Background We evaluate nationwide trends and urban–rural disparities in case fatality (in‐hospital mortality) and discharge dispositions among patients with primary intracerebral hemorrhage (ICH). Methods and Results In this repeated cross‐sectional study, we identified adult patients (≥18 years of age) with primary ICH from the National Inpatient Sample (2004–2018). Using a series of survey design Poisson regression models, with hospital location–time interaction, we report the adjusted risk ratio (aRR), 95% CI, and average marginal effect (AME) for factors associated with ICH case fatality and discharge dispositions. We performed a stratified analysis of each model among patients with extreme loss of function and minor to major loss of function. We identified 908 557 primary ICH hospitalizations (overall mean age [SD], 69.0 [15.0] years; 445 301 [49.0%] women; 49 884 [5.5%] rural ICH hospitalizations). The crude ICH case fatality rate was 25.3% (urban hospitals: 24.9%, rural hospitals:32.5%). Urban (versus rural) hospital patients had a lower likelihood of ICH case fatality (aRR, 0.86 [95% CI, 0.83–0.89]). ICH case fatality is declining over time; however, it is declining faster in urban hospitals (AME, −0.049 [95% CI, −0.051 to −0.047]) compared with rural hospitals (AME, −0.034 [95% CI, −0.040 to −0.027]). Conversely, home discharge is increasing significantly among urban hospitals (AME, 0.011 [95% CI, 0.008–0.014]) but not significantly changing in rural hospitals (AME, −0.001 [95% CI, −0.010 to 0.007]). Among patients with extreme loss of function, hospital location was not significantly associated with ICH case fatality or home discharge. Conclusions Improving access to neurocritical care resources, particularly in resource‐limited communities, may reduce the ICH outcomes disparity gap.