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Background Insurance-related disparities in access to time-sensitive neurovascular interventions and post-acute care after stroke are important to identify. However, contemporary national estimates across stroke subtypes remain limited. We sought to evaluate the degree of payer-based differences in in-hospital outcomes, procedure utilization, discharge destination, and resource use among U.S. adults hospitalized with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH).Methods We performed a cross-sectional analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (NIS), 2017-2022. Adult hospitalizations with a principal diagnosis of AIS, ICH, or SAH were included; traumatic hemorrhage was excluded. We compared private versus Medicaid insurance. Primary outcomes were in-hospital mortality, routine home discharge, non-routine discharge, length of stay (LOS), and inflation-adjusted hospitalization costs (2022 USD). Secondary outcomes included AIS reperfusion therapies (mechanical thrombectomy; intravenous thrombolysis), SAH aneurysm treatment (coiling/clipping), ICH surgical evacuation, and post-acute destination endpoints (transfer to short-term hospital as an inpatient rehabilitation facility; skilled nursing facility discharge; home health care). Survey-weighted multivariable logistic regression was used to calculate adjusted odds ratios (aOR) for binary outcomes, and survey-weighted Gamma models with a log link were used to estimate adjusted mean ratios (AMR) for LOS and cost, adjusting for demographics, socioeconomic markers, and stroke severity.Results Among 3,209,635 stroke hospitalizations, 620,605 (19.3%) had private insurance, 329,230 (10.3%) Medicaid, and 2,042,845 (63.6%) Medicare; the Medicaid-versus-private analytic cohort included 949,835 hospitalizations. In adjusted analyses, in-hospital mortality was similar for Medicaid versus private insurance (aOR 1.02, 95% CI 0.97-1.09). However, disparities emerged during the acute phase of care. In AIS, Medicaid was associated with lower odds of mechanical thrombectomy (aOR 0.78, 95% CI 0.73-0.84) and IV thrombolysis compared with private insurance (aOR 0.76, 95% CI 0.73-0.79). In ICH, Medicaid was associated with lower odds of surgical evacuation (aOR 0.68, 95% CI 0.59-0.79). Disparities persisted after the acute hospitalization. Medicaid was associated with lower odds of transfer to an inpatient rehabilitation facility (aOR 0.86, 95% CI 0.81-0.92), and higher odds of discharge to a skilled nursing facility (aOR 1.07, 95% CI 1.04-1.09) or with home health services (aOR 1.24, 95% CI 1.20-1.29). Consistent with this trajectory, Medicaid was associated with lower odds of routine discharge home (aOR 0.79, 95% CI 0.77-0.81), higher odds of non-routine discharge (aOR 1.23, 95% CI 1.21-1.26), a 29% longer length of stay (AMR 1.29, 95% CI 1.27-1.31), and 5% higher hospitalization costs (AMR 1.05, 95% CI 1.03-1.06).Conclusion In a contemporary national sample across all stroke subtypes, Medicaid status was not associated with differences in in-hospital mortality, but was consistently associated with a structurally inferior care trajectory. Compared with private insurance, Medicaid was linked to lower access to acute reperfusion therapies, less favorable post-acute discharge pathways, and greater resource utilization. These findings suggest that although payer status does not determine survival, it strongly influences the quality and continuity of care thereafter. Targeted policy interventions are needed to urgently address these reimbursement-driven disparities.Disclosures L. Khan: None. A. Salman: None. M. Abbasi: None. S. Afzal: None. F. Shafi: None. M. Ali: None. M. Omer: None. S. Patel: None. B. Alam: None.