By Karen Brown, New England Public Media, KFF Health News

Michele Andrews had been seeing her internist in Northampton, Massachusetts, a small city two hours west of Boston, for about 10 years. She was happy with the care, though she started to notice it was becoming harder to get an appointment.

Related Articles

COVID worsened shortages of doctors and nurses. Five years on, rural hospitals still struggle

St. Paul audiology specialist finds balance issues are big business

MN Health Department updates fish consumption guidelines for PFAS

A 6-hour morning routine? First, try a few simple habits to start your day

Whooping cough cases are rising again in the US, challenging public health departments

“You’d call and you’re talking about weeks to a month,” Andrews said.

That’s not surprising, as many workplace surveys show the supply of primary care doctors has fallen well below the demand, especially in rural areas such as western Massachusetts. But Andrews still wasn’t prepared for the letter that arrived last summer from her doctor, Christine Baker, at Pioneer Valley Internal Medicine.

“We are writing to inform you of an exciting change we will be making in our Internal Medicine Practice,” the letter read. “As of September 1st, 2024, we will be switching to Concierge Membership Practice.”

Concierge medicine is a business model in which a doctor charges patients a monthly or annual membership fee — even as the patients continue paying insurance premiums, copays, and deductibles. In exchange for the membership fee, doctors limit their number of patients.

Many physicians who’ve made the change said it resolved some of the pressures they faced in primary care, such as having too many patients to see in too short a time.

Andrews was floored when she got the letter. “The second paragraph tells me the yearly fee for joining will be $1,000 per year for existing patients. It’ll be $1,500 for new patients,” she said.

Although numbers are not tracked in any one place, the trade magazine Concierge Medicine Today estimates there are 7,000 to 22,000 concierge physicians in the U.S. Membership fees range from $1,000 to as high as $50,000 a year.

Critics say concierge medicine helps only patients who have extra money to spend on health care, while shrinking the supply of more traditional primary care practices in a community. It can particularly affect rural communities already experiencing a shortage of primary care options.

Andrews and her husband had three months to either join and pay the fee or leave the practice. They left.

“I’m insulted and I’m offended,” Andrews said. “I would never, never expect to have to pay more out of my pocket to get the kind of care that I should be getting with my insurance premiums.”

Baker, Andrews’ former physician, said fewer than half her patients opted to stay — shrinking her patient load from 1,700 to around 800, which she considers much more manageable. Baker said she had been feeling so stressed that she considered retiring.

“I knew some people would be very unhappy. I knew some would like it,” she said. “And a lot of people who didn’t sign up said, ‘I get why you’re doing it.’”

Patty Healey, another patient at Baker’s practice, said she didn’t consider leaving.

“I knew I had to pay,” Healey said. As a retired nurse, Healey knew about the shortages in primary care, and she was convinced that if she left, she’d have a very difficult time finding a new doctor. Healey was open to the idea that she might like the concierge model.

“It might be to my benefit, because maybe I’ll get earlier appointments and maybe I’ll be able to spend a longer period of time talking about my concerns,” she said.

This is the conundrum of concierge medicine, according to Michael Dill, director of workforce studies at the Association of American Medical Colleges. The quality of care may go up for those who can and do pay the fees, Dill said. “But that means fewer people have access,” he said. “So each time any physician makes that switch, it exacerbates the shortage.”

Blue Canyon Primary Care offers “direct primary care” in Northampton, Massachusetts, for patients who pay $225 a month. Direct primary care is similar to concierge medicine but does not accept insurance. Patients must pay out-of-pocket and can seek reimbursement from their insurers afterward. (Karen Brown/New England Public Media/TNS)

His association estimates the U.S. will face a shortage of 20,200 to 40,400 primary care doctors within the next decade.

A state analysis found that the percentage of residents in western Massachusetts who said they had a primary care provider was lower than in several other regions of the state.

Dill said the impact of concierge care is worse in rural areas, which often already experience physician shortages. “If even one or two make that switch, you’re going to feel it,” Dill said.

Rebecca Starr, an internist who specializes in geriatric care, recently started a concierge practice in Northampton.

For many years, she consulted for a medical group whose patients got only 15 minutes with a primary care doctor, “and that was hardly enough time to review medications, much less manage chronic conditions,” she said.

When Starr opened her own medical practice, she wanted to offer longer appointments — but still bring in enough revenue to make the business work.

“I did feel a little torn,” Starr said. While it was her dream to offer high-quality care in a small practice, she said, “I have to do it in a way that I have to charge people, in addition to what insurance is paying for.”

Starr said her fee is $3,600 a year, and her patient load will be capped at 200, much lower than the 1,000 or even 2,000 patients that some doctors have. But she still hasn’t hit her limit.

“Certainly there’s some people that would love to join and can’t join because they have limited income,” Starr said.

Many doctors making the switch to concierge medicine say the membership model is the only way to have the kind of personal relationships with patients that attracted them to the profession in the first place.

“It’s a way to practice self-preservation in this field that is punishing patients and doctors alike,” said internal medicine physician Shayne Taylor, who recently opened a practice offering “direct primary care” in Northampton. The direct primary care model is similar to concierge care in that it involves charging a recurring fee to patients, but direct care bypasses insurance companies altogether.

Taylor’s patients, capped at 300, pay her $225 a month for basic primary care visits — and they must have health insurance to cover care such as X-rays and medications, which her practice does not provide. But Taylor doesn’t accept insurance for any of her services, which saves her administrative costs.

“We get a lot of pushback because people are saying, ‘Oh, this is elitist, and this is only going to be accessible to people that have money,’” Taylor said.

But she said the traditional primary care model doesn’t work. “We cannot spend so much time seeing so many patients and documenting in such a way to get an extra $17 from the insurance company.”

While much of the pushback on the membership model comes from patients and policy experts, some of the resistance comes from physicians.

Paul Carlan, a primary care doctor who runs Valley Medical Group in western Massachusetts, said his practice is more stretched than ever. One reason is that the group’s clinics are absorbing some of the patients who have lost their doctor to concierge medicine.

“We all contribute through our tax dollars, which fund these training programs,” Carlan said.

“And so, to some degree, the folks who practice health care in our country are a public good,” Carlan said. “We should be worried when folks are making decisions about how to practice in ways that reduce their capacity to deliver that good back to the public.”

But Taylor, who has the direct primary care practice, said it’s not fair to demand that individual doctors take on the task of fixing a dysfunctional health care system.

“It’s either we do something like this,” Taylor said, “or we quit.”

This article is from a partnership that includes New England Public Media , NPR , and KFF Health News.

©2025 KFF Health News. Distributed by Tribune Content Agency, LLC.

Hyunmin Kim, Margaret Giles of Morningstar

A 529 college savings plan can be a powerful tool when saving for future education expenses because investments in the plan can increase tax-free, but many savers don’t take full advantage of all the benefits that 529 plans have to offer.

Related Articles

St. Paul schools after-school activities canceled Monday due to weather

International students in U.S., MN see legal records restored with fed reversal

19 states sue Trump administration over push to end diversity programs in public schools

ICE is reversing the termination of legal status for international students around the US

Minnesota academic leaders among hundreds condemning Trump ‘overreach’

One common deterrent to investing through a 529 plan is the concern that assets in a 529 account will reduce financial aid eligibility. While it’s true that 529 assets have an impact on financial aid, the effect is likely smaller than you think.

Do 529 plans affect financial aid?

The short answer is yes. An increase in the means to fund higher education naturally means the beneficiary is eligible for less need-based aid.

However, assets in a 529 plan have a lesser impact on financial aid packages than income does. A student’s federal financial aid is based on an estimate of what a family can contribute annually from their income and assets. Income is the largest portion of this measurement of a student’s ability to pay for college, which is represented by the Student Aid Index, or SAI, on the Free Application for Federal Student Aid, or FAFSA. The SAI replaced the expected family contribution, which was previously used on the application.

Typically, the SAI calculation expects parents to use 25% to 35% of their adjusted available income to cover college costs, though that number can go as high as 47%. Parental contribution from assets, including 529 account balances, is assessed at a much lower maximum of 5.64%. So, if a family has a 529 account with $10,000, this raises the expected family contribution by at most $564 and reduces the federal aid package by the same amount.

A 529 plan’s impact depends on who owns the account

The impact of 529 assets on a beneficiary’s financial aid package depends on who owns the account. As outlined above, if the plan is owned by the beneficiary’s parent, then 5.64% of the account’s value is considered in the SAI, which determines a student’s financial aid eligibility on the FAFSA.

On the other hand, if the plan is owned by the student, then up to 20% of the account value may be considered in calculating financial aid eligibility.

With changes to the federal student aid calculation as part of the FAFSA Simplification Act that took effect for the 2024-25 academic year, 529 accounts owned by grandparents or other relatives are not considered student assets and won’t impact the beneficiary’s financial aid.

Siblings’ 529 assets don’t count for federal financial aid

After the FAFSA Simplification Act, assets in 529 accounts are counted as parental assets only for the beneficiary of the account. That means, if you have 529 accounts set up for your other children, the assets in those accounts are no longer counted toward the expected family contribution. As mentioned above, accounts owned by grandparents or other relatives will also be excluded from determining federal financial aid eligibility.

Financial aid eligibility differs between FAFSA and CSS profile

There are also schools that use the College Scholarship Service, or CSS, Profile (primarily private schools) to calculate their financial aid packages. The CSS Profile’s formula to calculate aid differs from FAFSA’s. For instance, the CSS Profile asks for all 529 accounts owned by the beneficiary’s parents, whereas the FAFSA only counts 529 accounts for which the student is the beneficiary. Moreover, the CSS Profile is customized by the institution, so each school can have its own formula to calculate its aid packages. While each school that uses CSS Profile information applies its own standards, this calculator estimates what your family might be expected to pay.

This article was provided to The Associated Press by Morningstar. For more personal finance content, go to  https://www.morningstar.com/personal-finance

By MATT O’BRIEN, AP Technology Writer

CAMBRIDGE, Mass. (AP) — After retreating from their workplace diversity, equity and inclusion programs, tech companies could now face a second reckoning over their DEI work in AI products.

In the White House and the Republican-led Congress, “woke AI” has replaced harmful algorithmic discrimination as a problem that needs fixing. Past efforts to “advance equity” in AI development and curb the production of “harmful and biased outputs” are a target of investigation, according to subpoenas sent to Amazon, Google, Meta, Microsoft, OpenAI and 10 other tech companies last month by the House Judiciary Committee.

And the standard-setting branch of the U.S. Commerce Department has deleted mentions of AI fairness, safety and “responsible AI” in its appeal for collaboration with outside researchers. It is instead instructing scientists to focus on “reducing ideological bias” in a way that will “enable human flourishing and economic competitiveness,” according to a copy of the document obtained by The Associated Press.

In some ways, tech workers are used to a whiplash of Washington-driven priorities affecting their work.

But the latest shift has raised concerns among experts in the field, including Harvard University sociologist Ellis Monk, who several years ago was approached by Google to help make its AI products more inclusive.

Back then, the tech industry already knew it had a problem with the branch of AI that trains machines to “see” and understand images. Computer vision held great commercial promise but echoed the historical biases found in earlier camera technologies that portrayed Black and brown people in an unflattering light.

“Black people or darker skinned people would come in the picture and we’d look ridiculous sometimes,” said Monk, a scholar of colorism, a form of discrimination based on people’s skin tones and other features.

Google adopted a color scale invented by Monk that improved how its AI image tools portray the diversity of human skin tones, replacing a decades-old standard originally designed for doctors treating white dermatology patients.

“Consumers definitely had a huge positive response to the changes,” he said.

Now Monk wonders whether such efforts will continue in the future. While he doesn’t believe that his Monk Skin Tone Scale is threatened because it’s already baked into dozens of products at Google and elsewhere — including camera phones, video games, AI image generators — he and other researchers worry that the new mood is chilling future initiatives and funding to make technology work better for everyone.

“Google wants their products to work for everybody, in India, China, Africa, et cetera. That part is kind of DEI-immune,” Monk said. “But could future funding for those kinds of projects be lowered? Absolutely, when the political mood shifts and when there’s a lot of pressure to get to market very quickly.”

Trump has cut hundreds of science, technology and health funding grants touching on DEI themes, but its influence on commercial development of chatbots and other AI products is more indirect. In investigating AI companies, Republican Rep. Jim Jordan, chair of the judiciary committee, said he wants to find out whether former President Joe Biden’s administration “coerced or colluded with” them to censor lawful speech.

Michael Kratsios, director of the White House’s Office of Science and Technology Policy, said at a Texas event this month that Biden’s AI policies were “promoting social divisions and redistribution in the name of equity.”

The Trump administration declined to make Kratsios available for an interview but quoted several examples of what he meant. One was a line from a Biden-era AI research strategy that said: “Without proper controls, AI systems can amplify, perpetuate, or exacerbate inequitable or undesirable outcomes for individuals and communities.”

Even before Biden took office, a growing body of research and personal anecdotes was attracting attention to the harms of AI bias.

One study showed self-driving car technology has a hard time detecting darker-skinned pedestrians, putting them in greater danger of getting run over. Another study asking popular AI text-to-image generators to make a picture of a surgeon found they produced a white man about 98% percent of the time, far higher than the real proportions even in a heavily male-dominated field.

Related Articles

Does a 529 plan affect financial aid?

China shrugs off threat of US tariffs to economy, says it has tools to protect jobs

Wall Street slips ahead of another week full of potential swings

Trump administration cuts more than $1.3M in grants from Minnesota museums, institutions

Business People: MPR culture and arts reporter Euan Kerr retiring after 40 years

Face-matching software for unlocking phones misidentified Asian faces. Police in U.S. cities wrongfully arrested Black men based on false face recognition matches. And a decade ago, Google’s own photos app sorted a picture of two Black people into a category labeled as “gorillas.”

Even government scientists in the first Trump administration concluded in 2019 that facial recognition technology was performing unevenly based on race, gender or age.

Biden’s election propelled some tech companies to accelerate their focus on AI fairness. The 2022 arrival of OpenAI’s ChatGPT added new priorities, sparking a commercial boom in new AI applications for composing documents and generating images, pressuring companies like Google to ease its caution and catch up.

Then came Google’s Gemini AI chatbot — and a flawed product rollout last year that would make it the symbol of “woke AI” that conservatives hoped to unravel. Left to their own devices, AI tools that generate images from a written prompt are prone to perpetuating the stereotypes accumulated from all the visual data they were trained on.

Google’s was no different, and when asked to depict people in various professions, it was more likely to favor lighter-skinned faces and men, and, when women were chosen, younger women, according to the company’s own public research.

Google tried to place technical guardrails to reduce those disparities before rolling out Gemini’s AI image generator just over a year ago. It ended up overcompensating for the bias, placing people of color and women in inaccurate historical settings, such as answering a request for American founding fathers with images of men in 18th century attire who appeared to be Black, Asian and Native American. Google quickly apologized and temporarily pulled the plug on the feature, but the outrage became a rallying cry taken up by the political right.

With Google CEO Sundar Pichai sitting nearby, Vice President JD Vance used an AI summit in Paris in February to decry the advancement of “downright ahistorical social agendas through AI,” naming the moment when Google’s AI image generator was “trying to tell us that George Washington was Black, or that America’s doughboys in World War I were, in fact, women.”

“We have to remember the lessons from that ridiculous moment,” Vance declared at the gathering. “And what we take from it is that the Trump administration will ensure that AI systems developed in America are free from ideological bias and never restrict our citizens’ right to free speech.”

A former Biden science adviser who attended that speech, Alondra Nelson, said the Trump administration’s new focus on AI’s “ideological bias” is in some ways a recognition of years of work to address algorithmic bias that can affect housing, mortgages, health care and other aspects of people’s lives.

“Fundamentally, to say that AI systems are ideologically biased is to say that you identify, recognize and are concerned about the problem of algorithmic bias, which is the problem that many of us have been worried about for a long time,” said Nelson, the former acting director of the White House’s Office of Science and Technology Policy who co-authored a set of principles to protect civil rights and civil liberties in AI applications.

But Nelson doesn’t see much room for collaboration amid the denigration of equitable AI initiatives.

“I think in this political space, unfortunately, that is quite unlikely,” she said. “Problems that have been differently named — algorithmic discrimination or algorithmic bias on the one hand, and ideological bias on the other —- will be regrettably seen us as two different problems.”

By ANIRUDDHA GHOSAL and HAU DINH

DA NANG, Vietnam (AP) — The Vietnam War ended on April 30, 1975, when the South Vietnamese capital of Saigon fell to Communist forces. But millions of people still face daily battles with its chemical legacy.

Nguyen Thanh Hai, 34, is one of millions with disabilities linked to Agent Orange. Born with severe developmental challenges, it’s a struggle for him to complete tasks others take for granted: buttoning the blue shirt he wears to a special school in Da Nang, practicing the alphabet, drawing shapes or forming simple sentences.

Hai grew up in Da Nang, the site of a U.S. air base where departing troops left behind huge amounts of Agent Orange that have lingered for decades, leeching into food and water supplies in areas like Hai’s village and affecting generations of residents.

Across Vietnam, U.S. forces sprayed sprayed 72 million liters (19 million gallons) of defoliants during the war to strip the enemy’s cover. More than half was Agent Orange, a blend of herbicides.

Agent Orange was laced with dioxin, a type of chemical linked to cancer, birth defects and lasting environmental damage. Today, 3 million people, including many children, still suffer serious health issues associated with exposure to it.

Vietnam has spent decades cleaning up the toxic legacy of the war, in part funded by belated U.S. assistance, but the work is far from complete. Now, millions in Vietnam are worried that the U.S. may abandon Agent Orange cleanup as President Donald Trump slashes foreign aid.

Decades of contamination

When the war ended, the U.S. turned its back on Vietnam, eager to turn the page on a painful chapter in its history.

But Vietnam was left with dozens of dioxin hotspots spread across 58 of its 63 provinces.

Vietnam says the health impacts last generations, threatening the children, grandchildren, and even great-grandchildren of people exposed to the chemicals with health complications ranging from cancer to birth defects that affects the spine and nervous system.

But the science about the human health impact — both to those exposed to Agent Orange and the generations that follow — remains unsettled. This is partly because when the two countries finally started working together in 2006, they focused on finding dioxin in the environment and clearing it instead of studying the still-contentious topic of its impact on human health, said Charles Bailey, co-author of the book “From Enemies to Partners: Vietnam, the U.S. and Agent Orange.”

“The science of causality is still incomplete,” said Bailey.

Vietnam identifies Agent Orange victims by checking family history, where they lived, and a list of health problems linked to the poison. And Hai’s disabilities were very likely linked to the spraying of the defoliant, added Bailey.

The 34-year-old dreams of becoming a soldier like his grandfather, was unable to leave home for years, waiting alone while his family went out to work. It was only five years ago that he began attending a special school. “I am happy here because I have many friends,” he said. Other students at the school hope to become tailors or makers of incense sticks.

The contamination also denuded Vietnam’s natural defenses. Nearly half of its mangrove trees, which shield shores from strong storms, were destroyed. Much of its tropical forest was irrevocably damaged, while the herbicide also leached the soil of nutrients in some of Vietnam’s most climate-vulnerable areas.

A massive cleanup begins

In the decades after the war ended, the recovering country fenced off heavily contaminated sites like Da Nang airport and began providing support to impacted families.

But the U.S. largely ignored growing evidence of health impacts — including on its own veterans — until the mid-2000s, when it and began funding cleanup in Vietnam. In 1991, the U.S. recognized that certain diseases could be related to exposure to Agent Orange and made veterans who had them eligible for benefits.

Since 1991, it has spent over $155 million to aid people with disabilities in areas affected by Agent Orange or littered by unexploded bombs, according to the U.S. State Department. The two countries have also cooperated to recover war dead, with the U.S. aiding Vietnam’s search for its own missing.

Cleaning up Agent Orange is expensive and often dangerous. Heavily polluted soil needs to be unearthed and heated in large ovens to very high temperatures, while less contaminated soil can be buried in secure landfills.

Despite years of work, large sites still need to cleared. In Da Nang, where an air base was contaminated during storage and transportation of Agent Orange, the U.S. completed a $110 million cleanup in 2018 but an area the size of 10 soccer fields still remains heavily contaminated.

Cooperation on war legacy issues also laid a foundation for growing U.S.-Vietnam ties, culminating in 2023 when Vietnam elevated the U.S. to its highest diplomatic status of comprehensive strategic partner.

“The United States considers Vietnam a key partner in advancing a free and open Indo-Pacific,” former U.S. Treasury Secretary Janet Yellen said in Vietnam in 2023.

Anxiety about aid cuts

But Donald Trump’s cuts to USAID stalled key projects in Vietnam, and while many have resumed, doubts remain about U.S. reliability.

Vietnam now has to negotiate a new reality where the U.S. president says the country can no longer afford to help other countries.

The country can’t handle the toxic chemicals that still persist without help, said Nguyen Van An, the chairman of Association for Victims of Agent Orange in Danang. “We always believe that the U.S. government and the manufacturers of this toxic chemical must have the responsibility to support the victims,” he said.

He said he hoped that any stoppages to ongoing projects due to shifting politics in Washington would be temporary.

Insufficient data means that experts can’t definitely say when the risk to human health will end. But the more urgent problem is if that cleanup efforts are interrupted, the now-exposed contaminated soil could get into waterways and harm more people.

A 10-year project to clear the some 500,000 cubic meters (650,000 cubic yards) of dioxin-contaminated soil — enough to fill 40,000 trucks — at Bien Hoa airbase was launched in 2020. It stopped for a week in March and then restarted.

But Bailey, who worked on issues related to the Agent Orange in Vietnam for years, said future USAID funding for the cleanup and a $30 million program for people with disabilities was uncertain.

With federal cuts to USAID, most staffers in Vietnam are expected to be gone by later this year, leaving nobody to administer funding for remediation programs, even if it is not cut itself.

“This basically leaves a very large mountain of contaminated soil. Only 30% of which has been dealt with and that is less contaminated,” said Bailey.

He added that less than half of the soil at Bien Hoa had been treated and much of the remaining soil was heavily contaminated and needed to be treated in an as-yet unbuilt incinerator.

Related Articles

In first 100 days, Trump struggles to make good on promises to quickly end Ukraine and Gaza wars

Major power outage in Spain and Portugal knocks out subway networks, traffic lights and ATM machines

Canadians vote in an election dominated by Trump’s trade war and bluster

Conclave to elect a new pope will start on May 7 as cardinals get to know one another

Russia declares a 72-hour ceasefire in Ukraine for next week to mark Victory Day in World War II

Tim Rieser, who was retired Sen. Patrick Leahy’s foreign policy aide when the Vermont Democrat secured the original funding for Vietnam War remediation projects and is now a senior advisor to Sen. Peter Welch, said Congress still supports the programs but it would be hard for them to continue without staff.

“For more than 30 years, the U.S. and Vietnam have worked together to rebuild relations by dealing with the worst legacies of the war, like Agent Orange,” he said. “Now the Trump administration is mindlessly shutting everything down, with no concern for the impact of their actions on relations with an important partner in the Indo-Pacific.”

The U.S. State Department said that war legacy projects like clearing dioxin at Bien Hoa or demining programs in central Vietnam remain “active and running,” adding that it would conduct assessments for the resources needed for their continuation.

Chuck Searcy, an American Vietnam War veteran who has worked on humanitarian programs in the country since 1995, said he worries that trust built over years could erode very rapidly. He pointed out that those who benefit from U.S. funded projects to address war legacies are “innocent victims.”

“They’ve been victimized twice, once by the war and the consequences that they’ve suffered. And now by having the rug pulled out from under them,” he said.

Associated Press journalist David Rising in Bangkok contributed to this report.