Diabetes is a chronic condition that affects more than 37 million people in the United States alone, with millions more living with prediabetes. In marginalized populations, the burden of diabetes is often compounded by systemic inequities in healthcare access, particularly insurance coverage gaps. These gaps can prevent individuals from receiving timely diagnosis, ongoing treatment, and essential management of their condition, leading to worse health outcomes and deepening existing health disparities.

Insurance coverage is a critical determinant of health outcomes for people with diabetes. Without adequate coverage, individuals may face significant barriers to accessing necessary medical care, medications, and supplies. Research consistently shows that uninsured adults with diabetes are less likely to receive recommended preventive care, such as annual foot exams, eye exams, and HbA1c testing. They are also more likely to experience avoidable hospitalizations and emergency department visits for diabetes-related complications.

The financial burden of diabetes management is substantial. The American Diabetes Association estimates that the total cost of diagnosed diabetes in the U.S. in 2022 was $412.9 billion, with $306.6 billion in direct medical costs. For uninsured or underinsured individuals, the cost of insulin, glucose monitoring supplies, and other essential treatments can be prohibitive. A study published in Health Affairs found that insulin prices more than tripled between 2002 and 2016, placing an increasingly heavy burden on patients without adequate insurance.

Delayed Diagnosis and Treatment

When insurance coverage is limited or unavailable, individuals often delay seeking medical care for early signs of diabetes. This delay can mean that diabetes is diagnosed only after complications have already developed. For example, a person might ignore symptoms of polydipsia, polyuria, or unexplained weight loss until they experience a diabetes-related emergency such as diabetic ketoacidosis or a hyperosmolar state. By the time proper care is initiated, the disease may have already caused damage to the eyes, kidneys, nerves, or cardiovascular system.

Insurance gaps also contribute to inconsistent primary care use. Without a regular source of care, individuals lack access to routine screening that could catch prediabetes early. According to the Centers for Disease Control and Prevention (CDC), screening for type 2 diabetes is recommended for adults aged 35 and older who are overweight or have other risk factors. However, CDC data shows that many uninsured individuals do not receive these screenings, allowing the disease to progress unchecked.

Medication Non-Adherence Due to Cost

Even after diagnosis, insurance gaps directly affect medication adherence. Patients without coverage or with high-deductible plans may skip doses, ration insulin, or forgo other medications due to cost. A survey by the Kaiser Family Foundation found that among adults with diabetes, those who were uninsured were more than twice as likely to report not taking their medication as prescribed because of cost compared to those with insurance. This non-adherence leads to poor glycemic control, increased risk of complications, and higher long-term healthcare costs.

The consequences of rationing insulin can be severe. Insulin is a lifesaving medication, but its high cost—often several hundred dollars per vial—places it out of reach for many. In 2020, the average list price of insulin was $98.70 per vial for analog insulin and $25 per vial for human insulin, but out-of-pocket costs can vary widely depending on insurance design. Some patients have resorted to using expired insulin or borrowing insulin from others, practices that can lead to dangerous fluctuations in blood glucose levels.

Disproportionate Burden on Marginalized Populations

Insurance coverage gaps do not affect all populations equally. Marginalized groups—including racial and ethnic minorities, low-income individuals, and rural residents—experience significantly higher rates of uninsurance and underinsurance. These disparities are rooted in structural inequities such as systemic racism, economic disadvantage, and geographic isolation. The intersection of these factors with diabetes management creates a compounding effect that worsens health outcomes.

Racial and Ethnic Minorities

According to the U.S. Department of Health and Human Services, African American and Hispanic adults have higher rates of diabetes than non-Hispanic white adults. They are also more likely to be uninsured. In 2021, the uninsured rate for Hispanic adults was 17%, compared to 8% for non-Hispanic white adults, according to the Kaiser Family Foundation. Among African American adults, the uninsured rate was 11%. These disparities in insurance coverage directly correlate with worse diabetes outcomes. For example, African Americans are 1.5 times more likely than whites to develop diabetes, 1.7 times more likely to have diabetic retinopathy, and 2.3 times more likely to experience end-stage renal disease.

Language barriers also play a significant role. Limited English proficiency can hinder communication with healthcare providers, making it harder to understand treatment plans, navigate insurance systems, and access preventive care. Cultural differences in dietary habits, health beliefs, and distrust of the medical system further complicate diabetes management.

Low-Income Communities

Income is one of the strongest predictors of health insurance status. People living below the federal poverty level are far more likely to be uninsured or have coverage that leaves them with high out-of-pocket costs. Many low-income individuals work in jobs that do not offer employer-sponsored insurance and earn too much to qualify for Medicaid in states that have not expanded coverage. This "coverage gap" affects nearly 2 million adults in the 10 states that have not adopted Medicaid expansion, as of 2023.

The financial strain of diabetes management is amplified for low-income individuals. They may live in food deserts where access to healthy food is limited, making it difficult to follow a diabetes-friendly diet. They may lack safe places to exercise or have jobs with unpredictable hours that interfere with medication schedules. These social determinants of health interact with insurance gaps to create a cycle of poor health and financial instability.

Rural Populations

Rural residents face unique challenges related to insurance and diabetes care. They are more likely to be uninsured than their urban counterparts, and they often have fewer healthcare providers in their communities. Rural hospitals and clinics have been closing at an alarming rate, leaving patients with long travel times to see a specialist or even a primary care provider. Telemedicine can help bridge some gaps, but broadband access remains limited in many rural areas.

According to the USDA Economic Research Service, the uninsured rate in rural areas was 11.5% in 2020, compared to 10.3% in urban areas. Rural residents also have higher rates of diabetes and are less likely to receive diabetes self-management education. The combination of insurance gaps and limited healthcare access puts rural populations at elevated risk for diabetes complications.

Policy Solutions to Close Coverage Gaps

Addressing insurance coverage gaps requires a multi-level approach that includes federal and state policy changes, insurance market reforms, and targeted programs for vulnerable populations. While no single solution can eliminate all disparities, a combination of policies can significantly improve access to diabetes care.

Medicaid Expansion

Medicaid expansion under the Affordable Care Act has been one of the most effective tools for reducing uninsured rates among low-income adults. As of 2024, 40 states and the District of Columbia have expanded Medicaid. However, the 10 non-expansion states—primarily in the South—continue to leave millions without coverage. Expanding Medicaid in these states would provide insurance to an estimated 1.5 million uninsured adults, many of whom have chronic conditions like diabetes. KFF research shows that expansion states have seen improvements in access to care, affordability, and health outcomes for people with chronic diseases.

In addition to expansion, states can adopt policies to simplify enrollment, eliminate premiums and cost-sharing for low-income enrollees, and provide continuous coverage for 12 months regardless of changes in income. These measures reduce churning and ensure that patients with diabetes do not experience disruptions in their care.

Sliding-Scale and Subsidized Insurance Programs

For individuals who do not qualify for Medicaid, sliding-scale insurance programs and subsidies through the Affordable Care Act marketplace can help make coverage more affordable. Enhanced premium tax credits and cost-sharing reductions lower out-of-pocket expenses for people with incomes between 100% and 400% of the federal poverty level. However, awareness of these subsidies remains low, and many eligible individuals do not enroll. Outreach and enrollment assistance—particularly in marginalized communities—is essential to maximize the impact of these programs.

Additionally, some states have created their own basic health programs or public option plans that provide comprehensive coverage at low cost. These models can be particularly beneficial for people with diabetes, as they typically cover essential health benefits including prescription drugs, behavioral health, and disease management programs.

Value-Based Care and Integrated Models

Value-based care models, such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), have the potential to improve diabetes care for insured populations by emphasizing prevention, care coordination, and population health management. For example, the Medicare Diabetes Prevention Program and initiatives to pay for insulin based on outcomes rather than volume can reduce overall costs while improving health. However, these models require adequate insurance coverage to function effectively. Without a baseline of coverage, patients cannot participate in preventive programs or access primary care providers who coordinate care.

Telehealth and Remote Monitoring

The expansion of telehealth during the COVID-19 pandemic has shown promise for improving diabetes management in underserved communities. Telemedicine allows patients to consult with endocrinologists, diabetes educators, and dietitians without traveling long distances. Continuous glucose monitoring (CGM) devices can be prescribed and managed remotely, providing real-time data to providers. However, insurance coverage for telehealth and CGM varies widely. Private insurers, Medicare, and Medicaid have expanded coverage for telehealth services, but some limitations remain, such as requirements for in-person visits or restrictions on the types of providers who can bill for telemedicine. Advocating for permanent parity in telehealth reimbursement is a critical policy priority.

Community-Based Interventions to Address Disparities

Policy changes alone are insufficient without community-based interventions that address the unique needs of marginalized populations. Culturally competent care, community health workers, and peer support programs can bridge gaps in the healthcare system.

Culturally Competent Diabetes Education

Diabetes self-management education (DSME) is a cornerstone of effective diabetes care, yet many marginalized populations have limited access to programs that reflect their cultural context. Culturally tailored DSME programs—such as those offered in Spanish or other languages, incorporating traditional foods and recipes, or delivered through faith-based organizations—have been shown to improve glycemic control and self-care behaviors. Healthcare systems should invest in developing and funding such programs in partnership with community organizations.

Community Health Workers

Community health workers (CHWs) are frontline public health workers who share backgrounds and experiences with the populations they serve. They can help patients navigate insurance enrollment, schedule appointments, communicate with providers, and manage daily diabetes tasks. CHWs also play a crucial role in building trust, particularly in communities that have historically experienced discrimination in healthcare. The American Diabetes Association recommends integrating CHWs into diabetes care teams as a strategy to reduce disparities.

Reducing Logistical Barriers

Transportation, childcare, and paid time off are often overlooked barriers to diabetes care. Patients without reliable transportation may miss appointments; those who cannot take time off work may skip follow-up visits. Community-based programs that offer transportation vouchers, telehealth options, or extended clinic hours can help. Additionally, providing diabetes supplies and medications at no cost in community settings—such as food pantries or mobile clinics—can address immediate needs while patients work to obtain insurance.

The Role of Healthcare Providers

Healthcare providers are on the front lines of identifying and mitigating insurance-related barriers. Screening patients for social needs—including insurance status, food insecurity, and medication costs—is a first step. Providers can then connect patients with resources such as patient assistance programs, sliding-scale pharmacies, or state-based insurance counselors.

Prescribing practices also matter. Choosing medications and supplies that are on a patient's insurance formulary is essential for adherence. When insurance coverage is uncertain, providers can prescribe 90-day supplies of medications to reduce the frequency of pharmacy visits. They can also advocate for patients by writing letters of medical necessity for coverage of advanced technologies like insulin pumps or CGM systems.

Finally, providers should be trained in cultural humility and implicit bias to ensure that all patients receive respectful, equitable care. Disparities in diabetes outcomes are not solely attributable to insurance gaps; they are also shaped by how patients are treated within the healthcare system. Addressing both structural and interpersonal factors is necessary for meaningful change.

Moving Towards Health Equity

Insurance coverage gaps are a powerful driver of diabetes health disparities in marginalized populations. By limiting access to timely diagnosis, ongoing treatment, and self-management support, these gaps contribute to higher rates of complications, hospitalizations, and mortality. However, the situation is not immutable. A combination of policy reforms—including Medicaid expansion, enhanced subsidies, and value-based payment models—along with community-based interventions and provider-level actions can reduce these disparities.

Equitable access to healthcare is not just a matter of fairness; it is a public health imperative. Diabetes is one of the most common and costly chronic diseases, and its burden falls disproportionately on those who already face the greatest social and economic challenges. Closing insurance gaps is a tangible step toward a future where everyone—regardless of race, income, or geography—can achieve optimal diabetes outcomes.

For more information on diabetes disparities and policy recommendations, see the American Diabetes Association and the National Institutes of Health resources on health equity.