A cross-sectional study of latent tuberculosis infection, insurance coverage, and usual sources of health care among non-US-born persons in the United States

Abstract

More than 70% of tuberculosis (TB) cases diagnosed in the United States (US) occur in non-US-born persons, and this population has experienced less than half the recent incidence rate declines of US-born persons (1.5% vs 4.2%, respectively). The great majority of TB cases in non-US-born persons are attributable to reactivation of latent tuberculosis infection (LTBI). Strategies to expand LTBI-focused TB prevention may depend on LTBI positive non-US-born persons’ access to, and ability to pay for, health care. To examine patterns of health insurance coverage and usual sources of health care among non-US-born persons with LTBI, and to estimate LTBI prevalence by insurance status and usual sources of health care. Self-reported health insurance and usual sources of care for non-US-born persons were analyzed in combination with markers for LTBI using 2011–2012 National Health and Nutrition Examination Survey (NHANES) data for 1793 sampled persons. A positive result on an interferon gamma release assay (IGRA), a blood test which measures immunological reactivity to Mycobacterium tuberculosis infection, was used as a proxy for LTBI. We calculated demographic category percentages by IGRA status, IGRA percentages by demographic category, and 95% confidence intervals for each percentage. Overall, 15.9% [95% confidence interval (CI) = 13.5, 18.7] of non-US-born persons were IGRA-positive. Of IGRA-positive non-US-born persons, 63.0% (95% CI = 55.4, 69.9) had insurance and 74.1% (95% CI = 69.2, 78.5) had a usual source of care. IGRA positivity was highest in persons with Medicare (29.1%; 95% CI: 20.9, 38.9). Our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach a large majority of non-US-born individuals with LTBI. With non-US-born Medicare beneficiaries’ high prevalence of LTBI and the high proportion of LTBI-positive non-US-born persons with private insurance, future TB prevention initiatives focused on these payer types are warranted.

Health insurance, healthcare utilization and language use among populations who experience risk for tuberculosis, California 2014–2017

“…While more than a third of Vietnameseborn 18-64 year-olds and one-fifth of those over 65 years old had public insurance, less than one in ten used government or community facilities. Consistent with other reports, this finding suggests that efforts to reach populations that experience risk should not focus solely on public healthcare systems and publicly funded clinics but must engage both public and private healthcare systems [25]. In addition, type of health insurance alone cannot predict the usual source of care in these populations that experience risk.…”

“…First, most persons who experience risk for TB had health insurance and were engaged with medical care. Analyses of health insurance coverage among non-U.S.-born persons using a variety of national datasets have reported similar results [24][25][26]. Barriers to healthcare access and utilization, such as cost and racial/ethnic discrimination, affected less than one in ten persons.…”

“…These results are most useful if, within country of birth strata, persons with LTBI have similar health care access and utilization patterns as those without LTBI. A recent national analysis suggests that this is the case [25]. While recent analyses have detailed heterogeneity in health insurance coverage by immigration legal status, similar analyses were not possible here because these data were not collected [26].…”

“…There was also a substantial difference in usual source of care by country of birth (Table 2). The proportion reporting a doctor's office as usual source of care was highest among Vietnamese-born persons at 73% (CI: 66-81) and lowest among Mexican-born persons, 31% (CI: [24][25][26][27][28][29][30][31][32][33][34]. The proportion reporting no usual source of care was highest among Mexican-born persons at 28% (CI: 26-30) and lowest among Indian-born persons at 11% (CI: 6-15).…”

“…Among U.S.-born, 54% (CI: 52-55) reported very good or excellent health. Lower proportions of good or excellent health were reported by persons born in Mexico or in Vietnam: 26% (CI: 24-28) and 29% (CI: [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]). The highest proportion with very good or excellent health was among persons born in India at 62% (CI: 52-71).…”