Both insulin pump and CGM use can improve glycemic management and quality of life among youth with T1D.17 There is robust literature demonstrating the strong association between SES and attainment of glycemic goals by youth with T1D,18 19 with generally higher glucose levels among youth from racial and ethnic minoritized backgrounds.20 21 In this nationwide analysis of diabetes technology use among commercially insured youth with T1D between 2011 and 2021, black and Hispanic youth were consistently less likely to receive insulin pump or CGM compared with white youth, but this disparity was no longer present among high-income families (those earning ≥US$200,000 per year).

In multivariate analysis, black youth were significantly less likely to use insulin pumps and CGM compared with white youth, while those with annual household incomes ≥US$200,000 were twice as likely to use these technologies than those from families earning under US$40,000 when controlling for other variables. Thus, both race/ethnicity and SES are important factors that operate independently to impact the utilization of diabetes technologies, which are increasingly regarded as the standard of care for T1D management.

Our results build on prior studies conducted in single centers and specialty group collaboratives, which have demonstrated gaps in diabetes technology use by both racial and ethnic minoritized youth and by youth from low-income households.22–24 However, those studies often had relatively small sample sizes, combined adult and pediatric populations, and included multiple insurance types.22–24 As a result, knowledge gaps remained regarding the effects of household income and racial/ethnic disparities in diabetes technology utilization, which were the primary focus areas of our study.

Within the same annual income brackets, race was a strong driver of insulin pump and CGM use among youth from families with incomes <US$75,000 annually. This is consistent with a multicenter study by Lin et al, who found a significant impact of race and annual household income on prescribing insulin pumps to youth with T1D within the first year of diagnosis.21 Our findings, therefore, underscore the important independent roles of race/ethnicity and low household income in affecting utilization of advanced diabetes care.

The reduction and eventual disappearance of racial disparities in utilization of diabetes technology at higher income levels was noted to occur gradually within racial groups, except among black youth, who experienced a substantial increase in utilization of diabetes technology within the high-income bracket (≥US$200,000 annually). Possible explanations for these gaps in technology utilization include implicit bias among healthcare professionals and systemic racism disproportionately affecting low-income black people.23 This is consistent with an earlier study conducted in adults with T1D, which detected racial disparities in the utilization of diabetes technologies identified through review of electronic health records. In that study, even after adjusting for social determinants of health, glycemic control, mental health, and diabetes outcomes, black patients remained less likely to receive information about or prescriptions for diabetes technologies.25 Another potential contributing factor to gaps in technology use is a lack of trust in healthcare systems among black individuals of lower SES.24 Wealthy black families may be better able to advocate for the receipt of evidence-based, guideline-recommended care compared with those with lower incomes.

The SEARCH for Diabetes in Youth study reported similar findings, showing a twofold increase in diabetes technology use from 2001 to 2019. However, racial, ethnic, and socioeconomic disparities persisted in that study, with no improvement over two decades. Additionally, higher SES—defined in that study by household income above US$75,000, parental college education, and private insurance—was associated with greater access to diabetes technologies.26 These data align with our findings of increasing trends in the utilization of diabetes technologies over the years across all racial groups and income levels, with the exception of insulin pump use among black youth that did not see such an increase.

While all youth included in our study were privately insured, household income affects the ability to afford copayments and deductibles associated with healthcare services. Despite having health insurance, lower-income families may find themselves forced to ration their utilization of healthcare, including diabetes technologies. Further studies are needed to fully explore the causes of limited utilization of diabetes technology among low-income families, as well as ways to mitigate these barriers.

To our knowledge, this is the first nationwide study using claims data for insulin pump and CGM therapy from a large private insurance provider. By focusing on insured youth, we eliminated the impact of insurance access on the ability to access diabetes care and to obtain and use diabetes technologies, enabling us to more directly assess the effect of household income (independent of insurance coverage) and to examine racial and ethnic disparities in care potentially driven by systemic biases and racism. By including a national cohort of youth across a long time frame, we sought to maximize the sample size and enable subgroup analyses stratified by race/ethnicity and income that were previously infeasible.

Nevertheless, our findings must be considered in the context of the study’s limitations. The use of claims data precludes us from examining the potential reasons for our findings, including the attitudes of the patients, families, and healthcare teams toward diabetes technology; differences in the availability of diabetes specialists with expertise in technology use; and clinicians’ comfort levels in prescribing and managing these technologies. The study’s timeline spans over a decade—a necessity to ensure the largest possible sample size to conduct the subgroup analyses—but this time frame also spans a period in which substantial advancements in diabetes technology (eg, the hybrid closed-loop system was introduced to the market in 2016) and changes in clinicians’ and patients’ understanding of the importance of these technologies in diabetes management. Other studies indicate that although insulin pump usage increased over time between 2005 and 2019, disparities in prescribing patterns and utilization persisted.26 These disparities were characterized by higher usage among individuals with private insurance, household incomes exceeding US$100,000, and those identifying as non-Hispanic white.21

Our findings underscore the importance of targeted interventions aimed at the equitable distribution of diabetes technology across all societal groups, rather than focusing solely on expanding diabetes technology without attention to equitable reach. Data from the T1D Exchange (T1DeX) Clinic Registry demonstrated that utilization of diabetes technology can mitigate, though not entirely eliminate, the negative association between higher A1C levels, lower SES (defined in that study as household income below US$50,000), and African American race within a mixed-age cohort receiving care in the T1DeX collaborative network.27 Addressing disparities in the utilization of evidence-based and guideline-recommended technology to all youth with T1D must be a priority, with specific attention to youth from low-income racially minoritized backgrounds who experience the greatest barriers to care.

Multilevel interventions for better and more equitable access to insulin pump and CGM technology are therefore needed to alleviate racial/ethnic and income-based disparities in their utilization. In 2024, the US Internal Revenue Service classified CGMs as “preventive” treatments for people with diabetes, thereby allowing for their inclusion on preventive drug lists implemented by commercial payors and to be covered by insurance even before the annual deductible is met.28 The impact of this important policy change will need to be examined. Insulin pumps are not classified this way, however, with persistent financial barriers to accessing this essential technology. Health systems also need to invest in culturally sensitive and tailored educational interventions to enhance utilization of diabetes technology. Increasing the availability of CDCES in underserved areas and fostering individuals from diverse backgrounds to enter the CDCES and endocrinology workforce may also help eliminate bias and improve access to care. Institutional initiatives and societal campaigns are needed to raise awareness, educate, and build trust in the effectiveness of advanced diabetes technology across diverse racial, ethnic, and socioeconomic groups. Finally, empowering youth and families with the information necessary for shared decision-making and equipping them with skills to manage diabetes technology effectively are also vital for successful diabetes management.17