Judicial Action Threatens Skin Cancer Prevention for 80 Million Americans

On Thursday, March 30, 2023, a Texas Federal Judge issued a decision in Braidwood v. Becerra that challenged the free-of-cost coverage of several preventive healthcare services, including skin cancer prevention counseling. The judge issued a nationwide halt to the Affordable Care Act (ACA) mandated coverage of United States Preventive Services Task Force (USPSTF) Grade A and B recommendations issued on or after March 23, 2010.¹ The USPSTF is the national authority on prevention-based medicine and is tasked with developing evidence-based recommendations on clinical preventive services.² Notably, the decision to halt coverage of these guideline-based recommendations puts sun exposure behavioral counseling at significant risk. On May 15, 2023, the Fifth Circuit Court of Appeals issued an administrative stay in Braidwood v. Becerra, but if a legal stay is unsuccessful, stopping coverage of preventive services is likely to have serious consequences for dermatologists, primary care providers, and patients.³

Current USPSTF guidelines on skin cancer prevention states the following as a Grade B recommendation: “The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer.”⁴ The USPSTF found evidence that when primary care providers provide behavioral counseling to patients between the ages of 6 months to 24 years with fair skin types, there is a moderate increase in the use of sun protection.⁵ Melanoma and nonmelanoma skin cancer is highly associated with unprotected sun exposure as early as childhood.⁵ However, it is not common for children and adolescents to visit a dermatologist regularly to receive this counseling. Hence, to lower the incidence of skin cancer, it is imperative that primary care providers have the resources to conduct consistent, free-of-cost, behavioral sun exposure counseling interventions with their patients. Halting ACA-mandated coverage of this counseling therefore will do the exact opposite.

Despite USPSTF recommendations, sun protection counseling rates during primary care visits consistently rank lowest amongst preventive health topics each year.⁶ In a 2016 survey of 1,506 US primary care providers (PCPs), only 48.5% reported regular skin cancer and sun protection counseling with patients.⁴ The study showed that the physicians who practiced consistent sun exposure counseling were strongly influenced by their awareness of the USPSTF Grade B sun exposure counseling recommendations.⁷ The ACA requirement to cover grade A/B recommendations likely empowered these physicians to consistently provide comprehensive sun exposure counseling services regardless of their patients’ ability to pay.

If the judge’s decision stands, insurers will no longer be required to cover sun exposure counseling as a free-of-cost preventive health service covered by the ACA. This may result in even fewer rates of consistent sun exposure counseling. Time constraints during patient visits were significant barriers for the 58.1% of providers who did not report consistent sun exposure counseling despite it being a free-of-cost service to patients.⁷ With lack of time in patient visits being a common complaint for physicians across the country, it is likely to expect a steep fall in skin cancer prevention counseling rates once it is no longer a free-of-cost service.

We must underline that a widespread halt to the ACA-mandated coverage of USPSTF Grade A and B recommendations may result in significantly fewer rates of consistent skin cancer prevention and behavioral counseling. While it is unclear how many insurers will drop coverage, the consequences of non-coverage for preventative services could be significant. A new Morning Consult Survey revealed that at least 40% of U.S. adults would refuse 11 of the 12, or 92%, of the preventive health services currently covered by the ACA if they were required to pay out-of-pocket costs.⁸ There are only 15 states with laws that protect access to preventive services without cost-sharing.⁶ For the millions of patients residing in the remaining 35 states, the loss of access to protected, free-of-cost preventive services can adversely impact health outcomes in drastic ways, especially in underserved communities where there is already limited access to medical resources. Skin cancer being the most common type of cancer in the United States, it is imperative that sun exposure counseling remain a protected, free-of-cost preventive health service accessible to everyone.

However, the judge’s decision may increase future melanoma prevalence and mortality. Melanoma is responsible for 80% of skin cancer deaths, and 2.2% of the U.S. adult population is expected to be diagnosed with melanoma in their lifetime.⁴ Several clinical trials have been conducted on the protective effectiveness of daily SPF use on skin cancer prevalence and mortality. One randomized clinical trial reported by the USPSTF showed that the intervention group who used SPF daily had a significantly decreased risk of squamous cell carcinoma and less melanoma cases when compared to the control group.^9,10 With an average yearly prevalence of 3,300,000 new cases of non-melanoma skin cancer and 91,270 new yearly cases of melanoma skin cancer, there is significant need for sun exposure counseling and skin cancer preventive services.^11–13

Numerous studies have proven the importance of SPF usage and skin cancer counseling on reducing the incidence of melanoma and non-melanoma skin cancer cases, thus preventing hundreds of deaths due to melanoma. The American Academy of Dermatology (AAD) has also published clear recommendations that support USPSTF guidelines, stating: “Regardless of previous skin cancer status, all individuals should protect themselves from the sun’s ultraviolet rays by using an SPF 30 or higher sunscreen, wearing protective clothing, and seeking shade.”¹⁴ Challenging ACA-mandated coverage of preventive health services like sun exposure counseling will likely mean thousands of more yearly cases of skin cancer and preventable deaths due to melanoma across the US.¹²

The ACA has improved access to free skin cancer counseling and other preventative services for over 80 million Americans.^15–17 The decision to stop coverage of several A/B ranked preventive services impacts many aspects of patients’ lives, including a predicted increase in future cardiovascular disease prevalence and decreased access to cholesterol statin medication, colon and lung cancer screenings, and perinatal depression prevention services.¹⁸ There may be a consequent increase in skin cancer as well.

Appealing the judge’s decision is a time-intensive, lengthy process that can unfortunately take years. Therefore, it is important that dermatologists and primary care providers across the U.S. advocate for maintaining access to these preventive health services. One way providers can actively participate during the appeals process is to file Amicus briefs with public health or patient advocacy associations. Amicus briefs can be an important avenue for patient advocacy by protecting the interests of patients who may be absent from proceedings but still impacted. Providers can also advocate on the state level for no-cost coverage of preventive services. Finally, providers should continue to make every effort to provide skin cancer prevention counseling for patients in their everyday interactions.

UV radiation exposure during early life significantly increases the risk of skin cancer in adulthood, which is why dermatologists and primary care providers play an important role in preventing melanoma and nonmelanoma skin cancer. Effective skin cancer prevention education and counseling can save lives. With time constraints remaining a significant barrier within the US healthcare system, it is imperative that the USPSTF sun exposure counseling recommendations remain a protected, free-of-cost, preventive health service that is accessible to all patients.

The debate of whether patients should be required to pay significant out-of-pocket costs for vital, high quality preventive services should not even be a consideration, let alone a partisan issue. Protecting and promoting access to health services that have been proven to reduce disease incidence and mortality should not be a governmental debate, but instead, an expectation and commitment towards preserving our humanity for one another.