Structural racism is not an abstract concept confined to sociology textbooks—it is a lived reality that shapes health outcomes for millions of Americans. In the context of diabetes, the data is stark: Black, Hispanic, Indigenous, and other racialized communities experience higher rates of diagnosis, more severe complications, and earlier mortality than their white counterparts. These inequities are not accidents of biology or individual behavior. They are the predictable result of centuries of discriminatory policies embedded in housing, education, employment, and, critically, healthcare delivery. Understanding how structural racism operates within the diabetes care ecosystem is the first step toward building a system that delivers health equity.

Defining Structural Racism in a Healthcare Context

Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. Unlike individual prejudice or interpersonal bias, structural racism is not about one person’s behavior. It is about the policies, practices, and norms that have been normalized over time and continue to produce inequitable outcomes. In healthcare specifically, structural racism manifests in the uneven distribution of resources, the design of insurance systems, the location of hospitals and clinics, the content of medical education, and the implicit biases that affect clinical decision-making.

The American Medical Association has explicitly recognized racism as a public health threat, and major government agencies such as the Centers for Disease Control and Prevention (CDC) now track structural racism as a determinant of health outcomes. This shift in institutional recognition is important, but it has not yet translated into the systemic changes needed to close racial gaps in diabetes care.

The Epidemiology of Racial Disparities in Diabetes

Examining the data reveals the depth of the disparity. According to the American Diabetes Association, non-Hispanic Black Americans are 60% more likely to be diagnosed with diabetes than non-Hispanic white Americans. Hispanic Americans have a 70% higher risk, and American Indian and Alaska Native adults are more than twice as likely to have diabetes. These disparities begin early and compound over a lifetime.

Beyond prevalence, outcomes are dramatically worse for minorities. Black adults with diabetes are 2.3 times more likely to undergo a lower-extremity amputation than white adults with diabetes, according to research published in JAMA Network Open. Hispanic individuals with diabetes are significantly more likely to develop end-stage renal disease, and Indigenous populations experience some of the highest rates of diabetic complications in the world. These statistics are not driven by genetics alone—they are driven by differential exposure to risk factors, differential access to care, and differential quality of care.

Pathways from Structural Racism to Diabetes Inequity

Residential Segregation and the Built Environment

Decades of redlining and discriminatory housing policies have concentrated racial minorities in neighborhoods with fewer resources. In these communities, one often finds fewer grocery stores with fresh produce, more fast-food outlets, fewer safe parks and recreational spaces, and higher levels of air pollution. These environmental characteristics directly influence diabetes risk: limited access to healthy food increases obesity rates, lack of safe spaces for physical activity reduces exercise, and chronic stress from neighborhood violence or economic precarity elevates cortisol levels, which in turn can impair glucose metabolism.

Economic Inequity and Insurance Coverage

Structural racism has produced a racial wealth gap that persists across generations. Black and Hispanic families have significantly lower median household incomes and less accumulated wealth than white families. This economic disadvantage translates into higher uninsured rates and underinsurance. Even after the Affordable Care Act expanded coverage, gaps remain. People without stable insurance are less likely to receive preventive diabetes screenings, less likely to afford medications, and less likely to have consistent disease management. They are also more likely to rely on emergency departments for acute complications rather than on primary care for ongoing management.

Healthcare System Factors

Healthcare systems themselves perpetuating disparities. Clinics and hospitals in minority neighborhoods are often underfunded, understaffed, and less likely to offer advanced diabetes management programs, such as continuous glucose monitoring systems, diabetes self-management education, or access to endocrinologists. Additionally, the implicit biases of healthcare providers can lead to less aggressive treatment of minority patients. Studies have shown that Black patients with diabetes are less likely to be prescribed newer, more effective medications and are less likely to be referred for specialty care. They also report experiencing discrimination during medical encounters, which reduces trust and adherence.

Barriers to Healthcare Access in Detail

The original article listing of barriers to healthcare access is accurate but can be expanded to capture the complexity of the lived experience. Below is a more detailed examination of each barrier as it pertains to racialized communities living with diabetes.

Limited Healthcare Facilities and Provider Shortages

Racial and ethnic minority communities are disproportionately served by federally qualified health centers (FQHCs) and other safety-net providers. While these centers are essential, they are often stretched thin, with fewer specialists and longer wait times for appointments. For a patient with diabetes, waiting weeks for a routine visit can delay critical interventions such as medication adjustments or foot exams. The shortage of endocrinologists is particularly acute in underserved areas, meaning that minority patients frequently receive diabetes care from primary care providers who may have less experience with complex management.

Economic Barriers at Every Turn

Diabetes is an expensive disease. The direct medical costs of diabetes in the United States exceeded $237 billion in 2017. For individuals, the cost of insulin, test strips, pumps, and doctor visits can be prohibitive, even for those with insurance. High deductible health plans and coinsurance rates create financial toxicity that disproportionately affects minority populations. Many patients ration their insulin or skip doses to save money, a dangerous practice that can lead to diabetic ketoacidosis or hypoglycemic emergencies. Economic barriers also extend to the cost of healthy food, diabetes-friendly meal delivery, and transportation to appointments.

Transportation as a Determinant of Health

Lack of reliable transportation is a major barrier for individuals living in food deserts or in neighborhoods underserved by public transit. For a patient who needs to see a podiatrist every three months, pick up prescription refills, and attend a diabetes education class, multiple trips can be logistically impossible without a car. This is a particularly acute problem for elderly individuals with diabetes, who may also have mobility limitations. Telehealth has partially addressed this gap since the COVID-19 pandemic, but not all patients have reliable internet access or devices capable of video visits.

Discrimination, Bias, and Mistrust

Experiencing or anticipating discrimination within healthcare settings is a powerful deterrent to seeking care. A growing body of research documents that minority patients receive less empathetic communication, shorter visit times, and fewer opportunities to ask questions. Historical abuses—such as the Tuskegee syphilis study—combined with contemporary experiences of dismissive care create a legacy of mistrust. For a patient of color with diabetes, this mistrust may manifest as reluctance to accept a new medication, skepticism about provider recommendations, or avoidance of care altogether until a crisis occurs.

Impact on Diabetes Outcomes: What the Data Show

The consequences of these barriers are measurable and devastating. Racial minorities with diabetes consistently experience higher rates of acute complications, chronic complications, and mortality.

Delayed Diagnosis and Advanced Disease at Presentation

Because of reduced access to primary care and preventive screening, minority patients are often diagnosed with diabetes at a later stage. At the time of diagnosis, they are more likely to already have complications such as diabetic retinopathy, kidney disease, or cardiovascular damage. This delayed diagnosis means that what could have been managed with early lifestyle intervention or metformin alone often requires more aggressive treatment from the outset.

Poor Glycemic Control

Multiple studies have found that Black and Hispanic patients with diabetes have higher average HbA1c levels compared to white patients, even after adjusting for socioeconomic status. This gap in glycemic control reflects not just medication adherence but also the cumulative effect of structural barriers: inconsistent access to medications, food insecurity, chronic stress, and poor health literacy, all of which are shaped by structural racism. Achieving glycemic control is difficult for anyone with diabetes, but the systemic obstacles faced by minority patients make it substantially harder.

Higher Rates of Amputation, Renal Failure, and Cardiovascular Disease

Perhaps the most graphic illustration of structural racism in diabetes is the excess of lower-extremity amputations among minority patients. Black patients with diabetes are 2.3 to 3 times more likely to undergo amputations than white patients. This disparity persists even in health systems that provide universal coverage, such as the Veterans Health Administration, suggesting that factors beyond insurance status—such as provider bias, reduced access to podiatry, and longer travel to wound care centers—are at work. Similarly, the incidence of end-stage renal disease among Hispanic and Indigenous individuals with diabetes is markedly higher than that of the white population, and cardiovascular mortality is elevated across all minority groups.

Strategies for Dismantling Structural Racism in Diabetes Care

Addressing the impact of structural racism on diabetes requires a multi-level approach that goes beyond individual behavior change or clinical interventions. The strategies below align with recommendations from organizations such as the National Institute of Diabetes and Digestive and Kidney Diseases and the CDC.

Policy and Systems-Level Reforms

Structural change begins with policy. This includes expanding Medicaid in states that have not yet done so, eliminating cost-sharing for diabetes medications and supplies, and enforcing stronger anti-discrimination protections in healthcare settings. The Inflation Reduction Act’s cap on insulin co-pays for Medicare beneficiaries is a step forward, but it does not cover the uninsured or those with private insurance. Universal coverage for diabetes self-management education, medical nutrition therapy, and continuous glucose monitoring is also essential. Additionally, policies that address the social determinants of health—such as housing vouchers, food assistance programs, and investment in public transit—are indirect but powerful interventions for diabetes equity.

Community-Engaged Approaches

Top-down interventions often fail in minority communities because they do not account for local contexts, cultural differences, or community priorities. Effective programs are co-designed with community members, leveraging community health workers, lay health educators, and trusted institutions such as churches or community centers. Diabetes self-management programs that are culturally tailored—using familiar foods in dietary guidance, incorporating family support structures, and providing health education in the patient’s primary language—have demonstrated stronger outcomes than generic programs.

Healthcare Provider Education and Anti-Bias Training

Implicit bias is pervasive in healthcare, but it can be mitigated. Training programs that teach providers about the clinical impacts of structural racism and provide tools for delivering culturally sensitive care should be integrated into medical education and continuing medical education. However, training alone is insufficient unless it is paired with institutional accountability—measuring and reporting quality metrics by race and ethnicity, implementing proactive systems to ensure all patients receive standard-of-care treatments, and creating feedback loops that hold providers and institutions responsible for disparities.

Research and Data Transparency

What is not measured cannot be fixed. Healthcare systems and insurers must collect and publicly report diabetes outcomes disaggregated by race, ethnicity, and other social identifiers. Researchers must prioritize studies that examine the root causes of disparities, including the role of structural racism, rather than simply documenting differences in outcomes. Funding agencies such as the National Institutes of Health have begun to require that grant applications address health equity, but this focus must translate into dedicated funding streams for community-based participatory research.

Improving Access to Care in Underserved Areas

Telehealth offers a promising avenue for reaching patients who face transportation barriers or live in areas with few specialists. However, the digital divide must be addressed. Programs that provide low-cost internet access, loaner tablets, and digital literacy training are essential for ensuring that telehealth expands rather than widens inequities. Mobile health units that bring diabetes care directly into neighborhoods, pharmacotherapy services in retail clinics, and school-based health programs are other strategies that have shown success in reaching underserved populations.

Conclusion: Moving from Awareness to Action

Structural racism is not an immutable force—it is a product of human decisions and therefore can be changed by different human decisions. The data on diabetes disparities in the United States are not merely a statistical curiosity; they represent millions of lives cut short, limbs lost, and kidneys failed, all because the systems that should serve everyone instead serve some far better than others. Addressing the impact of structural racism on diabetes healthcare access and outcomes is not an act of charity. It is an ethical and medical imperative. By implementing policy reforms, engaging communities, training providers, and holding institutions accountable, it is possible to build a healthcare system where a person’s race or ethnicity no longer predicts their likelihood of developing diabetes or dying from it.

Health equity is within reach, but only if we are willing to name the problem—structural racism—and commit to dismantling it across every level of society. For clinicians, researchers, policymakers, and patients alike, the work begins with understanding and ends only when the gaps are closed.