Equitable ischemic stroke recovery depends on both acute intervention and access to rehabilitation. Prior studies have examined the relationship between insurance payor and ischemic stroke outcomes or discharge disposition. Few have investigated the role insurance payor plays in discharge to inpatient rehabilitation among intensive care unit (ICU) ischemic stroke patients receiving tissue plasminogen activator (tPA) therapy. Insurance is an important mediator of healthcare outcomes that warrants extensive scrutiny.

The MIMIC-IV v3.1 database was used to examine whether insurance payor affects discharge to inpatient rehabilitation among ICU patients with ischemic stroke treated with tPA. Adults were identified using ICD-9/10 codes and alteplase prescriptions. A simplified Elixhauser score quantified comorbidities. Logistic regression tested the association between insurance type and rehabilitation discharge, adjusting for age, sex, race, and comorbidity burden. Odds ratios were calculated to estimate the strength and direction of associations.

A total of 361 ICU ischemic stroke patients receiving tPA were included in the analysis. After controlling for age, race, sex, and comorbidities, privately insured patients and Black patients had significantly lower odds of discharge to inpatient rehabilitation compared with White and publicly insured patients. Increased age and comorbidity burden were also significantly associated with lower odds of discharge to inpatient rehabilitation.

Among ICU ischemic stroke patients receiving tPA, the association between private insurance and reduced discharge to rehabilitation is counterintuitive but may reflect stricter coverage criteria, greater availability of outpatient or home-based therapy, and differences in discharge planning pathways. Likewise, the observed racial gap underscores structural inequities that extend beyond acute stroke management. Together, these findings suggest that access to rehabilitation is shaped not only by clinical factors but also by insurance design, resource availability, and broader social determinants of care that must be further investigated.