Nicole Smith-Holt, a college financial aid specialist in Richfield, Minnesota, got the call on a Tuesday in June 2017. Her son Alec had been found alone in his new apartment, slumped over and ice-cold. In shock and disbelief, Nicole assumed that an intruder must have broken in. After Nicole and her husband, James, arrived at Alec’s place, she asked the paramedics if they were certain that he was even dead. He was such a heavy sleeper—had they tried shaking him? “What in the world could have possibly happened?” Nicole recalled thinking. “He was 26 years old. Twenty-six-year-old boys don’t just drop dead!”



Detectives on the scene wouldn’t let Nicole and James into the apartment, so they waited outside with their daughters and a few close family friends. Neighbors lingered on the sidewalk as night fell. The medical examiner finally came out and told the small crowd that Alec had probably died late Monday evening. He’d been dead for nearly 24 hours. The examiner also noted that there was no insulin left in the house and nothing but a few test strips in his kit—an alarming state of affairs for a Type 1 diabetic, as Alec had been. The insulin pens in the fridge were all empty and looked like they’d been tampered with, as if he’d tried to extract every last drop. The medical examiner asked if anyone wanted to go inside and say goodbye. “Then it really hit,” Nicole told me. Two years after the fact, she half-laughed to think of it: It hadn’t even occurred to her that Alec’s diabetes might have killed him.



Alec’s landlord gave his family just days to clear out the apartment. Nicole drove Alec’s car to her home and began cleaning it in the driveway. It was a mess. “If I didn’t know better, I’d have thought he was living out of his car,” Nicole said. “It’s like, really—the back seat does not have to hold all of this garbage, how do you even fit people back here?!” But as she sifted through the detritus of his life, a story began to emerge. Alec had a habit of tossing his Walgreens prescription bags and receipts in the back seat. Looking at them all at once like this, Nicole realized, with the force of an epiphany, just how expensive his illness was.

Alec had been working as a manager at a family-owned restaurant, a business that was too small to be required to provide insurance under the Affordable Care Act. He had stayed on Nicole’s insurance, which she had obtained through her job, until his twenty-sixth birthday the month before. After that, his options on Minnesota’s Obamacare exchange were limited: His $35,000 salary entitled him to only partial subsidies, and he couldn’t afford to pay both the premiums and deductibles on offer. So he’d been paying for his insulin out of pocket.

Alec had tried to fill his prescription but came up short. Then he was dead.

When she found Alec’s final receipt, everything clicked: It was from June 22, just five days before he died, for over $1,300 worth of supplies. And then, on the bottom: NO SALE. Now the debris in Alec’s car felt less like trash and more like evidence. “I just got so angry,” Nicole told me. “I’m just grabbing all of this shit and throwing it in the garbage, and afterward I’m like, I should have saved it!” He’d tried to fill his prescription but came up short. Then he was dead.