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Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50-75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings - balancing increased CRC screening/testing costs against decreased cancer treatment costs - are approximately $30\u202fM and $970\u202fM for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.U48 DP005006/DP/NCCDPHP CDC HHS/United StatesU48 DP005017/DP/NCCDPHP CDC HHS/United StatesU48DP005006/ACL/ACL HHS/United StatesK07 CA211971/CA/NCI NIH HHS/United StatesK12 HS022981/HS/AHRQ HHS/United StatesU48DP005017/ACL/ACL HHS/United States2020-03-11T00:00:00Z31666187PMC70655117374vault:3508