Evidence-based federal policies aim to increase cancer screening follow-up, though barriers remain

Originally released 2022; updated August 2025 and March 2026

New insurance rules -- informed by University of Michigan research -- reduce financial and logistical barriers to follow up care for those patients with an abnormal initial screening test for colorectal, breast or cervical cancer. 

The first of these rule changes. which took effect in 2023, allow for people with an abnormal stool-based screening test for colon cancer to get a follow-up colonoscopy at no cost to them.  And in early 2026, the same will be true for follow-up diagnostic and navigation services after an abnormal screening mammogram for breast cancer, and follow-up navigation services after an abnormal initial screening test for cervical cancer.

The new rules could ensure more cancers are diagnosed earlier.

The rules, and U-M's research, relate to the part of the Affordable Care Act that makes certain cancer screenings and other preventive care available to patients at no cost. That provision was specifically designed to keep financial barriers like co-pays and insurance plan deductibles from getting in the way of detecting early signs of trouble. 

The provision recently withstood a legal challenge that went all the way to the Supreme Court, and was the subject of a ruling in June 2025 in the case of Kennedy v. Braidwood. The ruling preserves patients' ability to get no-cost screenings recommended for them by expert panels.

But what happens when the results of the free initial cancer screening are abnormal, and more scans or tests must be done to see if it’s really cancer? 

Measuring the frequency and cost to patients of this common outcome of initial cancer screening tests were the goals of several studies from U-M researchers and their colleagues, who measured costs that patients face for necessary follow-up tests after getting free screening for colon, cervical, lung or breast cancer. 

“For those who have an abnormal initial cancer screening test, it should be easy, not hard, to receive the recommended diagnostic services to determine the presence of cancer.  We are pleased that our research that identified financial and logistical barriers to follow up care was used to develop federal policies that will make it easier for individuals to complete the entire cancer screening process,” said A. Mark Fendrick, M.D., a general internal medicine physician at Michigan Medicine who helped lead the studies and directs U-M’s Center for Value-Based Insurance Design. “The main goal of cancer screening is to detect those people who could benefit from early detection.”

Failure to complete the screening process could lead to cancer progressing, potentially leading to worse patient outcomes and high medical costs. As in many situations, when cancer is detected at an early stage, treatments are more effective and less expensive.

Recent and upcoming changes to coverage for post-screening care

Their findings about the costs that patients faced when an initial stool-based screening for colorectal cancer showed abnormalities helped inform two federal rules that requires private health insurance plans and Medicare to provide coverage for follow-up colonoscopies without cost to the patient. For most people, the rule took effect with insurance plan years starting January 1, 2023.

As of January 2026, insurance plans also have new requirements to provide no-cost coverage of services after an abnormal initial screening mammogram for breast cancer and for navigation services for those undergoing breast and cervical cancer screening. These were also informed by U-M research on the costs of such post-screening care. 

A 2025 guideline from the Health Resources and Services Administration provides for no-cost coverage of both follow-up tests and navigation assistance for women whose initial breast cancer screening was not enough to rule out cancer. This can include additional imaging including magnetic resonance imaging (MRI), ultrasound, or additional mammography, as well as biopsy and pathology tests of tissue. 

Navigation services can include in-person, virtual or hybrid interactions that can support a patient's understanding of their need for additional tests and their ability to get follow-up tests. This can include referrals to support services that can remove barriers to those tests such as language translation, transportation, and social services.

For women whose cervical cancer screening showed potential issues, a guideline provides for patients to receive navigation services at no cost to them, but does not provide for no-cost follow-up tests. On January 5, 2026, HRSA announced updated cervical cancer screening guidelines that include a recommendation offering women ages 30 to 65 years and at average risk the option to self-collect samples for testing. The guideline also includes new language that addresses testing needed to complete the screening process. Full details of the updates can be found here. Updated guidelines take effect for most health insurance plans starting in 2027.

Currently, there is not a requirement for no-cost coverage for navigation services for patients who have had a positive screening for stool-based colorectal cancer. But Fendrick's colleagues Archana Radhakrishnan, M.D., and Jacob Kurlander, M.D., have designed a pilot study to provide such navigation to Michigan Medicine patients.

Fendrick notes that Medicare currently provides reimbursement for navigation services for patients who have a diagnosis of cancer. But until now, these services have not been coverable for patients who are being screened for cancer, but do not yet have a cancer diagnosis. 

He also notes that while the initial screening test for lung cancer is covered without cost-sharing, neither follow-up care nor navigation is covered without cost sharing.

The American Cancer Society has issued a statement on the broader issue of screening follow-up, and related costs.

Findings: costs after colorectal cancer screening 

The two colorectal cancer screening studies were published in January 2022 in Preventive Medicine Reports and December 2021 in JAMA Network Open.

Many average-risk adults opt for stool-based screening tests, such as those that look for blood or DNA markers of colorectal cancer, because they take less time and preparation than a screening colonoscopy, and they can be done at home. These options, as well as screening colonoscopy, are available without out-of-pocket costs. Clinical guidelines say that those who test positive on a stool test need a follow-up colonoscopy.

The JAMA Network Open study examined how often patients are charged, and what patients actually paid out of their own pockets, for such follow-up colonoscopies. It involves data from nearly 88,000 people with private insurance or Medicare coverage who had a stool-based test. 

In all, 16% of them went on to have a colonoscopy. During that colonoscopy, nearly 60% of the group had at least one polyp removed, because it might be cancerous or precancerous. 

More than half of the privately insured patients and 78% of the Medicare participants had to pay something out-of-pocket for their follow-up colonoscopy. It averaged around $100, no matter what kind of insurance the patients had. Those who had polyps removed paid more than those who didn’t. 

The Preventive Medicine study, based on a simulation using patient data, suggests that follow-up colonoscopies after positive stool tests could save up to four times as many years of life saved from colorectal cancer, and prevent twice as many deaths, when compared with the same number of people who have a colonoscopy as their initial colorectal screening test. This is because those having a colonoscopy after an abnormal stool test are at higher risk for actually having cancer than those having a primary screening colonoscopy.

The removal of these costs beginning in 2023 was a major step, Fendrick said. “This is an extremely important policy that could increase screening uptake, enhance equity and ultimately save lives. The removal of a cost barrier could help hundreds of thousands more people avoid the dilemma of having to decide if they can afford to follow up on their initial positive colorectal screening test,” said Fendrick. “However, the new rule does not include navigation services, which could help with non-financial barriers (e.g., scheduling, transportation etc) that deter patients from completing the screening process.”

Findings: Costs after breast cancer screening

The U-M team and colleagues from the University of Washington have looked at the follow-up costs faced by women who have concerning findings on their screening mammograms. Their results were published in 2021 in JAMA Network Open. 

Screening mammograms for certain women have been free from out-of-pocket costs since the Affordable Care Act’s provision took effect.

But between 2010 and 2017, the study shows, women who got additional imaging and biopsies after their screening mammogram faced ever-rising out-of-pocket costs. 

The study is based on data from 325,900 women between the ages of 40 and 64 who have job-related health insurance and had 418,378 additional breast imaging examinations or procedures after a screening mammogram.

Nearly all had a second mammogram, called a diagnostic mammogram, after the screening scan. From there, many went on to have additional scans and even biopsies to remove a bit of tissue for examination to determine if they had cancer. Those who went on to have a biopsy paid the most out of their own pockets, rising from an average of $91 in 2010 to $152 in 2017, whether they had ultrasound or MRI imaging before the biopsy. 

Findings: Costs after cervical cancer screening

In a 2022 paper published in Obstetrics & Gynecology, Fendrick collaborated with obstetrician/gynecologist Michelle Moniz, M.D., M.Sc., and others to look at what women paid out of their own pockets for a type of cervical exam called colposcopy.  Conducted after a Pap smear, HPV test or routine cervical exam gives abnormal results, a colposcopy can include a biopsy or other procedures.

Women who had a colposcopy without further procedures paid an average of $112, while those who had cells taken for further examination paid $155 on average. Those who had further procedures faced hundreds of dollars more in costs -- and this out-of-pocket cost rose sharply during the 13 years studied. By 2019, a woman who had additional care beyond a biopsy could expect to face a total bill of nearly $1,000.

“The recent release of federal proposals that eliminate cost-sharing for navigation services for commercially insured individuals and Medicaid beneficiaries whose initial cervical cancer screening test is abnormal is an important step forward to improve patient outcomes,” said Fendrick. “It is my hope that the use of similar evidence that informed the policies that eliminate cost-sharing for follow-up care after abnormal initial screening tests for colorectal and breast cancer will also be applied to cervical cancer.”
 

Findings: Costs after lung cancer screening

A team led by former U-M radiologist Ruth Carlos, M.D., and Fendrick documented the cost of follow-up tests for patients whose screening CT scan showed signs of potential lung cancer, and the findings were published in the Journal of American College of Radiology.  Such scans are fully covered for people who meet criteria for certain levels of past and current tobacco use.

In 2021, the U.S. Preventive Services Task Force recommended expansions of the populations eligible for CT screening for lung cancer. The changes were made with an eye toward reducing inequities in rates of early cancer detection among women and people who are Black, Indigenous, or Latinx. 

In all, 7.4% of the patients who had a lung cancer screening CT went on to have at least one follow-up invasive procedure. Over half of them were asked to pay something, sometimes hundreds or even thousands of dollars out of their own pockets, depending on the specific tests that were required to complete the screening process.

There is currently no provision for no-cost follow-up testing for patients after a lung cancer screening.