A narrative review and conceptual framework structural racism, insurance access, and black stroke outcomes

This narrative review synthesizes empirical, theoretical, and policy literature examining the intersection of structural racism and insurance access in shaping stroke inequities among Black Americans. The review introduces the Integrative Model of Stroke Inequity, which organizes the evidence into four interrelated mechanistic pathways: structural constraint, payer stratification, institutional stratification, and clinical interaction, which culminate in disparate stroke outcomes.

Despite advances in stroke prevention, acute treatment, and rehabilitation, Black Americans continue to experience disproportionate stroke burden and inequitable outcomes across the care continuum. These disparities are not fully explained by individual clinical risk factors, insurance coverage, or access to standardized care alone. Instead, they reflect broader structural and institutional processes that shape exposure to risk, access to high-quality care, treatment decisions, post-acute services, readmission, and long-term recovery.^1,2,3 REVIEW APPROACH: A narrative review approach was used to synthesize selected empirical studies, theoretical literature, clinical guidelines, and policy analyses relevant to structural racism, insurance status, payer stratification, stroke treatment, rehabilitation access, readmission, and health equity. The literature was organized thematically and interpreted through Critical Race Theory and Ecosocial Theory.^2,3 FINDINGS: Five interrelated themes were identified: structural racism as a foundational determinant of stroke inequity; payer status as a mediating mechanism; institutional stratification and site-of-care disparities; clinical interaction and treatment inequity; and standardized-system inequities conceptualized as the paradox of privilege. The first four themes map to the model's four mechanistic pathways, whereas the fifth functions as a cross-cutting construct. Evidence suggests that racial disparities persist in acute stroke treatment, rehabilitation access, and outcomes even within systems designed to standardize care.^4,5,6 CONCLUSION: Stroke inequities among Black Americans are produced through interacting structural, payer, institutional, and clinical mechanisms. The Integrative Model of Stroke Inequity distinguishes these mechanisms, clarifies how they may accumulate across the stroke continuum, and identifies points for future research, nursing and interprofessional practice, health-system accountability, and policy intervention.