by Kylie A. Fletcher, BS; Eva Rawlings Parker, MD, DTMH; and Brian C. Drolet, MD
Ms. Fletcher is with Vanderbilt University School of Medicine in Nashville, Tennessee. Dr. Parker is with the Department of Dermatology at Vanderbilt University Medical Center in Nashville, Tennessee, and the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Drolet is with the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center in Nashville, Tennessee, and the Department of Plastic Surgery at Vanderbilt University Medical Center in Nashville, Tennessee.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.
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.
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.1,16Sun 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.
References
American Academy of Dermatology. Stats: skin cancer. 2022. Accessed 7 Jun 2023. https://www.aad.org/media/stats-skin-cancer
American Academy of Dermatology. Practice safe sun. Updated 11 Apr 2024. Accessed 16 Sep 2023. https://www.aad.org/public/everyday-care/sun-protection/shade-clothing-sunscreen/practice-safe-sun
US Department of Health and Human Services. About the Affordable Care Act (ACA): preventive care. Reviewed 17 Mar 2022. Accessed 16 Oct 2023. https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html
US Preventive Services Task Force. About the USPSTF. Accessed 16 Oct 2023. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf
US Preventive Services Task Force. Published Recommendations. Accessed 25 Sep 2023. www.uspreventiveservicestaskforce.org/uspstf/topic_search_results
Department of Health and Human Services. Health Benefits & Coverage: Preventive Services. 2023. Accessed 25 Sep 2023. www.healthcare.gov/coverage/preventive-care-benefits/
Green AC, Wallingford SC, McBride P. Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence. Prog Biophys Mol Biol. 2011;107(3):349–355.
Olsen CM, Wilson LF, Green AC, et al. How many melanomas might be prevented if more people applied sunscreen regularly? Br J Dermatol. 2018;178(1):140–147.
Gordon L, Olsen C, Whiteman DC, et al. Prevention versus early detection for long-term control of melanoma and keratinocyte carcinomas: a cost-effectiveness modelling study. BMJ Open. 2020;26;10(2):e034388.
Wolverton SE, Wu JJ. Comprehensive Dermatologic Drug Therapy. 4th ed. Elsevier; 2020.
Parker ER. The influence of climate change on skin cancer incidence—a review of the evidence. Int J Womens Dermatol. 2020;17;7(1):17–27. Erratum in: Int J Womens Dermatol. 2021;28;7(5Part B):867.
Humphreys G. Shedding light on occupational exposure to the sun. Bull World Health Organ. 2024;1;102(03):154–156.
Myerson R, Crawford S, Wherry LR. Medicaid expansion increased preconception health counseling, folic acid intake, and postpartum contraception. Health Aff (Millwood). 2020;39(11):1883–1890.
Weig EA, Tull R, Chung J, et al. Assessing factors affecting sunscreen use and barriers to compliance: a cross-sectional survey-based study. J Dermatol Treat. 2020;31(4):403–405.
Patel S, Patel S, Shah RM, et al. Engagement in sun-protective practices based on health insurance coverage: a cross-sectional analysis. J Am Acad Dermatol. 2022;87(6):1453–1455.
Hung M, Beazer IR, Su S, et al. An exploration of the use and impact of preventive measures on skin cancer. Healthcare (Basel). 2022;15;10(4):743.
US Bureau of Labor Statistics. Employee benefits: high deductible health plans and health savings accounts. 2020. Accessed 9 Aug 2023. https://www.bls.gov/ebs/factsheets/high-deductible-health-plans-and-health-savings-accounts.htm
Kullgren JT, Cliff EQ, Krenz C, et al. Use of health savings accounts among US adults enrolled in high-deductible health plans. JAMA Netw Open. 2020;1;3(7):e2011014.
Mahler HI. Reasons for using and failing to use sunscreen. JAMA Dermatol. 2014;150(1):90–91.
Tsai J, Chien AL. Photoprotection for skin of color. Am J Clin Dermatol. 2022;23(2):195–205.
Coups EJ, Stapleton JL, Manne SL, et al. Psychosocial correlates of sun protection behaviors among US Hispanic adults. J Behav Med. 2014;37(6):1082–1090.
Pichon LC, Corral I, Landrine H, et al. Sun-protection behaviors among African Americans. Am J Prev Med. 2010;38(3):288–295.
Wysong A, Gladstone H, Kim D, et al. Sunscreen use in NCAA collegiate athletes: Identifying targets for intervention and barriers to use. Prev Med. 2012;55(5):493–496.
Gao Y, Arron ST, Linos E, et al. Indoor tanning, sunless tanning, and sun-protection behaviors among sexual minority men. JAMA Dermatol. 2018;1;154(4):477–479.
Guy GP, Berkowitz Z, Watson M. Estimated cost of sunburn-associated visits to US hospital emergency departments. JAMA Dermatol. 2017;1;153(1):90–92.
US Preventive Services Task Force. Grade definitions. Updated Jun 2018. Accessed 14 Sep 2023. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions#july2012
Sunscreen Coverage as Preventive Care Under the Affordable Care Act: A Low-Cost Way to Reduce the Prevalence of the Most Common Cancer
Categories:
J Clin Aesthet Dermatol. 2025;18(2):56–59.
by Kylie A. Fletcher, BS; Eva Rawlings Parker, MD, DTMH; and Brian C. Drolet, MD
Ms. Fletcher is with Vanderbilt University School of Medicine in Nashville, Tennessee. Dr. Parker is with the Department of Dermatology at Vanderbilt University Medical Center in Nashville, Tennessee, and the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center in Nashville, Tennessee. Dr. Drolet is with the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center in Nashville, Tennessee, and the Department of Plastic Surgery at Vanderbilt University Medical Center in Nashville, Tennessee.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.
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.
Keywords: Sunscreen, UV protection, skin cancer, melanoma, nonmelanoma skin cancer, preventive care
Introduction
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.
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.
References
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