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Rural residents have higher rates of diabetes and diabetes-related mortality than urban residents, complicated by higher rates of uninsurance. We sought to understand the association between rurality and health insurance and diabetes-related complications and management. Electronic health record data (EHR) from safety-net clinics across four states from 2014-2019 were used. Adjusted generalized estimating equation-based logistic regression models were fit. Among 29,019 patients with diabetes, we found no association between rurality and diabetes-related complications. Patients in large rural communities had higher odds of uncontrolled blood pressure and lower odds of statin prescriptions versus urban patients. Odds of chronic and acute complications documented in the EHR were lower for uninsured than insured patients as were statin and insulin prescriptions. Rurality was not associated with acute or chronic diabetes-related complications but was associated with underlying factors. Safety-net clinics can help address differences given their role in the rural health care system.