Closing Gaps in Stroke Care Starts With Defining the US Health Care Safety Net

Safety-net medical centers serve a crucial role in the US health care system, providing care for low-income, uninsured, and vulnerable patient populations. But for safety-net centers to maintain the funding and staff needed to deliver optimal stroke care, the very definition of a safety net must first be made clearer, according to an expert panel at the at the 2026 International Stroke Conference.

As the crowd continued to trickle into the early-morning session, Paula Chatterjee, MD, MPH, assistant professor of medicine at the University of Pennsylvania, general internist, and policy researcher, couldn’t help but point out the impressive attendance for a 7:30 AM start. Disparities in care have garnered increased attention across disease states in recent years, and stroke is no exception.

Defining Safety Net in the US Health Care System

Chatterjee emphasized that a wide range of medical centers could be defined as safety net, meaning the challenge is defining true safety-net hospitals across geographic regions to then allocate resources appropriately. While many think of urban hospitals in the context of safety-net care, rural centers can just as well be safety-net providers—the challenge is creating a definition that encompasses both.

And defining safety-net care, Chatterjee said, is crucial from a policy standpoint because safety-net hospitals require financial support, and they cannot receive that support if they are not well-defined. In this area, policy intent and reality have yet to align.

“We're seeing a mismatch between where financial support is supposed to be going to support the safety net and what the reality of safety net hospitals actually is, and that's why I think definition matters,” Chatterjee explained. “If you can't get money to where you think it needs to go, you're not going to achieve your policy goal.”

While different in many ways, rural and urban safety-net hospitals share some common traits, according to Chatterjee:

1. They disproportionately serve patients who bear structural determinants of health
2. Facilities face financial challenges providing care that is not compensated
3. There are limited resources to improve outcomes and contain costs

Despite these common issues, rural and urban safety-net hospitals require distinct policy solutions, Chatterjee said. In the rural setting, safety net facilities are often smaller than urban safety-net centers, and they tend to be geographically isolated. Rural facilities may also treat less Medicaid-insured patients in states that did not expand Medicaid, leading to more uncompensated care than at urban centers, which are often in cities in Medicaid expansion states, Chatterjee explained.

While potential solutions to support rural safety-net centers include bolstering transfer networks for timely stroke care, building the workforce by recruiting and training people from rural areas to work in rural health centers, or even upfront investments to drive updates to rural safety-net medical centers, these solutions cannot be implemented if the targets are not clear.

“I'll end where I started and say that the US health care safety net is broad and diffuse,” Chatterjee said. “It is something that we need to define with a big tent definition but not be so imprecise that we don't actually achieve the policy goals that we're seeking out to achieve.”

Barriers to Evidence-Based Stroke Care in Safety-Net Hospitals

With the challenges around defining safety-net care and barriers to care improvement laid out, Nicole Gonzales, MD, FAHA, professor in the Department of Neurology at University of Colorado Anschutz, highlighted the overwhelming nature of even conceptualizing the issues affecting safety-net facilities in the US. In the context of delivering high-quality, evidence-based stroke care, there are obstacles to overcome at the patient, institutional, policy levels.

“What is true at all levels is, despite all the information that we have telling us about all of the different ways that inequity shows up in stroke care, there's a striking lack of knowledge about how we impact that,” Gonzales said.

Institution-level barriers include staffing challenges and burnout, emergency department inefficiencies, imaging and diagnostic barriers, and stroke center certification and post-acute care, among others, Gonzales said. Some issues, especially workforce shortages, worsened during and after the COVID-19 pandemic, she added. Issues like stroke center certification, she explained, may even be solved if the initiative is taken at the provider level to question why a center is not certified.

“People are creative and resourceful, and we surprise ourselves all the time, and some of these strategies can become feasible within safety-net hospitals when they're paired with the right policy,” Gonzales said. Policy can significantly shape stroke care, amplifying or attenuating certain struggles. For example, value-based penalties can disproportionately affect safety-net hospitals, increasing strain on systems if social risk is not fully adjusted.

As far as what can work to make progress on the many issues impacting stroke care at safety-net systems, many solutions come down to appropriate tailoring for the target system and community. Even something as seemingly straightforward as increasing stroke symptom recognition education in the community—including emergency medical service providers, physicians, and neurologists—is important and effective, but this education must be community-based, multi-modal, and culturally tailored to have the greatest impact, Gonzalez said. A common problem with such programs is that they are launched with grants that dry up and render programs unsustainable.

Mobile stroke units are another intervention with potential to address disparities in stroke treatment, with research showing potential to reduce time to treatment in underserved and marginalized communities.¹ Government legislation could also be more wide spanning, like a Lithuanian national policy that improved access to reperfusion therapy and increased treatment at stroke centers.²

“The goal is not to do everything that we know works, the goal is to pick one thing and start there,” Gonzales concluded. “Find it, adapt it, tailor it, iterate it, and learn from it. And this is about progress that is meaningful because it's locally designed with local people who are invested parties, and that helps with sustainability, as well.”

Telestroke as a Bridge for Access Gaps and Financial Threats to Rural Hospitals

Bart M. Demaerschalk, MD, FAHA, professor emeritus of neurology at Mayo Clinic College of Medicine and chief digital office and director of vascular brain health at Atria Research and Global Health Institute, discussed the evolution of telemedicine as a bridge to underserved areas. Reflecting on his work with the Mayo Clinic's telestroke network, he noted that while telestroke can equalize emergency metrics—such as diagnosis accuracy and thrombolysis eligibility—outcomes can still suffer post-emergency if the partnership isn't integrated into the hospital's broader culture.

“You've heard from our speakers about the cost of care and the financial constraints that affect rural, remote, underserved, safety-net hospitals in rural communities,” Demaerschalk said. “We're also not well-served in terms of our diagnostic coding and reimbursement. In particular, with individuals with large-vessel occlusion ischemic stroke, costs are higher than for small-vessel ischemic stroke, but the reimbursement may not be on par.” Safety-net hospitals in rural communities, particularly for those large-vessel occlusion ischemic stroke patients that are not candidates for thrombectomy, have higher costs of care in community hospitals without adequate reimbursement, he explained.

The adoption of telestroke has also been disproportionately driven by competition and financial status in urban areas, whereas in rural settings, it remains a vital necessity for basic access. Demaerschalk pointed to the FAST Act and expanded Medicare telestroke billing as essential drivers for continued growth in both settings.

Demaerschalk reiterated the potential of technology to facilitate stroke care in the community, including equipped mobile stroke units and telerobotic stroke interventions, which have potential to address gaps in stroke treatment availability outside of major centers. Still, much work is needed to operationalize something like telerobotic medicine, he noted.

He closed his talk with an emphasis on teamwork to address the issues he and other presenters discussed.

“I'll summarize by saying this is our collective challenge—for us here and for you in the audience. What have we witnessed together as the as the barriers?” Demaerschalk asked. “What challenges can be overcome, and what solutions are present today, and what's in store for us in the future?”

Tim Putnam, DHA, LFACHE, faculty member at the Medical University of South Carolina, former president of the National Rural Health Association, and former CEO of critical access hospitals in Illinois and Indiana, drew on decades as a hospital CEO and EMT to illustrate how fragmented systems—rather than a lack of clinical knowledge—continue to delay stroke care, particularly in rural communities.

“It's not about a lack of good people, it's not about a lack of resources,” Putnam said. “Many times, it's not about a lot of research. It's about doing the right things and coordinating it together. You have heard of the US healthcare system—it doesn't exist.” Putnam argued that the US does not operate as a cohesive health care system, and that emergency care teams in rural areas essentially rebuild workflows for every patient encounter rather than standardizing the process. This is a persistent challenge in the realm of stroke care, where seconds matter when it comes to treating patients for the best possible outcomes.

Putnam noted that many rural hospitals are cutting services or placing essential staff on call—often signs of financial distress preceding closure. In outlining financial challenges, he added that the One Big Beautiful Bill Act created more issues for rural hospitals but trimming back the provider tax and changing the 340B program that do not stand to benefit rural systems. The changes to Medicaid work requirements can also lead to losses. Overall, reimbursements will drop an estimated 4% for hospitals,³ he explained.

The new $50 billion Rural Health Care Transformation Fund, while intended to quell some of these impacts, may allow work to infrastructure, workforce, technology and building systems, Putnam said. Alabama intends to use some of these funds for a stroke trauma network, for example, while North Dakota will aim to reduce the number of strokes occurring in rural areas in the first place, and Minnesota aims to close the distance between residents and stroke centers.

“I don't know whether that's going to work or not,” Putnam said. “We'll see what happens. Everybody's doing something slightly different, but the deal is we need to build a better health care system. I cannot tell you whether this $50 billion in Rural Transformation Fund money is going to do that. It's going to start a lot of different projects, and going to start a lot of discussion.”

References

1. Grotta JC, Yamal JM, Parker SA, et al. Prospective, multicenter, controlled trial of mobile stroke units. N Engl J Med. 2021;385(11):971-981. doi:10.1056/NEJMoa2103879

2. Masiliūnas R, Vilionskis A, Bornstein NM, Rastenytė D, Jatužis D. The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania. Eur Stroke J. 2022;7(2):134-142. doi:10.1177/23969873221089158

3. Levinson Z, Neuman T, Godwin J. What are the implications of the 2025 budget reconciliation bill for hospitals? KFF. June 12, 2025. Accessed February 4, 2026. https://www.kff.org/medicaid/what-are-the-implications-of-the-2025-budget-reconciliation-bill-for-hospitals/