Closing America’s Diabetes Divide: A $412 Billion Opportunity to Transform Diabetes Care

Despite significant advancements in diabetes care, millions of Americans in underserved communities still encounter daunting barriers to managing their condition. For these individuals, access to preventive screenings, affordable medications, and sustained disease management remains out of reach. 

While innovations in remote blood glucose monitoring and drug therapies have improved outcomes for many, research shows some of these breakthroughs like GLP-1s are actually widening the gap, as underserved communities remain left behind on effective and affordable access to new therapies.

Managing diabetes is an overwhelming and lifelong process, affecting over 38 million Americans, particularly in areas where resources are scarce. Care providers in these communities often face fragmented coordination, limited access to data-driven tools, and socioeconomic constraints that make achieving optimal health in their neighborhoods a challenge. This disparity between medical advancements and accessibility leaves many rural, low-income and minority communities disproportionately vulnerable to further health complications.

With diabetes now costing the U.S. healthcare system more than $412 billion annually, closing the gap requires more than cutting-edge therapeutics. A community-centered approach that integrates social drivers of health (SDOH), data-driven insights, and patient-centered strategies is essential. By addressing each community’s unique needs with tailored, culturally responsive care and cross-sector collaboration, we can empower healthcare providers to drive lasting, equitable outcomes.

Reducing costs through proactive, data-driven care

The long-term costs of diabetes-related complications — from hospital readmissions and advanced treatments for heart disease to emergency interventions for kidney failure — place an immense strain on public health systems and local healthcare providers alike. With U.S. diabetes costs expected to reach $622 billion by 2030, the need for preventive care approaches has never been more urgent, especially in communities where access to consistent treatment and care intervention is limited.

For safety net providers, identifying and monitoring high-risk patients is essential to closing care gaps and preventing avoidable complications. Automated tools that offer a comprehensive, real-time view of patient populations empower interdisciplinary care teams to pinpoint care gaps, prioritize urgent needs, and ensure timely follow-ups. By incorporating these population health insights into routine care plans, care managers can play a proactive role in treating diabetes, tailoring interventions to address the unique needs of each community.

These tools also enable interdisciplinary teams to stratify individuals by risk level to close gaps and efficiently deliver services where they’re most needed. Real-time data visualization of populations by risk level can help care teams streamline coordination, expand reach, improve engagement, and reduce health disparities associated with chronic conditions.

Closing gaps with early detection and risk identification

With an estimated 8.7 million Americans living with undiagnosed diabetes and nearly 98 million with prediabetes, early detection is key. In underserved areas, diabetes is often hindered by SDOH factors including transportation and language barriers, food insecurity, and financial and geographic limitations — making it challenging for individuals to access routine screenings and early diagnosis. Addressing these issues involves more than identifying patients at risk; it requires building culturally tailored care pathways to ensure these individuals can access the support they need.

When integrated with ADT, claims and practice management data, population health insights help identify those most at risk and intervene before complications develop. Community health centers (CHCs) and other safety net providers can help ensure timely patient follow ups after discharge, provide education, and recognize issues with medications or treatment plans, allowing care teams to identify gaps by need and ensure that at-risk individuals receive timely, personalized treatment and on-going support. This data-driven approach is key to slowing the progression of diabetes and reducing avoidable healthcare costs, while promoting equitable, sustainable outcomes for vulnerable communities.

Empowering communities through education and engagement

For diabetes patients, particularly those in underserved communities, effective disease management relies on consistent education and engagement. When patients understand their condition and are equipped with self-management tools, they can better adhere to treatment plans, make healthier lifestyle choices, and prevent complications. Community health workers and patient educators are instrumental in bridging gaps between healthcare providers and patients by offering culturally responsive education on diabetes self-management.

Referrals to Diabetes Self-Management Education (DSME) programs are crucial in guiding patients to monitor their blood glucose, make informed dietary choices, and incorporate physical activity into their routines. By integrating DSME into community settings, these programs become more accessible, fostering a supportive network for patients — particularly in areas where resources are scarce. This community-based approach to education helps empower patients to take control of their health, bolstering long-term well-being and resilience against the complications of diabetes.

Strengthening health equity with partnerships 

Addressing diabetes disparities involves not only high-quality clinical care but also ensuring that treatment is accessible, inclusive, and tailored to each community’s cultural context. Effective partnerships among healthcare providers, social care organizations, and local leaders are vital to reaching underserved populations and delivering the resources they need to manage their health.

Primary care physicians who adopt the Patient-Centered Medical Home (PCMH) model, which focuses on the whole person, can improve outcomes and reduce costs by fostering continuity and team-based quality of care. In addition, the PCMH model employs bilingual, culturally competent staff to further compassionate care delivery, making measurable strides in health equity.

Building a future of accessible, effective diabetes care 

Diabetes care management has made great strides, but fully realizing its potential requires addressing longstanding gaps in early intervention, health literacy and easily accessible care — especially through community health centers and health workers who serve as trusted local resources. Embracing data-driven insights in population health allows healthcare providers to pinpoint and prioritize at-risk individuals, ensuring that each community receives personalized, culturally competent support. 

By prioritizing early intervention, enhancing patient education, and fostering strong community partnerships, the U.S. health system can enable a future where effective, equitable diabetes management is within reach. This path not only eases the national burden but empowers underserved communities to lead healthier, more fulfilling lives, supported by care that truly meets their needs.

Photo: gustavofrazao, Getty Images

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