Colorectal crisis: Healthcare cuts jeopardize cancer screenings for Bay Area’s vulnerable

SAN FRANCISCO, CA., 8/20/2026 — Nancy Villena remembers that a “thousand things” flashed through her mind three years ago when the Petaluma Health Center called and said her stool test was abnormal.

After days of worry, including concern about her lack of health insurance, Villena met with a physician, who told her that her sample showed blood and she would need a colonoscopy. Villena was shocked — she had no symptoms. She had only gone to the health center because she finally had time to check on her health after arriving in Santa Rosa five years ago from Peru. 

The health center connected Villena to Operation Access, a San Francisco-based nonprofit that steers low-income, uninsured people in Northern California to medical groups that provide colonoscopies free of charge. 

Nine polyps were found and removed during Villena’s colonoscopy, a procedure which she said saved her life. 

“Thanks to [Operation Access], I am here at this moment,” said Villena. “I can enjoy something great that I have in my life, which are my grandchildren, my children.” 

Villena was one of the lucky ones. 

Due to the policies of H.R.1, better known as President Donald Trump’s One Big Beautiful Bill Act, millions of people are predicted to lose their health insurance, straining an already strapped safety-net healthcare system. H.R. 1 will slash billions from Medicaid funding and eliminate Affordable Care Act subsidies. 

Without health insurance, people will lose access to primary medical care, including critical preventive services such as colorectal cancer screening. According to a 2023 national health survey, only 23% of uninsured people completed colorectal cancer screening compared to 62% of people with private insurance and 56% of those with public insurance such as Medicare and Medicaid. 

According to a March study in the Journal of the American Medical Association Oncology, over the first two years of the implementation of H.R. 1 policies in 2027-2028, nearly 700,000 people who lose Medicaid coverage will miss colorectal cancer screening, leading to undetected cancers and deaths. 

And nonprofits that help the uninsured access colorectal cancer screenings don’t have the resources to help them all. 

Colorectal cancer or cancer of the large intestine is now the leading cause of cancer-related deaths among young adults. The deaths of celebrities Chadwick Boseman and James van der Beek in their 40s due to the disease underscored this dire statistic. 

While colorectal cancer mortality has actually been declining among adults older than 65, death rates have increased every year since 2005 for people younger than 50. Reasons for this trend are not entirely clear but are likely related to diets high in processed foods, obesity, more sedentary lifestyles and failure to test. 

The case for timely screening 

Colorectal cancer deaths can be prevented by timely screening with a colonoscopy or stool test. The United States Preventive Services Task Force recommends all people at average risk for colorectal cancer and without symptoms start screening at age 45. 

If colorectal cancer is caught early, five-year survival rates are as high as 90%, according to the American Cancer Society. 

But if timely screening is not completed, and colorectal cancer is diagnosed at an advanced stage, five-year survival rates can be as low as 13%. 

A stool test or colonoscopy requires an order or referral from a health care provider. For someone without health insurance, access to a healthcare provider is tenuous at best, and that situation is expected to significantly worsen. 

One year since the passage of H.R.1 in July 2025, more than one million Californians have already lost their Medicaid or Affordable Care Act health insurance, according to Vaishu Jawahar, policy director for Protect Our Care, a national advocacy group for health care as a right rather than a privilege. 

During a town hall meeting sponsored by the office of U.S. Rep. Mark DeSaulnier, D-Walnut Creek, Jawahar said the expiration of Affordable Care Act tax subsidies has led many young people to drop out of coverage, believing they are healthy enough to forego insurance. This trend bodes poorly as colorectal cancer cases continue to rise among young adults. 

The UC Berkeley Labor Center projected that due to federal and state policies adopted in 2025, nearly 5 million Californians under age 65 will be uninsured by 2030, nearly doubling the state’s uninsured rate among those under 65 to 14.7%. 

Among low-income Californians, defined as those who live at or below twice the federal poverty line, the uninsured rate is expected to increase from about 9% to 24% or nearly one in four low-income residents, according to the Labor Center. 

Dr. Ori Tzvieli, a family medicine physician and the medical director of the Contra Costa County public health system, predicts that colorectal cancer cases will rise as more people lose their health insurance. 

“I see no way around the fact that fewer people will have insurance, and fewer people will get screening as a result, and then more people will be diagnosed later, and mortality rates will go up,” said Tzvieli. 

Among the nine counties of the Bay Area, Contra Costa County had the second-highest colorectal cancer death rate, after San Benito County, according to the most recent 2019-2023 data from the University of California, San Francisco Greater Bay Area Cancer Registry. Tzvieli was not certain why the numbers were so high but speculated that lack of access to medical care could be a reason. 

Tzvieli said the predicted doubling of the state’s uninsured rate will largely occur among people from marginalized communities. 

“They’re mostly going to be disproportionately poor, disproportionately Black and brown,” said Tzvieli. “Those are populations … already struggling to do colorectal cancer screening.” 

Tzvieli said that on a population level, there will be a two- to four-year time lag before we start seeing increases in colorectal cancer cases and deaths due to loss of insurance. 

Setting records for the wrong reasons 

Ali Balick, program director at Operation Access, said that the organization is already seeing the downstream effects of people falling off Medicaid. Operation Access provided more than 300 colonoscopies last year and is on track to provide over 400 by the end of 2026, an all-time high for the organization. 

“We are going to break the record this year for the number of colonoscopies coordinated through our program,” said Balick. “A large part of that has to do with Medi-Cal being cut.” 

Balick said that when the state expanded Medicaid coverage to undocumented adults, Operation Access saw a large drop in colonoscopy referrals from health clinics, because Medicaid-insured individuals could access the procedure elsewhere. 

But now with people losing Medicaid coverage or unable to access it due to state policies that froze enrollment for undocumented adults, Balick said she has seen an 11% increase in colonoscopy referrals this year compared to last. 

And Balick worries about keeping up with the growing demand for colonoscopies, because Operation Access lost about half its funding last year. 

The group cut staff who were crucial to navigating clients through the complicated colonoscopy process — from instructions on how to complete bowel cleansing prior to the procedure to finding transportation to and from the colonoscopy center to even booking a hotel in San Francisco for a client from Mendocino. 

Balick said the average wait time from the initial colonoscopy referral to completion of the procedure is 80 days. She fears wait times will become longer with increased demand and fewer resources at the organization. 

Wait time is crucial, because most of the referred clients are at high risk for colorectal cancer, having had an initial “positive” stool test which detected blood in the stool. The longer the wait, the greater the danger of an undetected cancer. 

For asymptomatic, low-risk patients, a stool sample that can be collected at home is a simpler, noninvasive and lower-cost method to conduct initial screening for colorectal cancer. Studies have shown that regular stool-based tests decrease colorectal cancer mortality and have a higher participation rate than colonoscopy. 

As the American Cancer Society has noted, the best colorectal cancer screening test is the test that gets done. 

But if a stool test is “positive,” meaning that blood is found in the stool, the individual is deemed at high risk for colorectal cancer and still must proceed to a colonoscopy to determine the cause of the abnormal stool test. 

Dr. Brad Williams, chief medical officer at Mission Neighborhood Health Center, a federally qualified health center in San Francisco that serves a majority Latino and Hispanic population, said that the stool test is the standard colorectal cancer screening tool for average-risk patients at his organization. 

Federally qualified health centers like Mission Neighborhood play a critical role in educating patients about colorectal cancer and in providing services to low-income residents. They receive federal grants to provide comprehensive primary care services to underserved populations, including people who are unhoused, low-income, uninsured or Medicaid-eligible. 

In addition to federal grants, these health centers rely on Medicaid for operational costs. With looming Medicaid cuts on the horizon, a large source of funding could be lost — tragic because the centers have taken a creative approach to outreach and have shown considerable success. 

More than 95% of the patients at Mission Neighborhood Health Center live at or below 200% of the federal poverty level, according to the most recent 2025 data from the Health Resources and Services Administration, the agency that oversees federally qualified health centers. 

Due to California’s prior expansion of Medi-Cal and concerted efforts at the center to enroll its patients, the uninsured rate at Mission Neighborhood dropped to 6% in 2025 compared to 17% in 2023. Among the 170 grant-funded, federally qualified health centers in California, the uninsured rate was 9% in 2025. Despite serving a patient population with a multitude of socioeconomic barriers to accessing primary care, including a 22% unhoused population, Mission Neighborhood had an above-average colorectal cancer screening rate of 50% in 2025. The average screening rate among grant-funded, federally qualified health centers in California was 44%. 

Breaking through cultural barriers 

Williams said that hiring Spanish-speaking community health workers or promotoras was his center’s most impactful initiative in raising screening rates. 

Seed money for the promotoras program was provided by the California Colorectal Cancer Coalition, a statewide advocacy group. Mission Neighborhood Health Center has three promotoras who, among their other duties, focus on colorectal cancer screening.

Promotoras are community members trained by the health center to educate their patients about the importance of screening and to help them navigate the stool collection process. Promotoras mail out the stool kits and follow up with patients who have not completed them in a timely manner. 

Williams said that because promotoras are peers, patients trust them. Promotoras can address and help overcome hesitations that patients have about colorectal cancer screening. Williams said that one idea prevalent in the Latino communities he serves is the concept that one must have symptoms to seek medical care. 

“Just the concept that we would screen to find a cancer before you present with symptoms — that to some patients is really just a completely foreign and new concept,” said Williams. “(Promotoras are) excellent with dealing with those kinds of preconceptions.” 

Maria Sanchez, a promotora at Mission Neighborhood Health Center, echoed Williams’ assessment, saying that in her culture, people from Latin America “never heard” about colorectal cancer screening. 

Originally from Mexico, Sanchez said she comes from the same community as her clients. To convince people to complete screening, she said she speaks with them as if she is chatting with her mother or grandmother. Sanchez said she believes she has saved many lives. 

Help for marginalized communities 

In another neighborhood in San Francisco, Dr. Daniel O’Neill, chief medical officer at the San Francisco Community Health Center, cares for a different patient population. His organization serves a large, unhoused population in the Tenderloin district. About 68% of the center’s clients are unhoused, according to 2025 data. 

The health center also manages the Taimon Booton Navigation Center, a shelter for unhoused transgender and gender-nonconforming people, and Trans: Thrive, a drop-in community center. The Taimon Booton Center is the only shelter in Northern California connected to a federally qualified health center. 

O’Neill said that unlike most federally qualified health centers that start with medical services and then build out case management programs to address their patients’ socioeconomic needs, his organization had already created a robust program over many years of caring for unhoused people. Becoming a federally qualified health center more than 10 years ago was the “cherry on top.” 

O’Neill said that a healthcare system that serves marginalized communities must have a vigorous care coordination network which can help navigate people through Abraham Maslow’s hierarchy of needs — housing, food security, addiction management, mental health treatment — before tackling preventive care, including colorectal cancer screening. 

“We’ve got a really strong team,” said O’Neill. “We are actually able to have longitudinal relationships with these patients.” 

Due to these established relationships, which include street medicine teams that go to where patients are, O’Neill achieved the daunting task of increasing his center’s colorectal cancer screening rate from 18% in 2024 to 30% in May this year. 

O’Neill has had to think outside of the box to achieve this. 

One initiative gave $20 cash cards to patients who completed their colorectal cancer screening. This incentive program was funded by the San Francisco Cancer Initiative, a collaboration between the University of California, San Francisco and the San Francisco Department of Health. 

Due to reductions in funding, however, the maximum annual stipend to health clinics for colorectal cancer screening was cut in half to $2,500, according to program manager Kara Lugtu. 

O’Neill said a lack of toilets for unhoused patients is a significant barrier to completing screening. One innovative endeavor nicknamed, “Poop on Demand,” encouraged patients who were visiting the health center for another appointment to submit a stool sample in one of the center’s bathrooms. O’Neill said a handful of patients were able to do so. 

When unhoused patients need a colonoscopy, a lack of toilets presents a seemingly insurmountable challenge. They need to complete a bowel cleanse before the procedure as well as recover in a safe place from sedation given during the colonoscopy. 

O’Neill turned to the Medical Respite and Sobering Center programs of the San Francisco Department of Public Health. These programs provide temporary shelter for unhoused people who have complex medical and mental health conditions. The facilities are staffed by nurses and other healthcare providers. 

Unhoused patients from the San Francisco Community Health Center who needed a colonoscopy were able to complete their bowel cleanse at a medical respite center near the Tenderloin. They were also able to recover at the facility after the procedure. 

“An ounce of prevention is worth a pound of cure here,” said O’Neill. “We have to think of creative ways to get folks from A to B. And in resource-strained settings, that is our everyday mantra.” 

Safety net under pressure 

As the policies of H.R. 1 are implemented over the ensuing years, with millions of Californians expected to become uninsured, safety-net health care systems, including federally qualified health centers and public hospitals and clinics, will be inundated. 

Dr. Grant Colfax, director of Contra Costa Health, which includes a 167-bed public hospital and 11 clinics, projected that over the next five years, the county’s healthcare system, which relies on state and federal funding, will be nearly $1 billion in debt. 

And as health centers in the Bay Area absorb more uninsured patients, the safety-net patchwork of promotoras, case managers, street medicine providers, groups like Operation Access and the San Francisco Cancer Initiative, and innovate programs like the colonoscopy medical respite program will be hard-pressed to survive. 

It’s not at all clear the Contra Costa County public healthcare system can ramp up its indigent care program from its current tally of less than 100 patients to 15,000 patients, the number of patients in the system prior to the Affordable Care Act, according to Tzvieli. Nor is it clear whether Nancy Villena will be able to complete the follow-up colonoscopy she will likely need in another three to five years. 

During his healthcare townhall meeting in July, DeSaulnier, who is also a co-sponsor of the 2025 Medicare for All Act, which is currently languishing in legislative purgatory, was blunt about the aftermath of H.R.1. 

“People will die because of our healthcare policy,” he said.