Many countries with a high tuberculosis (TB) burden are adopting social health insurance (SHI) schemes. However, the national TB programs (NTPs) of these countries are only just starting to grapple with the effects of SHI on their operations. Here, we review the rationale for analyzing TB programs in light of the changes brought by SHI. We consider the influence of certain purchasing decisions on TB care and prevention, and the opportunities that SHI may present for NTPs to broaden private sector engagement, extract TB data across the health sector, and facilitate quality improvement efforts. We also explore which functions are likely to be performed by SHI systems, which require special attention with the advent of SHI, and the metrics that indicate how much of TB care seeking and treatment can be reached and influenced by SHI. SHI presents certain risks for TB programs, but also opportunities to adapt to a more modern health system and to bring quality TB care and treatment to more people.