Money matters in type 1 diabetes: how technology access and affordability impact HbA1c in kids worldwide

Since its discovery, insulin has been and continues to be the essential therapy for the management of type 1 diabetes (T1D). In recent years, the management of T1D has changed dramatically thanks to new technologies available for both insulin delivery and blood glucose measurement. 

Continuous glucose monitors (CGM) are now used by many to measure minute-to-minute blood sugar values, giving a fuller picture of the dynamics of blood sugar levels without frequent finger pricks and glucometer sticks. Importantly, access to more long-established technology like glucometers remains necessary for CGM users and non-users alike. Rather than multiple daily injections, many people now choose insulin pumps (also known as continuous subcutaneous insulin infusion) as their insulin delivery method. 

The most recently available technology are automated insulin delivery (AID) systems (also known as artificial pancreas or hybrid closed-loop systems) where insulin pumps automatically adjust insulin delivery based on CGM readings to help manage some fluctuations in blood sugar. Notably, they do require manual input for insulin bolus adjustments. Today, Diabetes Canada recommends the use of these newer technologies, including AID systems, for all people with T1D who wish to use them, including children, for their established benefits for both quality of life and HbA1c outcomes. However, access to and affordability of newer technologies is a challenge in Canada and even more so in developing countries.

How does access impact A1C?

HbA1c, A1C, or glycated hemoglobin is a single measurement that indicates average blood glucose levels over the past two to three months. For adults living with T1D, the target HbA1c is typically less than 7%, although it can vary, and the International Society for Pediatric and Adolescent Diabetes (ISPAD) target for children is less than 6.5%. A 2025 study compared average HbA1c of children with T1D by the local access to and reimbursement for insulin, glucometers, CGMs, and insulin pumps. This study included data from 42 349 children and young adults (< 21 years old) with T1D, from 81 centers across 56 countries. 

Centers were classified according to availability and reimbursement as: 

1. Fully available and reimbursed
2. Limited reimbursement
3. Out of pocket payment
4. No availability or by sponsors

Reimbursement for T1D tech varies globally

In 19 out of 56 countries (34%), there was complete reimbursement for all 4 categories (insulin, CGM, insulin pumps, and glucometers). On the other hand, 8 countries had no reimbursement for insulin or these technologies. Reimbursement for CGM was more common than reimbursement for insulin pumps and AID systems and the majority of countries outside of Europe did not have full insulin reimbursement. 

Reimbursement is associated with lower HbA1c

Having availability and full reimbursement for these 4 categories was associated with lower average HbA1c values. Centers with full availability and reimbursement for CGM had an average HbA1c of 7.6% compared to 9.6% for centres where there was no reimbursement or that relied on sponsors. Similarly, centres with full availability and reimbursement for insulin pumps, glucometers, or insulins on had an average HbA1c of 7.6-7.7% compared to 10.1-10.5% for centres without access to any reimbursement for each. 

Reimbursement is associated with attaining HbA1c targets

When children had full access and reimbursement for insulin pumps or CGM, around 19% reached target HbA1c goals (< 6.5%). With limited reimbursement, this number was around 10% and, where payments are out of pocket or where these technologies are not available at all, only 5-8% achieved this target. 

What we know about socioeconomic disparities in Canada

Canadian centers in Alberta and Nova Scotia were considered as limited reimbursement for insulins in this study because certain widely used insulins in other provinces are not fully covered or have some access limitations (e.g., copayments or limiting criteria). Also, in Quebec, insulin pumps are only available to those starting this therapy under age 18, highlighting the room for improvement here in Canada. 

Apart from public health insurance, socioeconomic factors play a huge role in individual and population health outcomes. Data from the BETTER registry has shown that T1D is no exception; higher socioeconomic status is associated with less short- and long-term complications and greater technology use. On the other hand, there are Canadian credits and benefits that can be used to help support eligible people and families with T1D, partially compensating for the high costs related to diabetes management.

Overall, this data suggests that limiting inequities and making essential parts of the treatment (insulin, CGM & pumps) accessible while limiting costs for people living with T1D, is an imperative to help people achieve glycemic goals to prevent serious complications.

Want to get involved in research?

If you would like to contribute your lived experience to research that can be used to advocate for better coverage, join the BETTER registry today!

Reference:

Santova A, de Bock M, Lanzinger S, Goldbloom EB, Bratina N, Barcala C, Alhomaidah D, Pande AR, Guness PK, Dzivite-Krisane I, Limbert C, Sumnik Z; SWEET Study Group. Global Inequities in Diabetes Technology and Insulin Access and Glycemic Outcomes. JAMA Netw Open. 2025 Aug 1;8(8):e2528933. doi: 10.1001/jamanetworkopen.2025.28933. PMID: 40864470; PMCID: PMC12391998.