Federally qualified health centers, commonly known as FQHCs, are community-based clinics that receive federal funding to provide primary care to medically underserved populations, regardless of a patient’s ability to pay. They serve as the medical home for millions of Americans who lack insurance, live below the federal poverty level, or face geographic and linguistic barriers to care. Because these clinics concentrate some of the most socially vulnerable patients in the country, they offer a unique window into how diabetes is really being managed at the bottom of the socioeconomic spectrum—a population that is often invisible in national surveys and clinical trials.

The research team, led by Young-Rock Hong of Emory School of Medicine and Ashby F. Walker of the University of Florida, conducted a cross-sectional analysis of electronic health record data from 40 federally qualified health centers spanning 17 states during 2024. The cohort included 16,267 adults aged 18 to 75 years with either type 1 diabetes or type 2 diabetes treated with insulin. The investigators examined demographic and socioeconomic characteristics, calculated weighted mean HbA1c values, measured the proportion of patients with HbA1c above 9.0 percent, and documented the use of continuous glucose monitors and insulin pumps. Glycemic control was then compared across race and ethnicity, insurance type, and federal poverty level, allowing the team to map the social contours of blood sugar control with unusual granularity.

The demographic profile of the cohort underscores who relies on safety-net care. Just under 14 percent of patients had type 1 diabetes, an autoimmune condition that absolutely requires insulin for survival, while the remainder had type 2 diabetes complicated enough to necessitate insulin injections. More than half of the patients were female, 39 percent were Hispanic, and 28 percent were non-Hispanic Black. Most strikingly, 53.8 percent of the entire cohort lived below the federal poverty level. These are patients for whom the daily arithmetic of diabetes—insulin dosing, carbohydrate counting, glucose checking—collides with food insecurity, unstable housing, and the constant pressure of economic precarity.

The headline finding was the glycemic burden itself. The weighted mean HbA1c across the cohort was 9.09 percent, well above the generally recommended target of below 7 percent for most adults, and 50.8 percent of patients exceeded 9.0 percent. For context, HbA1c reflects average blood glucose over roughly the preceding two to three months, because glucose molecules irreversibly bind to hemoglobin in red blood cells. Every sustained elevation translates into cumulative damage to blood vessels, nerves, kidneys, and eyes. An HbA1c persistently above 9 percent corresponds to average glucose levels far beyond the renal threshold, and it is associated with sharply increased risks of retinopathy, nephropathy, neuropathy, cardiovascular disease, and acute crises such as diabetic ketoacidosis.

The disparities within the cohort were equally consequential. Glycemic control varied significantly by race and ethnicity, by insurance type, and by poverty level, with each comparison reaching statistical significance. Non-Hispanic Black patients with type 1 diabetes had the highest mean HbA1c of any subgroup, at 9.83 percent—a figure that is especially alarming because type 1 diabetes is unforgiving without adequate tools and support. Uninsured patients fared worst overall, with a mean HbA1c of 9.51 percent, a finding that speaks directly to the consequences of fragmented access to medications, supplies, and specialist care. The gradient across poverty levels reinforces what diabetes researchers have long suspected: glycemic control is not merely a matter of individual willpower but is structurally determined by the resources patients can bring to bear on their disease.

Perhaps the most sobering numbers in the study concern technology. Continuous glucose monitors, which sample interstitial glucose every few minutes and stream the data to a smartphone or reader, and insulin pumps, which deliver precise, adjustable doses of insulin through a subcutaneous catheter, have become standard of care in much of endocrine practice. Clinical guidelines increasingly recommend CGM for all patients on insulin, and automated insulin delivery systems that couple pumps to CGM sensors have demonstrated substantial improvements in time-in-range and reductions in hypoglycemia. Yet in this nationwide safety-net cohort, documented CGM use was just 1.8 percent overall and insulin pump use just 2.9 percent. Even among patients with type 1 diabetes—the group for whom these devices are most clearly indicated—only 4.3 percent had documented CGM use and only 7.8 percent used a pump.

The word documented deserves emphasis. The researchers measured what was recorded in the electronic health record, and it is possible that some patients obtained devices outside their health center’s system, or that clinicians failed to record device use consistently. But even granting generous margins for documentation gaps, the order of magnitude is unmistakable. National data from endocrinology practices and commercial insurance claims suggest CGM adoption rates among insulin-using patients that are many times higher than what was observed here. The gap is not a mystery of biology; it is a story of cost, coverage, referral pathways, and the practical realities of delivering technology-intensive care in clinics that are often stretched to their limits.

Diabetes technology is expensive, but the economics are more complicated than a simple price tag. CGM sensors and pump supplies require reliable insurance coverage or out-of-pocket spending that is prohibitive for patients living below the poverty line. Devices also demand training, technical support, and data review during clinical encounters—resources that safety-net clinics may struggle to provide. Prior authorization requirements, device-specific coverage criteria, and the administrative burden of applications can stall prescriptions indefinitely. Meanwhile, patients juggling multiple jobs, transportation challenges, and language barriers may find the onboarding process for these systems effectively inaccessible even when coverage exists on paper. The result is a self-reinforcing loop in which the patients who stand to benefit most from technology are the least likely to receive it.

The authors of the study describe their findings as establishing a critical contemporary baseline for this population and highlight an urgent need for targeted interventions to improve glycemic control and expand technology access in safety-net settings. That framing matters, because baselines are what make progress measurable. The work was supported by the Leona M. and Harry B. Helmsley Charitable Trust, and portions of the results were previously presented at the International Conference on Advanced Technologies and Treatments for Diabetes in Amsterdam and at the American Diabetes Association’s Scientific Sessions in Chicago. As automated insulin delivery, smarter sensors, and data-driven care models accelerate for the insured, studies like this one serve as a reminder that the benefits of biomedical innovation are not self-distributing. Closing the gap will require deliberate policy—expanded coverage, streamlined prior authorization, investment in clinic infrastructure, and diabetes education programs designed for the communities that safety-net clinics serve. Otherwise, the technological revolution in diabetes care risks becoming one more axis along which American health outcomes diverge.

Subject of Research: Glycemic control and diabetes technology use among insulin-requiring adults treated at US federally qualified health centers

Article Title: Characterizing glycemic control and technology use among insulin-requiring patients at federally qualified health centers: a cross-sectional study

Article References: Characterizing glycemic control and technology use among insulin-requiring patients at federally qualified health centers: a cross-sectional study. (n.d.). https://doi.org/10.1186/s12902-026-02541-2

Image Credits: AI Generated

DOI: 10.1186/s12902-026-02541-2

Keywords: diabetes, HbA1c, federally qualified health centers, continuous glucose monitoring, insulin pumps, health disparities, type 1 diabetes, type 2 diabetes, safety-net care, health equity, diabetes technology, uninsured patients