival is outlandishly priced, especially in comparison to other countries that offer the exact same quantity and quality. This disparity has made life a difficult burden to diabetic Americans and, in many unfortunate cases, led to medical struggles and even deaths from the lack of access to the product.

Just this year, the Biden Administration has pushed to cap insulin costs to a set amount per month. Some large insulin manufacturers have stepped up to the plate and lowered their prices to as low as $35 per month. While this is fantastic news, it does not change the many lives affected due to previously excessive prices.

Still from PAY OR DIE ©MTV Documentary Films

In a documentary filmed before this past year’s historic price cap, directors Rachael Dyer and Scott Alexander Ruderman (both making their feature-directorial debuts) explore everyday people who are, or were, struggling to live their lives because of the cost of a liquid of the utmost importance to their survival. The documentary covers Type 1 diabetics who either have faced challenges or are currently having trouble affording insulin. The directors also highlight many heartbreaking cases of folks who have died due to the lack of affordable insulin.

Dyer and Ruderman wisely start the film off by establishing a connection for the audience with a young man named Alec. Through many interviews with Alec’s loved ones, we get to learn all about him: his personality, how he interacted with others, his favorite holiday, and his hopes and dreams. The viewer then discovers that Alec passed away less than a month after having to be removed from his parents’ health insurance due to the unaffordable cost of insulin for an individual without insurance.

Still from PAY OR DIE ©MTV Documentary Films

After Alec’s tragic death, his mother is compelled to take action. She and her husband attend rallies and meetings with others who have lost loved ones to insulin deficiencies. She also works to get a bill passed in the name of her son that will help give Minnesotans emergency access to insulin when they are in dire need.

After we are introduced to Alec’s family and sympathize with them, we are further saddened to learn of more unbelievable instances of hardship. We meet several different Americans whose lives were changed forever after their diagnosis. Many have struggled so much that they couldn’t afford a roof over their head, and others have rationed their insulin and took the risk of damaging their well-being to save money.

l-r: Alec Smith’s parents James and Nicole in PAY OR DIE ©MTV Documentary Films

In between the intimate, personal stories of everyday diabetic Americans, the filmmakers do a fantastic job of helping the audience understand the science and medical background of Type 1 diabetes and insulin. A few medical experts wonderfully explain in simple terms what happens when people have diabetes and how insulin helps them. The history of insulin is also briefly touched upon, which is intriguing to discover.

The documentary’s main focus comes into the spotlight once again near the conclusion of the film, with Alec’s mother presenting her Alec Smith Insulin Affordability Act to a Minnesota legislature. Spoiler alert: it passes not only in Minnesota, but also when brought up in a few other states as well. It’s an uplifting and positive conclusion to a doc that is very bleak for most of its runtime, though bleak to an effective end.

Co-director Scott Alexander Ruderman holding a vial of insulin ©MTV Documentary Films

Pay or Die is one of the most stunning and upsetting documentaries I’ve seen in quite some time. Still, it does offer a glimmer of hope and a call to action to help soften the blow. Now, even though the U.S. has finally made strides to make insulin affordable again, it cannot change the stories of those who have had to endure hardship under the previous pricing model, and it can’t bring back those we’ve lost forever.


Matt Patti has enjoyed voicing his opinions on films from a young age. He has lived in the Baltimore, Maryland, area since 2015 and is a graduate of Stevenson University’s Film & Moving Image program. Matt is currently back at Stevenson University, working as the School of Design, Arts, and Communication's Studio Manager.

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