Why are kids dying at the dentist?

Is pediatric dental anesthesia safe?

dental anesthesiologist for dental sedation


Right on the homepage of the ADSA is a big box: “getting sedated at the dentist: there’s nothing to worry about”.   Recent news, however, seems to contradict that statement. In Texas alone, there are at least 85 reported deaths of patients who died following dental procedures between 2010 and 2015. Two pediatric dental anesthesia deaths in California (6 year old boy Caleb Sears and 3 year old girl Marvalena Rady have been in the news recently.  In these cases,  anesthesia was reportedly administered by dentists with anesthesia training. But what constitutes ‘anesthesia training’?  Does that imply the clinician is a dentist anesthesiologist? What is a dentist anesthesiologist, and how does that differ from a physician anesthesiologist, oral surgeon, or dentist with an anesthesia license?


What’s in a name?  No wonder people are confused.

In the FAQ section of the ADSA website, they state “Anesthesia is administered by a licensed anesthesiologist, who was trained in a formal anesthesia residency program.”   This is confusing to patients, as well as to the journalists covering these deaths. Many readers believe that a ‘licensed anesthesiologist’ is a physician who is a board certified anesthesiologist, not understanding that this is a dental professional designation. To take the ADBA exam to practice dental anesthesia, dentists must have completed a 2-3 year dental anesthesia residency after completion of dental school.  For physicians, “anesthesiology residency” refers 4 years of training after completion of medical school, and perhaps up to 2 more years  fellowship training to specialize in pediatric anesthesiology.

Most people assume the title “anesthesiologist” refers to a physician specialist, just as when flight attendants asks if there is a “doctor” on board, they specifically mean a medical doctor rather than a person who holds a doctoral level academic degree.  I am not disparaging the dental programs. I’m just saying the terminology is confusing, and patients have a right to know the difference.  [Update:  one dentist anesthesiologist wrote to me and shared this perspective, saying that at least monthly, he has conversations about confusion related to anesthesia clinicians.  In his words, how can we “expect the public to understand the difference of what a CRNA, an anesthesia assistant, a physician anesthesiologist, and a dentist anesthesiologist is if even the professionals in our field don’t know what a dentist anesthesiologist is?”  I cannot agree more.]

What about safety standards?

Anesthesiology News recently reported on this issue. According to Joel Weaver, DDs, PhD, spokesman for the American Dental Association (ADA) “the educational and training requirements to administer sedation and anesthesia are regulated by individual state dental boards”.  Kenneth Reed, DMD, is the president of the American Dental Society of Anesthesiology (ADSA), agrees: “there are no nationwide standards; there are only guidelines”.

Caleb Sears’ father Tim Sears talked about the confusion many parents have about the difference between care by a medical doctor specializing in anesthesiology vs other clinicians giving anesthesia: “The risks vary and parents should know that. I only wish we had known that”.

But dentists can perform sedation and anesthesia themselves, without the need for a physician or dental anesthesiologist, as long as the dentist has met the requirements of his or her own state dental board. Dr. Herlich, DMD, MD – a medical doctor and also a dentist who acts as the liason between the American Society of Anesthesiology (ASA) and the ADSA – says that dental boards and dental offices do not have to follow ASA standards of care.

Moreover, after publishing this post, I received many informative emails from dental anesthesiologists who told me (and this paragraph is clearly an update to the original post) that the politics and economic interests are a major barrier.  I didn’t know that the ADA has refused to recognize the specialty group of dentist anesthesiologists, despite three decades of advocacy efforts by the ASDA.  Apparently, this is linked in part to insurance issues and to the economic interests of groups such as those teaching “weekend anesthesiology training offered to dentists at motels” according to Dr. Michael W. Davis, DDS.   As he notes, if the ADA recognized the specialty of dentist anesthesiologists, ” dental anesthesiologists would be better positioned to help establish clinical standards of care for anesthesiology. We might have a group which actually monitored patient morbidity and mortality associated with dental sedation (not currently done, except informally by the media). We might have a dental specialty group, which could best educate the dental profession and public, on dental sedation matters.”   It certainly makes sense to me that if the specialty has not been recognized, the issue of informed consent is further muddied.  One dental anesthesiologist told me it is actually illegal in his state for him to call himself a Dentist Anesthesiologist to his patients, because of the lack of recognition by the ADA and his state laws of the expertise he has earned by completing his postgraduate training and passing the examinations of both the American Dental Board of Anesthesiology and the National Dental Board of Anesthesiology.  This seems to be an absurd situation in which the clinicians within the specialty of dentistry who possess the highest level of training in anesthesia are not recognized as having significantly more expertise than the “motel” programs Dr. Davis describes. Another letter I received stated that the ADA refuses to adopt ASA standards because of political pressure from dentists and oral surgeons who wish to retain their current ability to provide their own anesthesia services. Yet another told me that dentist anesthesiologists have been advocating for ADA to adopt ASA standards, especially capnography – a real time monitor of breathing – but have repeatedly been denied. He also said that ‘Dental Advanced Life Support was created so that dentists could circumvent ACLS and PALS requirements.  Of course, these are emails from clinicians who have chosen to correspond with me; as such, they represent just a sample of personal experiences and perspectives.


dental pediatric sedation : who is administering anesthesia


Respect for patients’ autonomy and decision-making

This may sound like an objection to the “dentist anesthesiologist” as a profession, but it is not. Simply, it is our duty as healthcare professionals to be transparent. Patients deserve to understand the differences among confusingly similar titles and designations. And moreover, patients should know whether their anesthesia will be given by a dentist anesthesiologist or an assistant with little formal training at all.  Patients have a right to this disclosure, as part of our professional respect for their autonomy to make their own medical decisions.

A pediatric anesthesiologist first becomes a medical doctor, then trains for four years to specialize in anesthesiology, and then spends an additional one to two years further sub-specializing in pediatric anesthesiology, because children are physiologically very different from adults. In fact, I’ve personally had parents of young patients ask me if I am a pediatric anesthesiologist, and because I am not, they have declined my care. I was not insulted that they wanted someone even more specialized.   I happily transferred their case to one of my pediatric anesthesiology colleagues.

Dr. Weaver of the American Dental Association agrees: “sedating children is very different from sedating adults. Many state dental boards require the dentist…to qualify for a special anesthesia permit.”   But as we have already learned, there are no national standards for what that permit requires, and some states do not require it at all.   And, the standards are determined by the ADA, not by the ABA or by medical boards or even the two national boards for dental anesthesiology.  

As long as the terminology is confusingly similar but the standards of safety are not standardized, and also do not reflect the standards of the American Society of Anesthesiologists, I think this is a problem.

To be clear, I value and respect all of the professionals and educational programs in this post. My purpose is simply to raise awareness of the issue of confusion for patients, who have the right to understand the training and roles of the people caring for them as well as the risks of anesthesia. That is the basis of the “informed consent” process, which is at the heart of shared medical decision making. A common theme emerging from these recent deaths is that parents felt they were not fully informed. But without question, patients deserve to be fully informed.  If you go to the emergency room, you may see a nurse practitioner (NP) or physician assistant (PA) instead of a physician. If you have surgery, an NP or PA may be performing portions of the procedure. There is nothing wrong with the variety of clinicians in healthcare.  Certainly, all clinical professionals have experienced or will experience adverse patient outcomes over their careers, and this does not necessarily imply that errors was made.

Patients simply have a right to know.  And, they have a right to demand safety standards for anesthesiology that reflect the standards of anesthesiologists,  equally applied in all states. 


  1. JC Lydon MD; fellow Tar Heel and physician anesthesiologist July 26, 2016 Reply

    Abandon the political correctness, Majorie. No child should die in a dentist’s office, period. If they had co-morbidities that placed them at risk, they should have been done in the hospital with an anesthesiologist, if not a pediatric anesthesiologist, in attendance. If they didn’t have co-morbities, it makes this outcome 10 times worse. Yes, disclosure is an issue, and honesty should prevail. But it seems to me that once again, this is a scope of practice issue. Oral surgeons that do some time in an anesthesia department are not anesthesiologists and shouldn’t function as such. Was there false advertising involved in the pediatric cases ? Finally, I am troubled by the lack of national sedation standards on the part of the dentists. 85 deaths over 5 years in Texas dental offices seems like an epidemic to me. Seems to me that the Texas Board of Medicine has some work to do.
    I always enjoy your postings.

    • Author
      Marjorie Stiegler July 29, 2016 Reply

      Hi JC, thanks for your comment and your feedback on this post and the recent APRN post. I really appreciate your words, and that you enjoy the blog! As you can tell, my goal is really to share information so that readers can make up their own minds about these issues, rather than to engage in political activism. One reason for that is simply my guess that if readers feel the post is political, they may not read it, share it, or consider it deeply. We are all so polarized, and people are so often quickly dismissive of views that don’t match their own. Of course, I do have my own personal opinion on these issues. I think it would be a disgrace for the VA system (and probably then, Medicare, and then private insurers) to limit veterans’ access to physicians in all domains, including primary care, anesthesiology, obstetrics, radiology, etc as the rule proposes. And I personally think that any outpatient sedation setting – and the states that license those clinicians and environments – should meet the standards of the ASA in terms of monitoring, emergency plans, and dedicated skilled clinicians capable of rapid diagnosis and rescue of life-threatening emergencies. This is an issue not only for dental care, but for outpatient endoscopy and other office-based procedures. It may be scope of practice, but it is also very much a state law and licensure problem. I don’t really understand how it can be so variable from one state to the next. To my knowledge, there is no equivalent in medicine. Although we must obtain licensure in a given state to practice there, the standards for obtaining that licensure and the scope of practice for medical doctors is the same in every state. All practices in all states follow ASA standards and guidelines for safe anesthesiology care. Why is there so much variability for other clinicians’ requirements and privileges? I totally agree with you – lack of national standards is a big problem. I also agree that no child should die in the dentist’s office ever, just as the APSF’s mission is that no person should ever be harmed from anesthesia. But I try to keep in mind that adverse events do happen – even to us doctors – and do not always represent error, incompetence, or negligence. So I suppose my concern is more about elevating those safety, education, and qualification standards than about the actual people doing the job. Thanks again for your comments!

  2. Rainy Suon July 27, 2016 Reply

    Yeah, please look at your statistics…. 85 deaths/5yrs — that’s 17/year out of how many sedations?
    Were all of these healthy ASA one children? No.
    How many were done by dentist anesthesiologist? I not sure any of them…
    How many child dental deaths ever with a dental anesthesiologist — please look that up.
    Also please look up how many pediatric dental GA cases are performed per year.
    Deaths are extremely rare with a dental anesthesiologist.
    Deaths occur with oral surgeons and general dentists (oral sedation) — this is the major source of ‘deaths, in a dental office.
    Statistically, the more cases that are done the more chance of a bad outcome — and not necessarily due to operator error.
    The dentist anesthesiologist may be the first to anesthetize a toddler — even a fairly thorough workup can miss an undiagnosed condition…
    I don’t disagree with your idea of informed consent – fantastic.
    Just FYI dental anesthesiologists have a stellar record.

    • Author
      Marjorie Stiegler July 29, 2016 Reply

      Thanks for your comment, Rainy. I agree completely that statistically, more case volume = higher chance of problems. I also agree that adverse events do not necessarily imply error – that is a huge theme on my blog. Certainly, major adverse events are rare in all arenas of healthcare, and we are all very fortunate that is the case, because bad things can happen to any of us, in any setting, with any patient. My post is intended to discuss the issue of inconsistent standards, confusing terminology, and informed consent. I believe those are important for patient safety and patient centered decision making, regardless of the skills and track record for the professionals involved, which I am not disparaging.

  3. Just a thought August 2, 2016 Reply

    What if the numbers show that more deaths in the dental office are caused by MD anesthesiologists than dentist anesthesiologists? Would you write a blog about that? Should that be part of informed consent as well…that your child has a higher chance of an adverse outcome with an MD anesthesiologist in a dental office than with a dentist anesthesiologist?

    Should MD anesthesiologists put in their informed consent that they don’t have training in their residencies providing anesthesia in the dental office environment, without they typical operating room/surgery center setup but dentist anesthesiologists are specifically trained in that environment?

    Please do some research on numbers and deaths as well. There may very well be more MD anesthesiologist related deaths in the pediatric dental office than by dentist anesthesiologists…

    • Author
      Marjorie Stiegler August 3, 2016 Reply

      Thanks for your comment. My entire purpose is to raise awareness of safety standards and to include patients in the conversation. I have not said that dental anesthesiologists are responsible for more deaths than physicians anesthesiologists. I am saying, however, that anesthesia can be given by a myriad of clinicians and assistants, or in a single-operator situation by the dentist alone, and that part of the conversation with patients should include information about who is providing sedation or anesthesia. And I do believe that the various societies, boards, and laws should meet some minimum standard of safety, which is yet to be achieved. This is a problem of politics, and a conversation of healthcare literacy.

  4. Russ August 2, 2016 Reply

    Great article. I have two questions for you. I know some of those deaths occurred in the dental office under the supervision of an MD physician anesthesiologist. Did you separate those in your dental office death stats?

    Also according to the ACGME there are only three anesthesia specialties which include cardiothoracic anesthesia, pain management, and critical care. The non-accredited opportunities for fellowships/continued training include pediatric anesthesia. Should patients be aware that when you refer a patient to a pediatric anesthesiologist that they are being seen by a physician who completed advanced training in a specialty that is not accredited by the ACGME?

    • Author
      Marjorie Stiegler August 3, 2016 Reply

      Hello Russ, thanks for your comment. Because my focus is on the variety of standards across states, and the concept of informed consent, I did not do independent statistical analysis for this piece. Also, the ABA does indeed offer board certification upon passing and exam and completing the fellowship training. The American Board of Medical Specialties and the American Board of Anesthesiology offer accredited specialty certifications to cardiac anesthesiology, critical care medicine, pain medicine, hospice and palliative medicine, sleep medicine and pediatric anesthesiology. This information can be found at theaba.org But I certainly agree that patients should be aware of the issues you raise. I always tell parents that – even though I have experience anesthetizing many young children – I am not a pediatric specialist, and that we can arrange for their care to be transferred to someone who is.

  5. Steve August 2, 2016 Reply

    FYI, on March 26, 2016 Daisy Lynn a 14 month old child dies in a dental office in Austin, Texas. General anesthesia was provided by an MD anesthesiologist.

    Also, Dental Anesthesiologists do not take any exam offered by ADA. There is a board certification process and examination offered by ADBA (American Dental Board of Anesthesiology).

    Many dental anesthesia residencies are 3 years in length, the same as MD anesthesia programs. The dental anesthesia residents are trained in the same class of MD anesthesia residents following the same curriculum but with more focus on head and neck and pediatric anesthesia.

    Dental Anesthesiologists have far more training in pediatric anesthesia than an average MD anesthesiologist by the time they finish their residencies.

    Dental Anesthesiologists are trained to perform in an office setting. Average MD Anesthesiologists are not trained in office based anesthesia and are not comfortable providing anesthesia services in an office setting.

    • Author
      Marjorie Stiegler August 3, 2016 Reply

      Thank you Steve. I have corrected the error you point out – although the link about board certification always directed to the ADBA, I incorrectly wrote ADA. Certainly, adverse events can occur in any setting, to any patient, and under the care of even the most skilled and vigilant clinician. My post is not about whether dental anesthesiologists are qualified to provide anesthesia care. Certainly, as a dental anesthesiologist, you represent the highest level of training in anesthesia in your discipline. It is about the wide variety of practice models (solo-operator, assistant with little anesthesia training, assistant with robust training, dental anesthesiologist, physician anesthesiologist, office, outpatient center, hospital) and the inconsistencies across state standards for safety. Patients should know about the differences, and have an absolute right to understand who is caring for them and their loved ones. And as you point out, environment is very important. Anesthesiologists do have training in a variety of outpatient centers and office based practices, but what is more likely to be important is the support staff and the resources of that office environment to assist with the management of an emergency, should one arise.

  6. Whitmore Lane August 3, 2016 Reply

    I would like to clarify a few misunderstandings. First of all, in order to get to the webpage that concerns you about confusion about whether a dentist anesthesiologist is or is not a physician anesthesiologist, please look at the home page that one first sees. It clearly states that we are the American Society of DENTIST Anesthesiologists. Furthermore on this home page, it clearly states that “We are DENTISTS who are trained extensively in the specialized field of anesthesia.” It is hard to believe that anyone would think that we are not dentists when viewing other pages..

    Secondly, while medical anesthesia training requires 3 years after a year internship, there are many anesthesiologists still practicing who trained for 2 years after internship. Likewise, while many dentist anesthesiologists completed 2 years of anesthesiology residency after dental school, the current accreditation standards require dentist anesthesiologists to have a three year residency, with a minimum of 12 months in the hospital operating room and 24 months exclusively devoted to clinical anesthesia experience, All ASDA members must have had at least 2 years to be members, but 3 years is now the standard.

    Thirdly, our accreditation standards require completion of 800 deep sedation/general anesthetics, including 300 nasal intubations, 75 anesthetics for patients with special needs, and 100 anesthetics for dental procedures. No physician or CRNA has any of those requirements that are extremely important in the dental office. Additionally our accreditation standards require 125 anesthetics for children age 7 or less, whereas physicians need 100 children less than age 12 ( with 20 of those less than 3 years and 5 less than 3 months). CRNAs need 25 children ages 2 – 12, 10 cases under age 2 and 5 neonates. Oral surgeons (5 month O.R. anesthesia rotation) are required to do 300 total anesthetics including 50 anesthetics for children 18 years or younger. With more pediatric case requirements than anyone else, it is fair to say that dentist anesthesiologists are superbly trained to manage anesthesia for reasonably healthy adults and children in the dental office. Like physicians and CRNAs, we do not do sick or severely medically compromised children in an office..

    Fourthly, dentist anesthesiologists are the only dentists who provide just the anesthesia for patients in the office of the operating dentist. Oral surgeons almost exclusively practice as operator-anesthetists in their offices. Nationwide, there are perhaps 250 dentist anesthesiologists and about 5 or 6,000 oral surgeons. People often confuse us with oral surgeons because we both have “anesthesia training” and we are both dentists, but that is where the comparison stops. Please don’t confuse us with other dentists and oral surgeons. Our anesthesia training is far different.

    Finally to be perfectly honest, I know of 3 dental office deaths in the last few years where physician anesthesiologists were providing the anesthesia. These have been made public at the following sites” so this information is far from rumor.

    1.One was in California with a well-known physician anesthesiologist . 57 y.o. patient


    2. A Maryland physician anesthesiologist had a 17 y.o. teenager who died in an oral surgeon’s office;

    3. A physician anesthesiologist had a dental office death in Texas of a 14-month old child..

    There is no question that anesthesia given anywhere by anyone can result in unfortunate outcomes. It is unfair for anyone to say that nobody should ever die having just a tonsillectomy or just a BPS or just having a child’s 15 painful rotting teeth being treated. Our emphasis should be to find out where the problems are and correct them.

    • Author
      Marjorie Stiegler August 3, 2016 Reply

      Thanks for your comments. I totally agree – dental anesthesiologists are superbly trained and properly credentialed. When I use our two professional titles as an illustration of confusion, I mean confusing to patients, not to web searchers who are explicitly looking for dentist anesthesiologists. I think of parents being told by their dentist that work is necessary for their child, and that the child will be given sedation or anesthesia. Many parents wouldn’t know to ask whether it will be an anesthesiologist, whether dentist or physician by background. They may be unknowingly agreeing to sedation by someone with far less training, and if you are right that oral surgeons do this, but dentists do not, yet people are often confused – well, that is entirely my point. People are confused by the requirements, training, background, and state-specific standards of care. I’m certain that specialists like you are highly qualified, and that some states have very robust standards and guidelines, but that is not true across all states for all patients undergoing sedation or anesthesia in an office. I also agree that physicians are involved in deaths, even when well trained and vigilant, and even if no error is made (and also, of course, when error is made). But I am concerned about the national lack of consensus for qualifications of the various types of caregivers permitted to administer anesthesia, the vast majority of whom are neither physician nor dentist anesthesiologists. And, I am concerned about general public confusion and lack of knowledge about this issue. Who is going to be giving the anesthesia and monitoring the patient? It is hard for me to understand why anyone objects to the suggestion that patients have be informed about this. Thanks also for your correction on the new standard of 3 years for residency, which I hope is more accurately represented now in the updated post.

  7. PhysicianOnFIRE August 22, 2016 Reply

    This was an eye-opening post! I’ve been a practicing anesthesiologist for more than a decade, and my father and his father were both dentists.

    I have never heard the term “dentist anesthesiologist” until a few minutes ago. I guess that’s another reason we’ve added additional syllables to the heptasyllabic moutthful title we physicians have been using for decades.

    Thank you for bringing the issue to light.

    Physician on FIRE
    Physician Anesthesiologist

  8. Kate June 17, 2017 Reply

    I am an MD anesthesiologist myself and there’s no way that I would allow a dentist anesthesiologist to care for my own child.

  9. John July 13, 2017 Reply

    This article isn’t about dentists vs MDs, or dental anesthesiologist vs MD anesthesiologist, and I do not understand why so many dentist anesthesiologist are not understanding this and are taking it personally. It’s about having standards of care to improve outcomes. Everyone can have bad outcomes. Doesn’t matter MD or Dentist. The question is how can we REDUCE these bad outcomes. First is to have DATA. It’s crazy how morbidity and mortality isn’t even recorded by an association/board. Does it make sense to you that the rest of healthcare have standards but dentist anesthesiology does not? Id love for dentist anesthesiologist to continue doing anesthesiology in dental offices, but there needs to be standards. I dont know how dentist anesthesiologists can even argue this. Can you really argue against mandating capnography? Will that capnography hurt your patient? I highly doubt it. But it may just save your patient’s life.

  10. DoItForTheKids July 13, 2017 Reply

    Pediatric anesthesiologist here (MD version). I think the bigger question is, should ANY kid EVER die in a dentists office? Many surgeries that we perform, we accept a low likelihood of mortality because the alternative is worse. Is there a mortality risk to leaving dental caries untreated? Maybe there is. Do more kids die of dental abscesses every year than from receiving sedation in an office setting? Apparently we don’t know since nobody wants to actually collect the data. You would think it would be a win-win for dental anesthesiologists: if yes, then they have a justifiable reason for doing it. If not, then they’re hurting kids and a reasonable human being would want to know that.

    Count me in the group that would never let my child receive sedation at a dentist’s office. I work with pediatric dentists on a regular basis, and respect what they do, and they respect what we do. And that means recognizing that bad s*** happens to even the best of us. But God forbid, I lose an airway or a child codes from an unrecognized heart condition in the OR in a children’s hospital, at least I have an ENT surgeon or a cardiologist minutes (or seconds away). I’m not slow to recognize it because I don’t have capnography, then waiting for an ambulance, then waiting on the ride to the nearest hospital, then waiting to get processed through the ED, etc.

  11. Annoyed July 31, 2017 Reply

    Why don’t you MD’s look up what dental anesthesiologists have done to set regulations before you assume none of us support that. In 2012, dental anesthesiologists tried for the 4th time to become a recognized specialty so that standards could be in place. You can thank the politically-motivated ADA and oral surgeons for blocking that move. The efforts have been made – even when dentistry as a whole has to take the fall for the death of a child that usually happens because of an oral surgeon playing operator-anesthetist or (drumroll) a PHYSICIAN ANESTHESIOLOGIST who does an OUT-PATIENT and OFFICE-BASED procedure in a DENTAL practice. Yea… thanks for killing our kids then claiming dental anesthesiologists are the ones screwing up when a dental anesthesiologist hasn’t killed a patient in nearly 40 years. #dropsmic

  12. O January 18, 2018 Reply

    As an oral surgeon, dentist, and physician, considering how diverse the patient population and how many procedures are being done, it is amazing how safe it is for a single operator model. However, I completely agree that it would be safer for surgery/anesthesia to be done in the hospital or in office with 2 doctors (anesthesiologist and oral surgeon). This is what I would prefer. In fact, our patient population is more diverse and challenging than many traditional elective medical procedures. Operating in a sedated airway, with secretions, bleeding, patient movement is common, removing something from in side the bone or other oral surgeries is no walk in the park. Many of the procedures we do are more invasive than many medical procedures.

    “Lets have all oral surgery done in the hospital or an office with 2 doctors!” However, the practical issue is who pays for it. The insurance company, government, employer or the patient? How many anesthesiologist is willing to perform office based anesthesia. Can hospital take care of millions of additional procedures? How would the patient feel about oral surgery in the hospital? I don’t understand why the oral surgeons are fighting for 1 operator model? To save money for insurance company, government, employer or the patient? The truth is, it is hard to fight the current system of patient expectation, referral expectation, and insurance protocols. Oral surgeons are providing services to millions of patients. Many of who are underserved and poor. Even if we can have enough anesthesiologist who are willing to provide care, I don’t think many would want to accept current reimbursement.

    I want 2 doctor model, but we have to address who pays for this and how do we make it happen.

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