Stroke Disparities: Access to Thrombectomy Uneven Across Race & Insurance

Disparities in access to life-saving treatment for ischemic stroke persist across the entire spectrum of care, even within healthcare systems designed to promote equitable access through regionalization and interhospital transfer. A recent analysis of over 300,000 stroke encounters in California between 2015 and 2021 reveals that race, ethnicity, and insurance status significantly influence where patients initially seek care, whether they are transferred to facilities capable of performing endovascular thrombectomy (EVT), and whether they receive this critical intervention.

The findings, presented at the International Stroke Conference 2026, highlight a troubling pattern: even with systems in place to ensure timely access to specialized stroke care, significant gaps remain, particularly for vulnerable populations. Luke Messac, MD, PhD, an attending emergency physician at Brigham and Women’s Hospital, and his team found that these disparities aren’t isolated to a single point in the care pathway but rather accumulate at each stage – initial presentation, transfer decisions, and EVT receipt.

Cumulative Disadvantage and the Role of Medicare

While Medicare eligibility at age 65 offers some degree of protection against these disparities, the study demonstrates it doesn’t eliminate them, especially for racially minoritized patients. For individuals under 65, the patterns of cumulative disadvantage are particularly stark. Patients who are both racially minoritized and have less favorable insurance coverage consistently experience worse outcomes.

“In patients under 65 [years], these tend to follow patterns of cumulative disadvantage, so patients who are racially minoritized or have undesirable insurance payer status tend to have the worst outcomes,” Dr. Messac explained. “In patients over 65 [years], those who are eligible for Medicare get some protected benefit from having Medicare, but not as much as you would hope, particularly if they are racially minoritized, so there are still patterns of disadvantage, even in insured patients.”

Transfer Systems: A Broken Lever for Equity?

Interhospital transfer is often considered a crucial mechanism for bridging the gap in access to specialized stroke care. However, the California study casts doubt on its effectiveness in mitigating disparities. The research indicates that for certain groups – particularly those who are racially minoritized and underinsured – the transfer system doesn’t function as intended.

“One would hope that transfer would help alleviate disparities so that patients who show up to centers without EVT capability would be able to transfer to those with EVT capability,” Dr. Messac stated. “Unfortunately, what we found is that for certain groups of patients, racially minoritized and poorly insured patients, that transfer system doesn’t work nearly as well as you would hope. So, particularly for those patients who show up to fewer resource centers, which also follow patterns of disadvantage, they’re not getting access to the best quality care that they need.”

Historical Investment and Resource Distribution

The study’s findings underscore the significant role of historical patterns of hospital investment and resource distribution in perpetuating these inequities. Patients are far more likely to present to EVT-capable centers if they are White or have private insurance or Medicare. Conversely, those without these advantages are less likely to initially seek care at facilities equipped to provide the most advanced stroke treatment.

“One thing you do see in the data that we have is that patients present to EVT-capable centers in widely disparate ways,” Dr. Messac noted. “If you are White or well insured, you have private insurance or Medicare, you are much more likely to show up to an EVT-capable center. If you are not, then you are less likely to show up to an EVT-capable center, and that often has to do with patterns of investment in racially minoritized areas, where patients who come to their closest center with stroke symptoms because of histories of disadvantage have fewer resources and therefore rely on systems of transfer that aren’t serving them as well.”

Disparities Throughout the Stroke Care Continuum

The analysis reveals that disparities emerge at every stage of the stroke care pathway – from initial presentation to an EVT-capable center, through the transfer process, and in the receipt of EVT. The fact that these disparities persist even during the transfer phase is particularly concerning, as this is a point where healthcare providers have a direct opportunity to intervene and ensure equitable access to care.

“They seem to be emerging along every stage of the continuum,” Dr. Messac explained. “So in presentation to an EVT-capable center, transfer, and EVT receipt, we see cumulative patterns of disadvantage. The transfer one is particularly disconcerting because that’s the one that we have a lot of control over. In the emergency room. I work in the emergency room. A lot of our work is deciding who needs transfer, how quickly they can be transferred, and where they’re going to be transferred to, and so seeing that pattern of disadvantage right there is particularly concerning. And that’s one that we can intervene on.”

Trust and Timely Care Seeking

The study also suggests that patient trust in the healthcare system may play a role in access to timely stroke care. Researchers observed that patients from racially minoritized groups and those with poor insurance status tended to present with more severe strokes, potentially indicating delays in seeking medical attention due to concerns about cost or a lack of trust in the healthcare system.

“One thing we did see is that the people who presented for stroke, regardless of where they presented, tended to have more severe strokes if they were from racially minoritized groups or had poor insurance status,” Dr. Messac said. “That might be people waiting at home longer or being less certain about coming into the hospital due to concerns about cost or concerns about trust. We don’t know that entirely from our data, but that is something that we need to look into further.”

Designing Future Stroke Care for Equity

As innovations in stroke care continue to emerge, it’s crucial to design these advancements in a way that avoids widening existing disparities. The study’s findings suggest that simply regionalizing systems of care and improving transfer protocols isn’t enough. A more targeted approach is needed to address the underlying systemic factors that contribute to inequities in access to stroke care.

“There’s been a ton of work done in recent years on stroke transfer patterns, in regionalizing systems of care, and in ensuring that patients who show up to less-resourced transfer centers have access to more resource centers if they need them,” Dr. Messac concluded. “But what we’re showing is that that is not yet working as intended. That is not working for the most disadvantaged patients, and it follows intersectional patterns of disadvantage, where racially minoritized and low-income patients still face the greatest barriers. And so what we need to do is figure out why those barriers still persist and what we can do to make sure that the system works for everybody.”