As colorectal cancer incidence grows among younger adults and patients have more screening options than ever before, insurance coverage may not be keeping up.
Adults younger than 65 account for 45% of all newly diagnosed colorectal cancer cases in the U.S., up from 27% in 1995. Colorectal cancer is now the leading cause of cancer-related mortality for adults younger than 50, with 3 in 4 colorectal cancer cases among adults younger than 50 diagnosed at an advanced stage.
While the industry’s core recommendations for patients at an average risk of developing colorectal cancer haven’t changed — colonoscopy every 10 years or annual stool-based testing — the menu of tests has expanded considerably. A new blood-based test, an at-home stool test that reads RNA markers and an updated Cologuard test were all added in the American Cancer Society’s most recent guideline update.
Expanded options are supposed to close the screening gap, but insurance coverage, several oncology leaders say, may be getting in the way.
An overdue screening age update waits on a dormant task force
“We’re seeing an epidemic in young people being diagnosed with colon cancer,” Anton Bilchik, MD, PhD, chief of medicine and director of the gastrointestinal and hepatobiliary program at Santa Monica, Calif.-based Providence Saint John’s Cancer Institute, told Becker’s. “In 2021 the U.S. Preventive Services Task Force reduced the screening age from age 50 to age 45, but many patients we’re seeing are in their 20s and 30s, and the incidence is even worse in underserved communities.”
The U.S. Preventive Services Task Force has been effectively sidelined for more than a year, with its most recent meeting in March 2025. Since then, meetings have been postponed or canceled. In May, HHS Secretary Robert F. Kennedy Jr. removed the task force’s two vice chairs.
Dr. Bilchik believes that when the task force meets again, the screening age will shift.
“It’s pretty clear that the screening age of 45 is too old,” he said. “My suspicion is that once they look at the data, the screening age will be reduced.”
Where the ‘no-cost’ promise breaks down
Under the ACA, health plans that started on or after Sept. 23, 2010, must cover colorectal cancer screening tests recommended by the USPSTF with no out-of-pocket costs to patients. In practice, that promise has had gaps — with patient cost-sharing still a “common practice” according to advocacy groups and a longstanding coverage loophole turning routine colonoscopies into billable “diagnostic” procedures.
One example of such a loophole occurs when patients undergo a colonoscopy after receiving a positive fecal immunochemical test.
Some patients prefer the much less invasive FIT, which identifies tiny amounts of blood in a stool sample, over a colonoscopy. According to screening guidelines, patients with a positive FIT test should undergo a follow-up colonoscopy within six months. On paper, those patients will have completed a single continuous screening episode, but billing systems don’t always see it that way.
Staci Wendt, PhD, research director at Providence’s Health Research Accelerator, told Becker’s that patients who end up being charged for the follow-up colonoscopy often wish they had simply opted to undergo the procedure in the first place.
Screening confusion also compounds affordability issues that predate any single policy change, according to Dr. Wendt.
“Even for people who do have health insurance coverage, a colonoscopy can put you at your full deductible for the year,” she said.
Medicaid changes could widen the gap further
Layered on top of this existing friction is a newer and larger threat: the coverage losses projected under the One Big Beautiful Bill Act’s Medicaid provisions.
About 7.5 million Medicaid-enrolled adults may lose coverage for cancer screening within the first two years after implementation of the 2025 Budget Reconciliation Bill.
The 2025 Budget Reconciliation Bill — commonly known as the One Big Beautiful Bill Act — ties work requirements and eligibility recertification to Medicaid enrollment. The bill also reduces federal Medicaid funding by nearly $1 trillion.
Loss of cancer screening coverage due to the One Big Beautiful Bill Act may result in 679,745 missed colorectal cancer screening tests, according to a study published Jan. 8 in JAMA Oncology.
Sarah Shubeck, MD, a surgical oncologist at University of Chicago Medicine and co-author of the study, said the coverage losses will disproportionately affect younger adults — the same group driving the rise in colorectal cancer incidence.
“These new requirements introduce administrative barriers that often mean paperwork or technical errors determine whether someone gets screened for cancer,” Dr. Shubeck said in a May 20 news release from UChicago. “A particularly concerning aspect is that people who are disproportionately likely to lose coverage are exactly the people most likely to benefit from early cancer detection: younger adults and people from vulnerable social groups.”
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