In the wake of the news

Falling mask mandates; your Netflix subscription; and beware the inaccurate, pricey and dangerous CT scan for bone density

CDC moves to challenge Florida judge’s mask mandate ban

(Late breaking news: The Centers for Disease Control and Prevention late this afternoon asked the Department of Justice to challenge the federal court decision banning a mask mandate.)

The Biden administration’s decision to punt on mask mandates is politically understandable, but leaves most health-aware citizens — especially those who are old, immuno-compromised or have serious pre-existing medical conditions — once again at sea on how to respond. Here’s the official “now that it’s not mandatory” advice: If you are in an environment where you will be in close contact with people whose vaccine and disease status is unknown, wear a mask and keep your distance.

Most airlines and public transportation agencies immediately affected by Monday’s federal court decision in Florida adopted that stance, even though keeping one’s distance isn’t a practical option on airplanes or crowded trains and buses. Reportedly, their employees, after months of abuse from people who object to mask mandates, cheered the ruling.

The only good news I can report for the health-conscious is that studies have repeatedly shown that masking alone is fairly effective at preventing contraction of the disease. Here’s the New York Times’ updated rundown on the latest science: Standard N-95 masks are anywhere from 57% to 90% effective at protecting the wearer from inhaling airborne viral particles. The tighter the fit, the better the protection.

It’s even more effective at preventing your spreading the virus to others. However, preventing disease no longer falls within the purview of the Centers for Disease Control and Prevention, according to U.S. District Judge Kathryn Kimball, the 35-year-old Trump appointee and conservative ideologue deemed unsuitable for her lifetime appointment by the American Bar Association because she lacked courtroom experience.

The 1944 Public Health Services Act states plainly that the government and its designated agency, the CDC, has the authority to promulgate regulations aimed at “identifying, isolating and destroying” diseases. Subsequent court rulings have said that enforcement measures could include “inspection, fumigation, disinfection, sanitation, pest extermination, destruction of animals or articles found to be so infected or contaminated as to be sources of dangerous infection to human beings.”

Judge Kimball’s ruling hinged on her definition of the word sanitation, which after consulting dictionaries in use in 1944, she concluded meant only cleaning up the vectors that spread disease, not preventing the spread itself. While she admits the dictionaries included prevention as a second definition of sanitation and would allow for mask mandates, she decided to limit word’s meaning to its first definition since it must be read “in context,” i.e., adjacent to the other measures mentioned which all involve clean-up.

If you want insight into where the Orwellian logic of conservative jurisprudence is headed, read pages 9 through 20 of her ruling here. Aaron Blake of the Washington Post provides a close reading here. Suffice it to say that if this ruling stands, the nation’s ability to protect itself during future public health emergencies, or a resurgence of the current one, will be severely limited.

It was disappointing to see the president defer to the CDC on whether to appeal the decision. But I was heartened late this afternoon by the agency’s decision to ask the Justice Department to appeal the decision. They had to do it. It was either that or drop the last two words (“and Prevention”) from its five-word name.

Gaslighting by the streamers

Netflix announced its first drop in monthly subscriptions yesterday, causing its stock price to drop like a rock. The company’s chairman and co-founder Reed Hastings blamed it on subscribers sharing their passwords with friends and family.

Talk about gaslighting (which my urban dictionary defines as “a false narrative to another group or persons which leads them to doubt their perceptions and become misled, disoriented or distressed). Password-sharing didn’t stop Netflix from posting substantial growth in its subscriber base every quarter for the past ten years.

Two things are happening: First, the number of streaming services offering original content and a huge catalog of rentable movies has grown substantially over the past decade, making online entertainment one of the most competitive industries in America. Amazon Prime, Apple Plus, Criterion, Disney Plus, HBO Max, Hulu, Paramount Plus, Showtime and more — all of them charge monthly fees somewhat below Netflix’ $15.49 a month, the cost of its standard (not bare bones) offering.

Second, despite this growing competition, Netflix has raised its price every year for the past three years. Based on what I’m paying for the exact same standard offering, that price has gone up 41% since January 2019 or well over 10% a year on average. Talk about inflation!

There are only so many hours in the day. And while accurate statistics on the nation’s television viewing habits are an elusive target, most observers agree television watching has been on the decline since the 2008-09 recession. A search of the internet finds estimates as high as nearly 8 hours a day and as low as under 3 hours a day, but all agree viewing time has continued dropping again after a temporary resurgence in the early days of the pandemic. Computer and telephone screentime has sharply eaten into tube time.

You’d think given all the competition for a shrinking market, the price would be dropping. But, no, most services are getting more aggressive in raising prices and limiting family sharing. Hastings said Netflix also plans to begin selling ads on its streaming service.

I predict consumers will react the only way they can when they’re offered more expensive but lower quality products. They will cut back on the number of services they buy. Netflix might consider rethinking its offerings instead of blaming its customers.

Beware that higher-priced CT bone density scan

MedPage Today’s Cheryl Clark last week posted an eye-opening exposé on the growing use of computer tomography (CT) scans to screen for osteoporosis, the weakening of the bones that affects one in four women over 65 and about one in 17 men. CT scans expose patients to 1000 to 3000 times more radiation compared to traditional x-ray machines; cost Medicare three times more; and are far more likely to exaggerate fracture risks.

While the overall use of the more expensive test is low, it is growing rapidly, Clark’s review of Medicare claims data showed. There is also extreme variation in where this growing use is taking place.

Some large states like Pennsylvania and New Jersey registered zero claims for CT bone density scans in 2019, meaning their physicians followed the U.S. Preventive Service Task Force guidelines that recommend using traditional x-ray machines. Smaller states like Alabama, Arkansas, Iowa, Mississippi, and Oklahoma, on the other hand, submitted hundreds of claims.

One has to read deep into story before its author offers a plausible explanation for physicians’ failure to follow the guidelines. Medicare pays almost three times more for a CT scan in a physician’s imaging center compared to what it pays for traditional x-rays.

Sadly, the x-ray payment has been sharply reduced over the years. That’s forced many physicians to close down their imaging centers and discontinue offering the test. As a result, the share of older women getting screened for osteoporosis has been on the decline for nearly two decades with fewer than half of older women receiving at least one test after turning 65.

That’s led to a rise in the fracture rate among older women, which is costing Medicare an estimated $3 billion a year for hip fractures alone, according to a coalition pushing for higher payments for the traditional x-rays (technically, it’s called dual-energy x-ray absorptiometry). The Fracture Prevention Coalition, comprised of 61 physician and women’s health groups, is pushing bipartisan legislation (S. 1943 and H.R. 3517) that would more than double Medicare reimbursement for the test.

Hopefully, even a divided Congress can find the political will to pass this necessary legislation. I’d add in an amendment, though. They should make the payment the same for whatever imaging test is used to scan for osteoporosis, which would eliminate any financial reward for using the more expensive, less accurate and more dangerous CT test.