Background: In 2009, China launched a major health care reform aimed at providing all citizens with equal access to reasonable-quality, basic health care, with financial risk protection. However, the impact of the reform on improving stroke prognoses is unknown, especially among low-income residents. Thus, we aimed to assess the impact of the health care reform, 10 years after implementation, on improving stroke prognoses among low-income residents. Methods: Stroke events and all deaths were registered, annually, between 1992 and 2018 in a township in Tianjin, China. We analyzed changes in stroke management (rates of neuroimaging-based diagnoses and hospitalization) and prognoses (case fatality rates and recurrence) before (1992-2008) and after (2009-2018) implementation of the health care reform. Findings: In total, 1462 patients were diagnosed with first-ever stroke during the study period. For patients aged ≥45 years, the rates of neuroimaging-based diagnoses and hospitalization were greater in the 2009-2018 period than in the 1992-2008 period, regardless of patient sex or stroke type. Among all stroke patients, the one-year case fatality rate in the 2009-2018 period was significantly lower than that in the earlier period (P<0·05); the case fatality rate for women aged ≥65 years decreased by 30·0% (23·3% vs. 33·3%; P=0·043). Overall, between the two periods, the stroke recurrence rate increased 1·9-fold (P=0·001), including a 2·5-fold increase in men (P=0·010). During the 2009–2018 period, the one-year case fatality rate was higher among elderly male patients not using medical insurance than among those using it (32·8% vs. 20·7%; P=0·050). Interpretation: These findings suggest that the implementation of universal medical insurance for residents in urban and rural China played a major role in improving the prognoses of low-income, rural, first-ever stroke patients, especially for elderly (≥65 years old) residents. However, elderly male patients not using medical insurance benefits had a high case fatality rate. Thus, restructuring of the government medical insurance policy to facilitate its use by low-income, rural residents is crucial for reducing the stroke burden in China. Funding Statement: The authors stated: None. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study was approved by the ethics committee of Tianjin Medical University General Hospital; written informed consent was obtained from each participant during recruitment.