A cross-sectional study of 16,267 insulin-requiring adults in federally qualified health centers across 17 states found that half had dangerous blood sugar, with HbA1c above 9.0%. Use of continuous glucose monitors and insulin pumps remained under 3%, despite the availability of technologies that could reduce hypoglycemia and improve time-in-range. The finding reframes diabetes risk as a system-level issue in safety-net settings, where technology access, clinical intensity, and patient support may lag behind guideline standards. For biotech and digital health vendors, it highlights a clear implementation wedge: remote monitoring and automated insulin management tools may be most impactful where elevated HbA1c is paired with limited device uptake.