The objective was to determine the association between material deprivation and direct healthcare costs and clinical outcomes following stroke in the context of a publicly funded universal healthcare system. In this population-based cohort study of patients with ischemic and hemorrhagic stroke admitted to hospital between 2008 and 2017 in Ontario, Canada, we used linked administrative data to identify the cohort, predictor variables, and outcomes. The exposure was a five-level neighborhood material deprivation index. The primary outcome was direct healthcare costs incurred by the public payer in the first year. Secondary outcomes were death and admission to long-term care. Among 90,289 patients with stroke, the mean (standard deviation) per-person costs increased with increasing material deprivation, from $50,602 ($55,582) in the least deprived quintile to $56,292 ($59,721) in the most deprived quintile (unadjusted relative cost ratio and 95% confidence intervals 1.11 [1.08,1.13] and adjusted relative cost ratio 1.07 [1.05,1.10] for least compared to most deprived quintile). People in the most deprived quintile had higher mortality within one year compared to the least deprived quintile (adjusted hazard ratio (HR) 1.07 [1.03,1.12]) as well as within three years (adjusted HR 1.09 [1.05,1.13]). Admission to long-term care increased incrementally with material deprivation and those in the most deprived quintile had an adjusted HR of 1.33 [1.24,1.43]) compared to those in the least deprived quintile. Material deprivation is a risk factor for increased costs and poor outcomes after stroke. Interventions targeting health inequities due to social determinants of health are needed.