Sunscreen Coverage as Preventive Care Under the Affordable Care Act: A Low-Cost Way to Reduce the Prevalence of the Most Common Cancer

Abstract

Skin cancer is the most commonly diagnosed malignancy in the United States, costing more than $8.1 billion annually in treatment-related expenses, yet with ultraviolet exposure considered the most significant risk factor for skin cancer development, cutaneous malignancy is also highly preventable. The Affordable Care Act (ACA) is committed to covering demonstrably effective preventive health care measures without patient cost sharing. To prevent skin cancer, the American Academy of Dermatology recommends applying sunscreen, donning sun-protective clothing, seeking shade, and avoiding midday sun. Additionally, The US Preventive Services Task Force recommends behavioral counseling for skin cancer prevention, including application of broad-spectrum sunscreen, from ages six months to 24 years of age. Despite these evidence-based recommendations and widespread precedent for ACA coverage of certain over-the-counter medications, dermatologic products such as sunscreen are notably excluded. Herein, we address an under-recognized insurance coverage gap for patients by outlining the evidence that sunscreen, as a primary prevention, dually reduces skin cancer incidence and healthcare costs, highlighting the critical need to address barriers to sunscreen utilization. As such, we advocate for amendment of current ACA coverage to include the cost of sunscreen as an evidence-based strategy to decrease the incidence of UV-induced cutaneous disease and associated treatment expenses.

Although highly preventable, skin cancer has the highest incidence of any malignancy in the United States (US).¹ Ultraviolet (UV) exposure, in particular, is considered the most important and preventable risk factor for cutaneous malignancy. Recommendations for prevention include sunscreen application, donning sun-protective clothing, seeking shade, and avoiding the midday sun.² Demonstrably effective disease-prevention strategies are a central component of the Affordable Care Act (ACA), which requires coverage of preventive health services without patient cost-sharing.³ However, under the ACA, for a service to be covered with no out-of-pocket costs, it must receive a level of evidence rating of A or B from the US Preventive Services Task Force (USPSTF).⁴ Examples of such services include cancer screening, dietary counseling, statin therapy, folic acid supplementation, fall prevention, immunizations, and depression screenings.^3,5,6 Despite widespread precedent for ACA coverage of certain over-the-counter medications, dermatologic products such as sunscreen are notably excluded.^5,6 A complete list is reflected in Table 1. Herein, we advocate for ACA inclusion of sunscreen as a proven, preventive-care measure for cutaneous malignancy.

TABLE 1.

Covered preventive services under the Affordable Care Act (ACA) for children, women, and adults with associated US Preventive Services Task Force (USPSTF) evidence grades^5,6

COVERED ENTITY	COVERED PREVENTIVE SERVICE UNDER ACA	USPSTF GRADE*
Children	Alcohol, tobacco, and drug use assessments for adolescents	B for tobacco; I for alcohol and drug
	Autism screening at 18 and 24 months	I
	Bilirubin concentration screening for newborns	IA
	Blood pressure screening	I
	Depression screening for adolescents beginning routinely at 12 years	B
	Developmental delay (speech and language) screening <3 years	I
	Dyslipidemia screening once between 9–11 years and once between 17–21 years, and for children at higher risk of lipid disorders	I
	Fluoride supplements if fluoride not present in drinking water source	B
	Fluoride varnish for all children as soon as teeth are present	B
	Ocular gonorrhea prevention medication for all newborns	A
	Hearing screening for all newborns and regular screenings for all as recommended by their provider	IA
	Hematocrit or hemoglobin screening for 6–24 months	I
	Hemoglobinopathies or sickle cell screening for newborns	IA
	Periodic hepatitis B screening for adolescents at higher risk	B
	Periodic HIV screening for adolescents at higher risk	A
	Hypothyroidism screening for newborns	R
	Pre-exposure prophylaxis (PrEP) HIV prevention medication for HIV-negative adolescents at high risk for contracting HIV through sex or injection drug use	A
	Immunizations for children from birth to age 18 years. Doses, schedule, and recommended target populations vary.	R
	Lead screening for children at risk of exposure	I
	Obesity screening and counseling	B
	Oral health risk assessment from 6 months to 6 years	IP
	Phenylketonuria screening for newborns	R
	Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk	B
	Skin cancer prevention with behavioral counseling	B
	Tuberculin testing for children at higher risk of tuberculosis	NL
	Vision screening at least once between 3–5 years	B
	Well-baby and well-child visits	NL
Women	Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies	B
	Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling	NL
	Folic acid 400–800mcg daily for women who may become pregnant	A
	Gestational diabetes screening for ≥ 24 weeks pregnant and those at high risk of developing gestational diabetes	B
	Gonorrhea screening if at higher risk	B
	Hepatitis B screening at first prenatal visit	A
	Maternal depression screening for mothers at well-baby visits	B
	Preeclampsia screening and prevention (aspirin 81mg daily after 12 weeks gestation) for pregnant women with high blood pressure	B
	Rh incompatibility screening for all pregnant women at first visit and follow-up testing at 24–28 weeks if higher risk	A
	Syphilis screening	A
	Expanded tobacco intervention and counseling for pregnant tobacco users	A
	Urinary tract or other infection screening	B
	Bone density screening for women > 65 years or ≤ 64 years if postmenopausal	B
	Breast cancer genetic test counseling (BRCA) if at higher risk	B
	Breast cancer mammography screenings every 2 years for 50–74 years	B
	Breast cancer chemoprevention counseling if at higher risk	B
	Cervical cancer screening, cervical cytology every 3 years for women 21–29 years, every 3 or 5 years for women 30–65 years, depending on screening type	A
	Chlamydia infection screening for < 24 years and ≥ 25 years if higher risk	B
	Domestic and interpersonal violence screening and counseling for all women of reproductive age	B
	HIV screening and counseling for everyone 15–65 years, and other ages at increased risk	A
	PrEP HIV prevention medication for HIV-negative women at high risk for contracting HIV through sex or injection drug use	A
	Urinary incontinence screening yearly	NL
	Well-woman visits to get recommended services for all women	NL
Adults	Abdominal aortic aneurysm one-time screening for men 65–75 years who have never smoked	B
	Alcohol misuse screening and counseling	B
	Blood pressure screening. Recommended annually if > 40 years or at high risk; every 3–5 years if 18–35 years	A
	Cardiovascular disease and colorectal cancer prevention (aspirin 81mg daily) for adults 40–59 years with ≥ 10% cardiovascular risk in next 10 years	C
	Cholesterol screening for adults of certain ages or at higher risk	NL
	Colorectal cancer screening for adults 45–75 years. Interval depends on screening test	B: 45–49 years; A: 50–75 years
	Depression screening	B
	Diabetes (Type 2) screening for adults 35–70 years with overweight or obesity	B
	Diet counseling for adults at higher risk for chronic disease	C
	Falls prevention (with exercise interventions) for adults ≥ 65 years, living in a community setting	B
	Hepatitis B screening for people at high risk	B
	Hepatitis C screening once for adults 18–79 years at low risk	B
	HIV screening for everyone 15–65 years and other ages at increased risk	A
	HIV PrEP medication for HIV-negative adults at high risk for contracting HIV through sex or injection drug use	A
	Immunizations for adults—doses, recommended ages, and recommended populations vary	R
	Lung cancer screening annually for adults 50–80 years who have a 20-pack-year history and are current smokers or quit in the past 15 years	B
	Obesity related counseling and intervention for those with BMI ≥ 30	B
	STI prevention counseling for adults at higher risk	B
	Statin preventive medication for adults 40–75 years who have ≥ 1 risk factors	B
	Syphilis screening for adults at higher risk	A
	Tobacco use screening for all adults and cessation interventions for tobacco users	A
	Tuberculosis screening one time for asymptomatic adults at high risk; continued screening recommended if continued risk of exposure	B

*USPSTF evidence grade definitions²⁶

A: Recommended service with high certainty the net benefit is substantial; B: Recommended service with high certainty the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial; C: Recommendation to selectively providing service to individual patients based on professional judgment and patient preferences. At least moderate certainty exists that the net benefit is small; D: Recommends against service due to moderate or high certainty the service has no net benefit or the harms outweigh the benefit; I: Current evidence is lacking, of poor quality, or conflicting and is insufficient to assess the balance of benefits and harms of the service; IA: Inactive with no plan to review evidence or update recommendations; IP: An update for the topic is in progress; NL: Recommendation is not listed on the USPSTF site; R: Referred to another entity for review and recommendations.

Children and young adults are most susceptible to the carcinogenic effects of ultraviolet radiation, with almost half of lifetime UV exposure occurring before 20 years old.^1,7 Sustaining more than four blistering sunburns between the ages of 15 to 20 years results in an 80 percent increase in melanoma risk and a 68 percent increase in nonmelanoma skin cancer risk.¹ Appropriately applied, sunscreen blocks 97 percent of sunburn-causing UVB rays, reduces the risk of squamous cell carcinoma by 40 percent, and reduces melanoma risk by 50 percent.^1,8,9 In addition to preventing UV-associated skin disease for the general public, sunscreen use carries important medical indications for specific high-risk populations. For example, many commonly prescribed medications (eg, antibiotics, retinoids, diuretics, NSAIDs) are notoriously photosensitizing and result in iatrogenic solar injuries.¹⁰ Meanwhile, outdoor workers, patients on chemotherapy or immunosuppressants including recipients of solid organ transplants, and those with certain genodermatoses such as xeroderma pigmentosa and oculocutaneous albinism carry markedly higher risk for the development of cutaneous malignancy as well as greater rates of skin cancer-related mortality; therefore sun-protective behaviors and access to sunscreen is paramount.^11,12

The USPSTF recommends behavioral counseling for skin cancer prevention, including application of broad-spectrum sunscreen, from patients aged six months to 24 years of age (B rating).⁵ Despite this recommendation, the cost of sunscreen is not covered by insurance under the ACA. While a number of studies show that increasing the affordability of preventive services by inclusion under the ACA increases access and utilization, one in six Americans cite cost as a barrier to sunscreen use.^13,14 For example, Medicaid patients use sunscreen less frequently than individuals with other insurance. However, Medicaid patients are more likely to seek shade and wear long sleeved shirts.¹⁵ This suggests that individuals of lower socioeconomic status are no less motivated to prevent skin cancer. Rather, the cost of sunscreen may be prohibitive. Such a lack of access may be particularly deleterious given that other sun-protective strategies may be less effective at preventing skin cancer than sunscreen.¹⁶ Moreover, while sunscreen is eligible for reimbursement through tax-advantaged health benefit accounts (HBAs) such as Health Saving Accounts, these options remain out-of-pocket expenses because such accounts merely reimburse for medical expenses from the employees’ pre-tax contributions.¹⁷ Furthermore, HBAs are not financially accessible for many Americans. According to the US Bureau of Labor Statistics, only 30 percent of workers have access to HBAs, and of those eligible, only 55 percent contribute.^17,18

Despite recommendations for sunscreen use by USPSTF and dermatological societies (eg, American Academy of Dermatology), other barriers to widespread use also exist.^2,5 Overall, male sex and darker skin type significantly predict lower adoption of sun protective measures.^16,19–22 Studies in US adults reveal that females are significantly more likely than males to use sunscreen, a problematic finding given that males experience higher rates of melanoma.^1,16,23 These trends may be explained, in part, by commonly held masculine notions of sunscreen as a cosmetic product, rather than a medical necessity.¹⁶ This perception is underscored by greater adoption of sunscreen use by sexual minority men compared to heterosexual men.²⁴ Concerningly, a quarter of White Americans do not apply sunscreen because it impairs tanning, suggesting the use of sunscreen, or lack thereof, is significantly influenced by appearance rather than health.¹⁹ Additionally, the rates of routine application of sunscreen as a means of photoprotection remains low among skin of color populations, including Asian, Hispanic, and Black individuals.^20,22 In fact, even with a greater risk of melanoma-related morbidity and mortality, the majority of Black Americans never utilize sunscreen.^1,16,20,22 Similarly, among collegiate athletes, more than 50 percent reported never using sunscreen despite spending on average four hours/day outdoors for 10 months/year.²³ Consequently, it is reasonable to argue that categorizing sunscreen as a preventive medical treatment has the power to change public narrative, increase access, and improve adoption rates for sun protection among groups with low utilization.

Notably, more than five million people are diagnosed with skin cancer annually in the US, costing more than $8.1 billion.^1,16 Sun exposure also has a high short-term cost, resulting in more than 33,000 emergency department visits for sunburn annually.²⁵ This costs the US healthcare system more $11.2 million per year for a largely avoidable injury and serves as an important risk factor for skin cancer development.^1,7,25 With a mere five percent increase in the prevalence of sunscreen usage over a 10-year period, an estimated 230,000 melanomas could be prevented in the US.⁸ Without intervention, however, Gordon et al⁹ estimated that 1.82 million quality-adjusted life years per 100,000 people will be lost over the ensuing 30 years due to skin cancer. This study also demonstrates that sunscreen as a primary prevention dually reduces skin cancer incidence as well as quality of life decrements and costs, highlighting the critical need to address cost barriers and misperceptions regarding sunscreen utilization.⁹ Consequently, because sunscreen use is associated with demonstrable health benefits and reduced healthcare costs, widespread insurance coverage stands to increase access and utilization, ultimately decreasing the incidence of UV-induced cutaneous disease and associated treatment expenses.

The ACA mandates payor coverage for certain over-the-counter drugs with presentation of a prescription from a licensed healthcare provider.^3,6 With sun protection serving as a key preventive measure for cutaneous malignancy, sunscreen should be classified as a medically necessary, prescription medication fully covered by insurance plans for those under 24 years and individuals in high-risk populations, at a minimum, and ideally, covered for all patients regardless of age or risk stratification. This would align with established preventive services coverage definitions under the ACA and is underscored by USPSTF’s current coverage requirement for behavioral sunscreen counseling in children and young adults. Consequently, enacting coverage mandates for sunscreen is fully supported by data on its effectiveness in skin cancer prevention and by existing precedence for coverage of other over-the-counter products.

SIGNIFICANCE FOR PUBLIC HEALTH

As the old adage goes, an ounce of prevention (or sunscreen) is worth a pound of cure. With one in five Americans developing skin cancer in their lifetime, UV exposure affects the health of millions of Americans, while imposing significant costs on the healthcare system.¹ Fortunately, this is a preventable problem, but barriers to sunscreen utilization must be reduced. Sunscreen is a well-established, evidence-based preventive measure yet is excluded from ACA-covered services. Recategorizing sunscreen as a covered, preventive treatment should improve the significant economic and perceptual barriers to usage, thereby enhancing sunscreen access and utilization. Ultimately, this would improve medical outcomes and decrease healthcare costs. Since the ACA was enacted, updates to the specific evidence-based preventive services recommendations have occurred. As such, we urge the USPSTF to amend existing coverage rules to include the cost of sunscreen as a justifiable public health intervention in the prevention of cutaneous malignancy.