THE STANDING SENATE COMMITTEE ON NATIONAL FINANCE
EVIDENCE
OTTAWA, Wednesday, October 26, 2022
The Standing Senate Committee on National Finance met with videoconference this day at 6:45 p.m. [ET] to study the subject matter of Bill C-31, An Act respecting cost of living relief measures related to dental care and rental housing.
Senator Percy Mockler (Chair) in the chair.
[English]
The Chair: I wish to welcome all senators to the Standing Senate Committee on National Finance, as well as viewers across Canada who are watching us on sencanada.ca.
[Translation]
My name is Percy Mockler. I am a senator from New Brunswick and the Chair of the Standing Senate Committee on National Finance.
I would like to go around the table and ask senators to introduce themselves, starting on my left.
Senator Loffreda: I am Tony Loffreda from Montreal, Quebec.
[English]
Senator Pate: Kim Pate, from the unceded and unsurrendered territory of the Algonquin Anishinaabeg here in Ottawa.
[Translation]
Senator Gignac: I am Clément Gignac from Quebec.
[English]
Senator Boehm: Peter Boehm, Ontario.
Senator Duncan: Pat Duncan from the Yukon.
Senator Yussuff: Hassan Yussuff, Ontario.
[Translation]
Senator Smith: I am Larry Smith, live from Hudson, Quebec.
Senator Dagenais: I am Jean-Guy Dagenais from Quebec.
Senator Galvez: I am Rosa Galvez from Quebec.
The Chair: Thank you, honourable senators.
[English]
Today, we resume our study on the subject matter of Bill C-31, An Act respecting cost of living relief measures related to dental care and rental housing, which was referred to this committee on October 20, 2022, by the Senate of Canada.
We have with us today representatives from the Canadian Dental Association and the Canadian Dental Hygienists Association.
[Translation]
The Canadian Dental Association is represented by its President, Dr. Lynn Tomkins, and its CEO, Dr. Aaron Burry.
[English]
From the Canadian Dental Hygienists Association, we have Ondina Love, Chief Executive Officer; and Sylvie Martel, Director of Dental Hygiene Practice.
Welcome to all of you, and thank you for accepting our invitation to appear before the Senate National Finance Committee.
[Translation]
Your testimony will help us focus on four key overarching principles: transparency, accountability, reliability and predictability.
[English]
I understand that Dr. Lynn Tomkins will be making opening remarks, to be followed by comments from Ms. Love. Dr. Tomkins, the floor is yours.
[Translation]
Dr. Lynn Tomkins, President, Canadian Dental Association: Good evening, senators and witnesses.
[English]
As I begin, I would like to recognize that I am joining you today from the traditional territory of the Huron-Wendat, the Haudenosaunee and the Anishinabek Nations and the Mississaugas of the Credit First Nation.
Thank you for inviting the Canadian Dental Association to one of your first meetings studying Bill C-31, which would implement the Canada dental benefit. I also appreciate having the opportunity to meet in person with many members of the Senate over the past week, and I look forward to continuing to engage with you in the weeks and months to come.
At CDA, we know that oral health is an essential component of overall health, and we believe that Canadians have a right to good oral health. That is why we fully support efforts by all levels of government to improve Canadians’ oral health and to enhance their access to dental care. Poor oral health strains other parts of the health care system, whether through hospital visits for dental emergencies or managing the long-term impact of poor oral health on systemic disease. This is particularly the case with children, as good childhood oral health serves as a foundation for the rest of a person’s life.
Unfortunately, despite progress over the last decades, tooth decay remains the most common, yet preventable, childhood chronic disease in Canada. It is the most common reason for Canadian children to undergo day surgery and is a leading cause of why children miss school. Beyond the risk of pain and infection, tooth decay can impact eating, sleep and proper growth; development of speech; tooth loss and malocclusion; and increase the need for dental treatment throughout life.
Having been in private practice for 35 years, I can testify that nothing is more heart-wrenching than seeing a child come in with severe dental decay. This often requires treatment under general anaesthesia in a surgical facility, which may involve lengthy wait times. In addition to the impact on a child’s health, the experience can lead to long-term dental fear and anxiety. Therefore, it is important to ensure that Canadian parents can access dental care for their children within months of the eruption of the first tooth. Early detection of susceptibility to dental decay and exposure to good oral hygiene habits and preventive care can make a lifetime of difference for a person’s mouth.
While Canada compares favourably to many other countries, too many people, including children, still do not receive the dental care they need. More than 6 million Canadians each year avoid visiting the dentist primarily because of cost, particularly those in low-income families. While every province and territory in Canada has some sort of publicly funded program for children, these vary from jurisdiction to jurisdiction and leave significant gaps. We, therefore, welcomed the government’s commitment earlier this year of a significant, ongoing investment in dental care.
CDA also appreciates the government’s phased-in approach to this initiative. This will allow time to consult and collaborate with all relevant stakeholders on a long-term solution that is a well informed, targeted, comprehensive and effective approach to improving access to dental care. This includes continuing to work with provincial and territorial governments on the interactions between federal proposals and existing dental programming.
CDA also appreciates the close collaboration demonstrated so far by Minister Duclos and Health Canada, and we look forward to working with them as they develop their long-term approach. In the coming months, the government, CDA and other oral health organizations must work together to promote awareness of the Canada dental benefit and to educate families on the importance of using the benefit to take care of their children’s oral health needs. Dentists and other front-line oral health providers will be the key touchpoints with patients as this benefit, and future proposals, are rolled out. In our recent submission to the House of Commons Finance Committee, we recommended that the government provide financial support to oral health organizations over the next several years for activities such as public awareness, patient education and member support.
Finally, I would like to very briefly highlight a few other items which CDA has recommended should be addressed in the context of enhancing access to dental care and improving Canadians’ oral health. They are improving the NIHB program and Indigenous oral health outcomes; better support for oral health data collection and research by regularly including oral health as part of federal health surveys; advancing the healthy eating strategy and incentivizing community water fluoridation; and addressing ongoing shortages of dental office staff and other workforce challenges.
Thank you again for inviting us to testify today. I would be happy, along with our CDA CEO Dr. Aaron Burry, to answer any questions you may have.
Ondina Love, Chief Executive Officer, Canadian Dental Hygienists Association: Good evening, Mr. Chair and committee members. I would like to acknowledge that I am joining you this evening from the traditional unceded territory of the Anishinabeg Algonquin Nation.
On behalf of CDHA and our members, I would like to thank you for inviting us to participate in your committee meeting tonight. CDHA is the collective national voice of over 30,000 dental hygienists in Canada, directly representing 22,000 members. Dental hygienists are the sixth-largest group of regulated health professionals in the country.
Part 1 of Bill C-31 enacts the dental benefit act. This legislation validates and addresses many issues regarding affordability and access to oral health care in Canada. Dental hygienists have heard clearly that delivering direct support to vulnerable populations within a national model will make a meaningful difference to the oral and overall health of Canadians. Dental caries, cavities, is the number one disease in the world and can be prevented, as Dr. Tomkins mentioned. This act recognizes the need to provide interim dental benefits to an estimated half million children, which is an excellent first step in reducing the burden of oral diseases and conditions across Canada.
CDHA has long called for improving access to preventive oral health services for people across Canada. This first stage of the Canada dental benefit is welcomed by dental hygienists, who see first-hand the effects of poor oral health on children. Unfortunately, financial insecurity influences how individuals without dental coverage prioritize their oral health needs. With limited disposable income, many people forgo regular preventive oral health care services, thus increasing their risk for oral diseases. It is critical that access to care for low-income groups be addressed, as this population carries most of the burden of oral diseases in this country.
As primary care providers, dental hygienists understand the importance of oral health to general health and well-being. Studies have shown that poor oral health is associated with serious systemic health conditions. These include diabetes, respiratory and cardiovascular diseases as well as adverse pregnancy outcomes. Dental hygienists also advise their clients on the risks associated with smoking, alcohol and substance use and sugar consumption, all of which can contribute to the incidence of tooth decay, periodontal disease — gingivitis and periodontitis — and many systemic diseases.
Research has shown that early childhood visits to a dentist or dental hygienist are effective in reducing the need for restorative treatments such as fillings later in life. These visits also offer opportunities for targeted oral health education such as instruction on proper oral hygiene practices and discussions about the importance of a healthy diet for oral and overall health. For these reasons, dental hygienists believe the top priority for the new federal dental care program must be oral health promotion and disease prevention. Another publicly funded program with a narrow focus on dental treatments alone will not be enough to achieve better long-term oral health outcomes.
As the delivery of oral health services is carried out by a variety of clinicians, the inclusion of dental hygienists within the definition of dental services providers in the proposed legislation is a positive step in expanding access to oral care. At a time when health care human resources are facing many challenges, the direction to engage the contributions of the entire oral health workforce paves the way for progress and success.
Dental hygienists offer innovative ways to improve access to care as they practise in a variety of settings such as stand-alone clinics, community clinics, daycares, schools and mobile settings. One of our members practising in British Columbia shared her perspective on how mobile dental hygiene practices that take their services directly to children help families by removing the barrier of parents having to take time off work to bring their child to a dental appointment.
Bill C-31 also aligns with the recently released 2022 report of the National Advisory Council on Poverty, which encourages the Government of Canada to implement the national dental care program for low-income Canadians as soon as possible.
As always, the Canadian Dental Hygienists Association seeks a public policy environment that is beneficial to the practice of dental hygiene and the overall health of Canadians. We look forward to continued collaboration with the federal government as you work towards the development of a comprehensive oral health care program with full implementation in the coming years.
Thank you very much for your time. CDHA’s Director of Dental Hygiene Practice, Sylvie Martel, and I look forward to your questions.
The Chair: Thank you very much for participating this evening.
Before proceeding to questions, I would ask members and witnesses in the room to please refrain from leaning in too close to the microphone, or remove your earpiece when doing so. This will avoid any sound feedback that could negatively impact the committee staff.
[Translation]
With that, we will move on to questions and answers. I would like to remind senators that they have five minutes for the first round.
[English]
When we move to the second round, you will have three minutes each. The clerk will inform me when the time is up.
I would also like to recognize that Senator Lankin is on the web and following the discussions and the meeting this evening. Welcome, Senator Lankin.
[Translation]
I’ll give the floor to Senator Gignac, who is first on the list to ask questions about Bill C-31.
[English]
Senator Gignac: Thank you to the witnesses for being available this evening.
My question will be addressed to both associations. Is there enough capacity in the system right now to accept all these new eligible Canadians under this new bill? Will you have an issue in terms of human resources to respond to these newly eligible people? We can start with Dr. Tomkins, followed by Ms. Love.
Dr. Tomkins: Thank you very much.
We have some concerns about the support staff that we have in the office. In the dental office, the dental assisting staff are the ones that you often see first and the ones that seat you and look after you. It is a very highly skilled and highly trained position. There is a shortage of dental assistants in Canada, and it existed before COVID and has been exacerbated since COVID. At any one time in Canada, one in three dental offices are looking to add staff to their roster. There is a bit of a concern there.
There is not a shortage of dentists. We have a distribution issue. We would like to see more young dentists going out to remote and rural areas, especially in the North, and I know in New Brunswick they would like to see more dentists as well. Anything we can do to encourage new graduates and dentists considering moving to these areas, including loan forgiveness, would be appreciated.
We will deal with the influx of new patients that come in. We dealt with COVID, so we feel like we can deal with anything, but there is an issue with the dental assisting support staff.
Ms. Love: There are 30,000 dental hygienists in Canada, and we have about 1,300 dental hygienists that practise independent of a dentist. They work in a variety of settings, such as mobile clinics. They work in daycares, schools, public health and research in a variety of settings.
We are seeing trends where dental hygienists in some regions — for example, in Newfoundland — work four days a week, Monday to Thursday, in a traditional dental office, and then on Fridays they will drive to remote communities and provide services independently. It is increasing access to care for some of these programs.
As Dr. Tomkins says, there are distribution issues. CDHA has been advocating for a number of years with ESDC on expanding the student loan forgiveness program to include dental hygienists and dentists. The government has announced they will be expanding the program beyond physicians and nurses this year, and we are hopeful it will include our oral health professionals because that will benefit and encourage students to work in those rural and remote communities.
Senator Gignac: Thank you.
[Translation]
Do I have time for a second question? Thank you.
Some provinces, such as Quebec, already offer free dental care to children up to age 9. In light of the participation rate, can you foresee percentages... What would the consequences be for provinces that presently do not have such a system, given Quebec’s experience? Would there be a significant increase of clients aged 10 and under?
I would like an idea of the consequences, in light of our experience in Quebec. Perhaps Dr. Tomkins could answer the question.
[English]
Dr. Tomkins: When you look across the country, there are variable plans from jurisdiction to jurisdiction that provide some type of child care programs and dental care programs. There is so much variation from jurisdiction to jurisdiction. This is what makes the discussion between the federal government and the provincial and territorial governments so important so that any federal plan rolled out will not adversely affect the existing provincial programs.
In Quebec, you have the 9 to 12 age group that potentially could be covered under this program, and going forward up to age 18 as phase two rolls out.
In terms of statistics, I will ask Dr. Aaron Burry to see if there are any specific amounts of utilization he can offer on that.
Dr. Aaron Burry, Chief Executive Officer, Canadian Dental Association: The utilization on programs will differ from province to province. It’s not uncommon to see utilization rates in the 30 to 40% range. There are others that are much higher. It depends on how long the program has been in existence, how comprehensive it is for coverage, et cetera. There are variations across the country. It is also based on things like how simple it is to enrol in the program or whether it is automatic. In some provinces, for example, Prince Edward Island, it’s automatic for every child, and there is a high utilization rate related to that because that is the program that covers all children in the province.
Senator Gignac: Thank you.
Senator Smith: Ms. Martel, we could ask you this question and then pass the question around.
Your organization commissioned a survey this year and found that 56% of Canadians 60 years and older do not have dental insurance. You noted that the health professionals have established a link between healthy mouths and healthy bodies. Following up on some of the discussions we had in previous meetings, I would like to ask if you could enlighten us with potential cost savings to the health care sector if the government were to implement a dental care program. Do you have numbers or data that you can share with us in this regard? Obviously both associations would probably have access to this type of information. It would be helpful if you could give us some ideas.
Sylvie Martel, Director of Dental Hygiene Practice, Canadian Dental Hygienists Association: When we commissioned that paper, you will see that there were very few programs across Canada that will look at oral health with seniors, and one of the findings is that the amount of coverage for oral health across Canada is very limited for seniors, and if there is coverage, the threshold or the eligibility criteria for seniors is so low that only a very small percentage of the eligible seniors are able to be part of certain programs. For example, in Ontario, where the threshold is very low, only a few seniors can participate in this. In terms of data, we have not looked into this further to give you percentages of usage. At this point in time, we know that our seniors are not taken care of.
You have alluded to the fact that in terms of cost savings, when we look at the link between the mouth and the rest of the body, we’re able to have an impact on the control of diabetes and the incidence of diabetes, as well as with stroke and cardiovascular and pulmonary diseases. In the long run, without having percentages of cost-saving measures, there is definitely an impact on general diseases if you are able to access oral health care and maintain good oral health.
Senator Smith: Would the focus on that type of question be better aimed at younger people? Is that where your focus is? The other question I have in the back of my mind is what about remote areas and territories in the North and across the northern part of Canada?
Ms. Martel: Could you repeat the beginning part of your question? Sorry.
Senator Smith: I’m trying to find out about the type of research or information that you have. If you had information on people 60 years old and older, what type of data do you have on young people? Does it go from 1 to 15 years old or 1 to 20 years old? The other thing I wanted to find out is what type of information do you have on the North in terms of participation in oral health. What comparison do you have between northern and southern Canada?
Ms. Martel: I will defer to Ms. Love to answer that question. She can answer more in depth than I can.
Ms. Love: If you’re looking at cost savings, one of the key measurable cost savings is emergency dental visits. In Ontario, the estimated cost to the health system for these visits ranges from $16 million to $30 million annually. Between 2011 and 2015, there was a yearly average of almost 28,000 visits to Alberta’s emergency rooms for dental reasons, costing the system up to $6.2 million annually. B.C. also saw high usage of emergency room visits for dental reasons, costing them $1.54 million.
Not only does this cost our health care system with avoidable visits, but emergency rooms are not the right places for people to get appropriate oral health care. For example, 70% of emergency room patients with oral-health-related issues were working adults, and 98% of them were seen and discharged within a two-hour time frame due to the non-urgent natures of those conditions and because they don’t get treatment. It’s estimated that 1 out of every 100 emergency room visits is for dental complaints, primarily from low-income adults without access to an oral health care provider.
Senator Smith: Do you have a national number for all the provinces in terms of emergency room visits?
Ms. Love: I don’t have a national number. We’ve been trying to look into this, but we just have some provincial data. A report was just released this week from the Office of the Chief Dental Officer of Canada which gives a lot of data on the public health program and the utilization of the public health program. That report just came out a few days ago.
Dr. Tomkins: Your question is extremely important, and it really highlights what we need. We need more good, long-term data on just exactly what the oral health situation is. When you look at something like the Canadian Health Measures Survey, the dental component of that is just coming up again this year, but it hasn’t been surveyed since 2008. If the government is looking at bringing out any sort of an oral health program with measurable outcomes, we need good data and good data collection. I mentioned that in my remarks. We need support for good data because, in some ways, we don’t have that kind of comprehensive data. We would appreciate you advocating for us on that. That would be great.
Dr. Burry: Just quickly, I can add two things to expand a little bit. I think the major impact to our health care system — and this was talked about — would be in removing cases from the emergency room. This does not help emergentologists at all. They don’t have the equipment for it. Cases are better seen by dentists. Costs in Ontario are $500 to $700 per patient, and essentially they can only get a prescription for painkillers.
The other group that was mentioned and which is really important is children aged 0 to 12 years. Those who go without any dental care can wind up with significant problems, often seen in a hospital operating room. That is a very expensive way to treat basic dentistry, so you want to do a lot of prevention. For over 25 years, I worked in that area, trying to reduce the number of kids going into OR as well as reducing the impact and burden on the health system.
Senator Pate: Thank you to all the witnesses. Thank you especially for outlining in a very cogent and clear way the impact of dental health care on health and the risks in terms of long-term care.
One of the issues occupying my mind is the adequacy of the amount being provided through the legislation. Will $650 per year be sufficient to cover off the sorts of services and supports that you see as ideally preventive? Dr. Burry, you just mentioned that’s essentially the cost of one emergency room visit. What issues do you see? What dental procedures do you foresee not being covered as a result of the inadequate funding?
Dr. Tomkins: First, we do appreciate that there will be some sort of a benefit for low-income children to get to the dentist, so it’s a good thing. This is an interim program. We understand it comes to an end in June 2024, bracketing two calendar years. Theoretically, that provides up to $1,300 per child. The amount of money being proposed per child will vary a lot, depending on the situation of the child and how old they are.
If we can get very little kids to come in — we advocate parents bringing their child to the dentist within six months of the eruption of the first tooth for disease susceptibility, evaluation and counselling of the parents. That will get that child on a good path.
If you look at another child who is coming in at age four with a few cavities, they will have an examination, some X-rays, diagnosis by the dentist, perhaps teeth cleaning, oral hygiene counselling by the dental hygienist on the team, and then perhaps a few fillings. That could also include the baby-tooth equivalent of root canals which sometimes teeth need when there are cavities. They are very small teeth, and cavities don’t have to be very big to affect the nerve.
The care will be limited. For some kids, it will be more than enough and, for some kids, it will not be enough. That is something to consider. Any long-term program needs to be more needs-based so that children who need more care get more care and kids who don’t need as much care don’t use the system as much.
Ms. Love: Yesterday, we had a technical briefing with CRA and Health Canada regarding this program. We were pleased to be informed that this program will be in addition to any provincial programs. That’s a good news story. It’s not going to detract from the programs currently in place. Each of the provinces offers some type of program. This will only enhance the ability to provide care for those children. That was a very good news story for us yesterday.
Senator Pate: In terms of a needs-based program, do you have a model that you could recommend that we might want to look at in terms of wording or language?
Dr. Tomkins: The provinces of P.E.I. and Newfoundland — and actually I think the Northwest Territories as well, or is it the Yukon — have just signed agreements with their provincial governments for children’s programs that are considered better. There is no ideal program. Some don’t cover certain things, so this program would perhaps have the capacity to top up the others. We had not heard that it could be in addition to existing programs. That would be something we would have to look into.
I will let Dr. Burry talk about international programs that have very good effect.
Dr. Burry: On the funding of dental care, this is a good first step or first movement. Internationally, we can look at the commitment of various governments. In Canada, about 6% of total expenditures have come from government. Other countries have been at this for a much longer long time. They started developing their programs after World War II, so they’re 70-plus years into development. We often think of places like Germany, Sweden, et cetera, even the U.K. They are contributing up to 40% of the total costs in terms of overall government expenditure. This is a first movement toward ensuring that more Canadians are covered. Again, in those countries where the systems include all of their residents and individuals, that is the level of government commitment currently being used in those various countries. The United States started making movement in this area in approximately 2010. They were the same as Canada, and they moved to about 12% of total government funding through things like Obamacare, as well as a much broader oral health strategy.
This is another part of something we’ve been talking about at the Canadian Dental Association so that it’s not just spending the money on treatment. We really need to look at a broader oral health strategy for the country, as other countries have done, so that we arrive at improving our overall health.
Senator Yussuff: Thank you, witnesses, for being here.
Let me start with the most basic of questions. Clearly, the people we are targeting here are poor families and their children having access to dental care. Based on your experience in your associations, what has been the challenge with poor families having access to dental care, recognizing that income is a huge challenge and people are spending additional money for dental care? What has been the experience within your associations with poor families accessing this?
I’ll use myself as an example. I have been fortunate since 18 years of age to have had access to dental care as part of workplace plans that I belonged to, but I know that’s not the norm. Now that I’m a senator, I have additional access to workplace plans because it comes with the job. I know for far too many families in this country, this is not the norm.
Who are the majority of people who access your services through your associations? Is it insurance-based or cash-based that is based on a family’s ability to help their kids when in dire conditions?
Dr. Tomkins: If we look overall at patients and families who access dental care more frequently, they will be in that so-called insured group, which are the two thirds of Canadians covered under some sort of a plan. We know that Canadians do value having their benefits through employer-sponsored health benefits. That is something we wouldn’t want to see disrupted by any program that’s brought in. If employers were to start dropping their plans because there is some new federal plan, that is a potential concern.
In my practice, I saw kids from all different socio-economic backgrounds. Being a new Canadian can be a barrier because language can be a barrier as well. Certainly finances are a barrier. Sometimes it’s the education and orientation of the parents and their knowledge of the importance of early visits to the dentist. Some feel that baby teeth are not very important. We prefer to consider them as primary teeth and the foundation of good oral health.
I think that’s part of what we would want in any program that’s coming out. We have asked for some support in getting information out to all parents, particularly to the parents of children who are eligible for this program, of the importance of bringing a child to the dentist early. Don’t wait until they’re 5 or 6. Bring them when they’re 12 to 18 months of age so they can be seen. I think education and outreach is a really important part of it.
With this interim program, the financial aspect is somewhat addressed, so now it’s a matter of education and outreach. I think all of us here would agree that education and prevention are the keys.
The Chair: Ms. Love, do you have any comments?
Ms. Love: Among our members, we have a number of dental hygienists who have a lot of innovative ways to reach out. We struck a task force to advise us on this national dental care benefit, with dental hygienists from every province and territory in the country who work in public health and work with these federally funded programs. We hear stories of dental hygienists going to daycares and finding out that only 2 out of 12 children have access to workplace-funded dental benefits. They help those other 10 children and their families sign up for whatever provincial programs are available. As Dr. Tomkins said, sometimes it is our health care providers helping them understand what programs are available and signing them up so they can have access.
Sylvie, you probably have further information through your work with that task force.
Ms. Martel: Yes, and like Dr. Tomkins said, outreach is important but also public education. Like Ms. Love was saying, there are a lot of parents out there who do not know they can access some benefits through different programs across the country.
I think what’s important here is that not all kids are treated equally, not only with the financial burden but also access to care within a close proximity, access to professionals and knowing which professional they can see on a regular basis. There is a cultural impact that comes with that, as well as a financial impact, but there is also access to the professionals in such a way that the burden is not larger for the parents to take their kids for treatment.
Senator Yussuff: Also, as indicated by you, this program will cover ages 12 and under. Some provincial programs do not allow 12-year-old kids to get access to dental care. Do we know what the gaps are in regard to provinces and how many kids might get coverage as a result of this program coming in? You now have a threshold that is hard on most provincial programs. More importantly, in terms of the data you provided, about 500,000 children will be impacted by this.
I can tell you, as a father, I’m fortunate that my daughter never had to worry about whether her teeth would be taken care of, including getting braces at an early age. Quite often kids grow up in a world where braces are not even a consideration, given the cost. Of course, this impacts the aesthetics of children’s teeth and also impacts how they look at themselves.
With regard to the gap that exists and also how we can deal with some of these children, another phase of this program will come at some point while working with the provinces. At some point, we’ll need to figure out what gaps we need to fill in because kids are very much struggling with this reality. For parents who are fortunate enough to have these resources available for their children, that’s great, but for too many in this country, they don’t have access and they’re struggling with this reality day in and day out.
Ms. Love: That’s an excellent question that I asked at the technical briefing yesterday, how much the federal government had budgeted for this program in terms of access. They’re estimating 500,000 don’t currently have access. They actually said between 600,000 and 700,000 children under 12, but they were hoping that 500,000 would access it. They did clarify that they have enough of a budget if there will be more than 500,000 who access these services. That was the answer provided yesterday.
Dr. Burry: One of the other key things is that there will be province-to-province differences. There will be some parts of the country where the provincial program is already relatively adequate and you won’t see that they will be applying for the federal benefit. They won’t need it in most of those cases.
In places like where we are in Ontario, there is a financial threshold. What this does is move it up. There will be families, like many of the farm families I see in Eastern Ontario, who don’t qualify on the income level but will qualify for this financial outcome, and that will allow them to take their four to six children to the dentist. That is the group I think the federal government is targeting. We raised this early on.
We’re looking not to have a lot of duplication and overlap between the programs. It re-emphasizes the need to go back and do more coordination between the provinces and the federal government around the benefit so that it maximizes what is actually happening out there, as well as starts to deal with some of the inadequacies of some of the provincial programs.
The Chair: Thank you. Ms. Martel, your hand is up. Do you want to make a comment?
Ms. Martel: Just to answer a little bit more to the person who was asking about the Quebec program that covers up to age 9, there is absolutely no prevention covered in that program from 0 to 9 years old, and of course, it doesn’t allow for children who are 10 plus, unless the parents are on a social assistance program, to access any types of benefits. So you will have an uptake within the province of Quebec for children wanting to have prevention done, such as cleaning or to see a dental hygienist. With the change in legislation in Quebec, where dental hygienists can actually provide services directly to clients without the supervision of a dentist, there’s an influx of dental hygienists who are now offering services directly to the client. You will see an uptake in the province of Quebec in regard to preventive services by dental hygienists for that category of 0 to 9 but also for children older than 9 years old.
Senator Galvez: My first question is to Dr. Tomkins. We have a colleague in the Senate that is a dentist. She is Indigenous and works in Indigenous communities in northern Manitoba. I asked her to provide me with a question. This is Senator McCallum’s question: With the high cost of dental treatment, $650 will not pay for much depending on the size of the restorations needed. It may cover an exam, and X-ray and maybe a couple of restorations depending on the size and per child. To ensure adequate care is provided, given the needs of the patient, what do you feel will be a dollar amount that would be more realistic? Can you give me an annual cost of dental care per child?
Dr. Tomkins: There is so much variation in what children need. That is a very good question, but a very difficult one to answer because some kids are, as I said earlier, going to need only very few treatments and some are going to need many more. If you have a child who has caries in all 20 primary teeth and needs to be treated in the hospital, this amount won’t come close to that. It might enable a dentist to put some silver diamine fluoride on some of the larger caries to put them on hold. It’s an excellent question, and I will defer to Dr. Burry, if he has statistics on that. I don’t think anyone has ever calculated the average cost per child because there is so much variation.
Dr. Burry: There is a difference between what it cost to program versus what it might cost to treat a child. There are really two costs. If you have a child, for example, treated in hospital, you have the cost to perform the dentistry, and in a child, that could be anywhere from $2,000 up to $5,000; and then we have the cost of the health care system. Minister Duclos has been using a number of the total utilization in dentistry, if you would like, both surgery as well as emergency departments, and that number is about $2 billion across the country.
When you look at those ranges, we are spending a lot of money for individuals who are being treated in hospital for very severe dental caries problems, and that will give a range of where there are the possibilities of doing this differently and not in the health care system. There is quite a range, and $650 for a relatively healthy child, as Dr. McCallum indicated, is likely adequate, but again, that’s why we talk about this as a good interim step to at least get individuals into the dental office. This also creates an opportunity for the government to see how many people are going to utilize the program and then try to design something that better meets the needs of individuals seeking care through the program.
Senator Galvez: In case you can do some estimates in the following days, I would appreciate it if you can send that information to the clerk of the committee.
Dr. Burry: Our pleasure to do so.
Senator Galvez: Thank you so much.
My question follows the question from my colleague Senator Gignac, not concerning the capacity per se but actually the expertise. We are talking about dental care in children. I have three children and had to take them to the dentist, and it was always a drama. We passed so many hygienists and so many dentists before we got the person that had the patience and the expertise to deal with children. Otherwise, my experience and other people’s experience is that the dentist will say, “Let’s put the baby or the child to sleep in order to make all the reparations that are needed,” and parents don’t like that. So talking about the capacity and the expertise, I know that dentists are mostly comfortable with adults, but what is the percentage of dentists and hygienists that are dealing with children this age? If we need to anaesthetize the child in the Northern regions, how will we go about it?
Dr. Tomkins: In dental school, we all get training in pediatric dentistry, and as we graduate and go into practice, people develop an affinity for certain areas, and there are people who decide that they are going to specialize in being pediatric dentists. I’m speaking to their group tomorrow. Dr. Burry can give the exact number of pediatric dentists across the country. They do tend to see more of these patients who have multiple areas of decay. I did talk about seeing young patients who need a lot of dentistry and who may need treatment in the OR, and that experience may affect the child’s future orientation to dentistry.
I found in practice that if I could get kids early and figure out what was going on with them and could grow them to the age of 6 or 7, if those kids needed some dental treatment, they were going to be very accepting of dental treatment and had expectations of being treated with kindness and respect. It became a positive outcome. In very small children, sometimes there is no alternative but to treat them with some sort of sedation; otherwise, you can create a truly phobic child if you have to have six or eight restorative appointments where you are doing two or three fillings at a time. That is not a good scene for a very small child.
Dr. Burry, how many pediatric dentists do we have in the country?
Dr. Burry: We will follow up and get the exact number in terms of pediatric dentists.
The other key issue — we have been advocating for this as the Canadian Dental Association — is an increased investment in places or surgery centres across the country, so moving these treatments out of the hospital. There are parts of the country where they now have these services where there is anaesthesia that could be provided out of the hospital and get the dental care quickly. The issue for our hospital care system across the country, especially with respect to pediatric dentistry, is there hasn’t been any growth in this since the 1990s. It’s the same capacity. At this particular point in 2020, what we have is this lack of growth, leading to the increased wait-lists. Communities have looked at alternatives, adding more operating rooms in some cases, but for the most part it’s surgery centres where we’re finding communities are using them. We have been advocating for the government to look at this as an investment in those types of facilities so we can move this out of hospitals.
Ms. Love: I wanted to comment on your question regarding people in the North. The federal government spends over $450 million a year flying people out of northern regions to have emergency dental treatment. For the last probably seven years, CDHA has had a contract with the Government of Nunavut where we fly in dental hygienists to 17 fly-in and remote communities to do preventive services for children 0 to 12. We do that in conjunction with the COHI aide in the community, the Children’s Oral Health Initiative, and it has been very successful. It went on pause during COVID, but we’re starting again in the next couple of weeks, bringing a dental hygienist in to do preventive care, which prevents that cost to fly people out for surgeries.
Senator Boehm: Thank you to our witnesses for responding so eloquently to the questions that have been asked.
Most of the questions I wanted to ask have been asked already, but I would like to zero in on the issue of staffing levels. That was raised earlier on, and Dr. Tomkins touched on it in her opening remarks. Did staffing levels suffer as a result of the COVID-19 pandemic? If so, have they more or less returned to pre-pandemic levels?
Dr. Tomkins: The question is whether they returned to pre-pandemic levels? No. I mentioned that on any given day, one in three dental offices is looking to add another person to their staff. There is a critical shortage. We did lose members of staff during COVID. They stopped coming into work in terms of dentistry. They didn’t die. They didn’t pass away, but we lost people working in the office because it’s tremendously stressful. Dentists were shut down for a little bit during the pandemic in the beginning, and then we came back.
In terms of the requirements, we had pretty stringent infection prevention and control requirements before. Throughout the pandemic, they have certainly become much more strict. I don’t know if you have been to your dental office, but you see us in there. We all look like we are astronauts or about to do brain surgery because we are covered in gowns and masks and shields and so on. Certain barriers and dividers had to be put up in dental offices. This created much more pressure on the front-line staff, who are primarily the dental assisting staff, because they are responsible for setting up everything, tearing down everything, making sure everything is sterilized. It has created a lot of pressure in the system.
I have to say I am quite proud of the way the profession stepped up. There hasn’t been a single case of transmission of COVID patient to doctor, doctor to patient, clinician to patient, in Canada. Any small transmissions that took place were unfortunately a part of the lunch room. Perhaps people relaxed a little. But in the clinical setting, there were no transmissions.
We are undertaking a project with the Canadian Dental Assistants’ Association. We applied for a grant to look at ways to encourage more people to consider dental assisting as a career and to encourage them to stay in the profession. That also includes distance-learning opportunities so they can do a lot of the didactic work remotely. The clinical work obviously has to be done in person. We are looking at creative ways of encouraging more people and also new Canadians to come into dental assisting.
Senator Boehm: It’s on that last point that I wanted to intervene in particular because we have about 400,000 newcomers coming every year. Some of them will need dental care and will probably fall under this program in one way or another. I’m thinking in particular of refugees. There is also the recognition of foreign credentials. I know that’s a provincial matter, but surely this could be a pool to tap in terms of both dentists and hygienists. I would like to get comments on that, actually from all of you, if you want to.
Dr. Tomkins: In Canada, we have two ways for foreign-trained dentists to come into the country. One is through the National Dental Examining Board of Canada with a series of examinations. They start with a credential evaluation and confirmation of what the person has graduated with in the country they’re coming from. Then there is a series of didactic examinations on content and knowledge and then clinical examinations. Any dentist coming into the country who is competent to the level of Canadian dental school graduate will be able to pass that exam.
The secondary route is that each of the dental schools has an internationally trained dentist program. Those dentists apply and come into the dental school partway through the second year of dentistry. They enter into the clinical years of third- and fourth-year dentistry, along with our regular DDS students, and they graduate with a degree from that university.
We have about 500 dentists a year coming in from outside the country, as well as our 500 graduates from the U of T school. We do have a program for that.
Most dentists who come from other countries may be interested in working as a dental assistant for a short period of time, but their goal is to practise dentistry. Dental assisting is a much shorter education process, and if people are looking to get a designated skill and then enter the workforce, we can make them aware that dental assisting is an attractive profession and one in which there is great need.
Senator Boehm: Any comment from the hygienists’ perspective?
Ms. Martel: Thank you. It’s a little bit of the same process for dental hygienists who are internationally trained. Under the Federation of Dental Hygiene Regulators of Canada, the applicant applies, and their curriculum and experience are assessed against the Canadian national competencies. If they are eligible or equivalent to Canadian programs, then they would sit the national certification program in Canada, which is a requirement in every province in Canada, other than Quebec, to practise and obtain a licence to practise in dental hygiene. The difficulty is that competency can vary greatly. In Europe, for example, there are some countries where dental hygiene does not exist, but there is a process to come into the country and have their credentials assessed.
On human resources, we did conduct a survey in 2019 — and we will repeat it next year — which showed about 18% of dental hygienists were planning to leave the profession in the next two years, and up to one in four in the next five years. Is it because of COVID? Of course, in 2019, we were just before COVID. It’s very hard to say, but if we look at the number of graduates in dental hygiene, every program in Canada is over-subscribed. We haven’t lost in terms of the influx of graduating dental hygienists obtaining licences to practise. We did not lose on that count, but the percentage of dental hygienists wanting to leave the profession in the next five years was higher in the 2019 survey.
Dr. Burry: On the assistants issue, there are no international standards related to this. We talked about hygiene and dentistry, and for those, there are international standards, and they are well trained. With people coming into Canada, we almost have to start from scratch because the Canadian system has some of the highest standards in the world. Dr. Tomkins mentioned just the daily understanding of how sterilization works in this country is very different than elsewhere. It’s very technical and highly sophisticated. Our assistants also take radiographs in this country, which is something you don’t often see. You can’t just start taking X-rays on day one when you come into an office. That requires a good amount of training.
The Chair: Dr. Burry, that’s why we’re the best country in the world.
Senator Duncan: A special thanks to our witnesses for appearing before us this evening.
Dr. Tomkins mentioned improving NIHB, non-insured health benefits. I may stand corrected, but I believe it was the Parliamentary Budget Officer who appeared before our committee and said that the program, albeit admittedly in its initial design stages, was modelled after NIHB. My question is really to the dental hygienists, and it’s a bit down in the weeds. The NIHB fee code, after which this program is modelled, would provide for a certain amount of cleaning or dental hygienist services. Are those fee codes enough to also provide the oral health care that dental hygienists can provide, particularly to a new patient and a young patient? That’s a bit down in the weeds, and it’s specific, but is that one area where we need improvement in the NIHB fee codes? Are there other suggestions that you have?
Ms. Love: Thank you very much for the question.
I have to note that we had over 100 dental hygienists in the Yukon three weeks ago for a sold-out summit. We had a presentation from the Office of the Chief Dental Officer. We had conversations about NIHB and the issues with the NIHB program. One good thing about this new kind of intern program is that the money can be used on top of the current benefit. That’s what they said yesterday in the technical briefing. The NIHB program has improved, but there is still significant room for improvement because there are caps on the number of units, for example, of scaling that children are eligible for.
The bigger issue is that, oftentimes, the children will travel great distances to receive services. If they need more services than are available, then they have to apply for an exemption to have more services. That means they have to be driven four hours back to their community and reschedule to commute all over again. With the price of gas and the economy these days, it’s very difficult. There are challenges with the logistics as well as some of the reimbursement levels for dental hygiene services for NIHB, but I do note that it has improved significantly over the last number of years.
Sylvie is probably more familiar with the program than I am, and she can add anything that I have missed.
Ms. Martel: I think you’ve just touched upon it. It was more about the logistics. The predetermination process is pretty lengthy and time consuming and, as Ondina was saying, there is definitely a need to look at the logistics of the program and also coverage for preventive services. Like you mentioned, there is very limited coverage in regard to the preventive services, and that would be beneficial even if there is a predetermination that is engaged for a particular client. We know that usually the situation will not change year over year and that there could be provision for that predetermination to increase and the number of units of services offered could lapse in two or three years’ time instead of having to be done every year within a 12-month period.
Senator Duncan: Since you met in Whitehorse and were in the Yukon and had these discussions, did you also discuss that the three northern territories offer dental services in the school system? In Nunavut, children in Grade 7 and under — and, of course, there is no income threshold. They are offered the dental services and dental hygienists at school. It is the same with the Northwest Territories and the Yukon. Granted there is a shortage of staff, but there is no income threshold. There is no charge for these services. Was it asked how these services, NIHB and this new program will fit together? Will it be people submitting paperwork to NIHB or paperwork to CRA? How will they tie together?
I am concerned about your comment about the lengthy approval process. Do you have any sort of recommendations for us that we could then pass on to the government?
Ms. Love: The technical briefing just happened yesterday. Dr. Hanley presented and met with our dental hygienists when we were in the Yukon, and we were appreciative that he did come. We had representatives from all the territories at that meeting as well. I think the biggest issue they raised was travel and the cost of travel. There should be more coordination from a primary health care perspective. When physicians or nurses go to communities, they should have dental hygienists or dentists going with them so that there is a team approach to providing care in those communities. That’s often not the case, and that is one of the big issues they talked about needing to address.
Senator Loffreda: Thank you to our panellists for being here this evening.
I’d like to start with a question for Dr. Tomkins, the Canadian Dental Association President, and maybe the other panellists can weigh in. It is nice to see you once again, Dr. Tomkins, and welcome to our committee.
A lot has been covered, and looking forward, I’d like to lean in a little more on the temporary nature of the program. It is an interim dental program expiring in June 2024. My question is if we can really take it away after two years. If we do, what will be the impact not only on the optics of taking it away but will there be any impact on the health of our children as to what you are seeing now with respect to poor families and families in need? Are they using dental care? What is the health situation if they are not?
The other question is that if it does become permanent and we do expand it, how high is the risk of displacement whereby corporations will say, “Well, we’re not going to insure our employees any more for dental care because now it’s being covered by the government”? It would be an excuse. Even though certain elements are being covered or partially covered, would corporations say at this point we are in a period of cost-cutting and fiscal responsibility. Is there any risk of that displacement happening?
Dr. Tomkins: Thank you for those questions.
First of all, when we talk about this being an interim program and that in the legislation it says it will come to an end — this program itself, this health spending account is really how we are considering it — at the end of June 2024, the good thing about this is that it gives us a bit of a breather to look at all the types of questions you raise.
Going forward, what I think we should anticipate and I hope we can anticipate is that when we get into the next phase of the program, that the 0-to-12 age group will be rolled into a more robust needs-based program that’s more like a private insurance plan. I see this CDP ending, or the Canada dental benefit ending, the idea that somebody goes into CRA and checks the boxes and gets a cheque and then goes and spends it at the dentist, but I do think we would be looking at rolling that group into whatever the larger plan is, because we understand that by the end of 2023 we will be looking at some sort of program for the 12-to-18 age group, persons with disabilities and seniors. This interim phase — and we appreciate that the minister is putting it out in phases and taking the time to look at the longer implications — I expect will be rolled into whatever program we will have, something that goes for kids from zero to 18, and they will all be part of that program together. That’s what I would hope. So I don’t think it will be taken away. It will just evolve into a different program.
The second issue you raise is an excellent one, because that is one of the concerns that was raised when we had round tables with dentists across the country this summer. They all raised the same point that if there is a very robust government program and the eligibility criteria are such that it includes families who make between $70,000 and $90,000 a year, that could potentially capture a lot of families, and employers could very well make a business decision to say that since the government is going to be providing this benefit, why should we, especially as we are entering into an era of high inflation and high interest rates with a lot of pressure on businesses and the bottom line. If you look at, for instance, in the United States when Obamacare came in, the government brought in reparative legislation to ensure that employers continued to have benefits for their staff. I think it has been done in some other countries as well. That is a concern that has been raised. Two thirds of Canadians have some sort of plan right now, and we would not want to see that displaced. That is going to be part of the discussion. How will we incentivize employers to continue to provide benefits to their staff? We know everyone is short-staffed so there is an employment situation in terms of attracting staff. Hopefully, the government will look at ways to promote, protect and incentivize employers to keep the plans they have.
Senator Loffreda: Any other comments from our other panellists?
Ms. Love: I agree with Dr. Tomkins. The current program has to evolve into another program, because the first one is tied to the Canada child care benefit, so when we evolve to accessing it to under 18 and to seniors, of course, seniors won’t qualify under the child benefit. The program is intended to evolve, and it gives us an opportunity to, as Dr. Tomkins said, work collaboratively and come up with the best program for Canadians to improve their oral health.
In terms of the fear for employers to drop their plan, it is a real fear, but I think you either incentivize employers to maintain their dental benefits or you disincentivize them through large government fines and penalties if they take them away.
Dr. Burry: This is an area where we have been advocating for some time for essentially an oral health strategy for the country to really focus on those Canadians. As previous surveys showed back in 2008, there are 20% of the population that is not doing well in Canada. We believe those numbers have not improved, but until there are surveys done and we start to focus on this as a priority, we really don’t know where Canada stands in terms of oral health compared to other countries.
Senator Loffreda: Thank you very much.
We discussed data, and Dr. Tomkins brought up the issue that you would need data. Here, too, maybe we can have some further comments. How can we really measure the success of this program? If we can’t measure the success of this program, how do we know the benefits are reaching the right people and they’re being taken and we know it’s the right thing to do and keep doing?
Dr. Tomkins: I think I agree; the right thing is to ensure that kids that don’t currently have access to dental care get dental care. How will we know? What we can find out from our members is going to be largely anecdotal. Certainly, we will be surveying our members to see, but dentists themselves would have no way of knowing if someone coming into the office was actually accessing this benefit unless they phoned the office first and told them. Theoretically, people would make an appointment, they would come in, they would pay for their appointment in cash, the treatment would be done and there would be no way of knowing that. We’d like to be as helpful as we can, but there is no way that dentists can track that without asking every patient who comes in if they are accessing the dental benefit. That is sort of discriminatory in a way, to actually have to police the program in order to get that type of information. It is going to be difficult to know, other than anecdotal reporting from our members. We will find out through our provincial and territorial dental associations if there is a perceived increase in patients showing up who potentially could be covered under this program, but we don’t really have any way of measuring it.
Dr. Burry: There are some measures in some provinces. Some do a better job of looking at the current status, for example, of schoolchildren. We’ve heard about this in the North. They certainly do this in Ontario. Certainly what you would want to see is using those measurements and then looking at that.
Again, this is coming back to the Canadian Health Measures Survey, where you’re looking at the survey of Canadians and looking at moving the bar. That’s setting some objectives nationally to say this is what we would like to look like as a country. This is what countries in Scandinavia have been doing since the 1960s. They have a very good sense of what the oral health status of their population is, as well as other European countries. In Canada, we haven’t been as dedicated to it and we’ve put it on the back burner for a long time.
[Translation]
Senator Dagenais: My question is for Dr. Tomkins. The need and the necessity for children to access dental care is unquestionable. However, my concern with Bill C-31 is the lack of information and of rules to control the costs.
I am not alone in saying this. The Parliamentary Budget Officer shared his concerns right here yesterday. As I have personal experience in managing a collective dental insurance program, I witnessed profiteering in the bills of certain professionals. The bill would be higher for a patient who had insurance than another bill for a patient who paid out of pocket. Is this normal? I do not believe so. As a matter of fact, I sometimes had a dental officer check the billing, and he told me that some were overcharging: They were not charging the amount established for a certain service.
To avoid this type of situation, do you believe we should create a price chart for the services that will be offered, so we can avoid such abuses? I dealt with this for eight years. When someone asks a dentist what the price will be, they are often asked if they have insurance. If they do, it is not the same price. I would like to hear your thoughts on this.
[English]
Dr. Tomkins: Well, I feel that I have to defend the professional integrity of my profession in that our fees to our patients are the same whether they are insured or not. Each province and territory has a suggested fee guide that is based on real data in terms of economic data, the cost of providing care and so on.
In terms of the Office of the Parliamentary Budget Officer and the government finding out if they’re getting value for money or that the money is being used appropriately, that is a great question to be posed to the CRA in how they intend to monitor where the money goes out of this program.
[Translation]
Senator Dagenais: I do not want to get into it too much, but I myself had to intervene in certain files concerning dentists.
Based on your experience with children’s oral health, what proportion of children will need more than the established $650 worth of care? Have you looked into this? Between you and me, if there is major work to be done, $650 is not a lot of money. How did you estimate the proportion of children who will need care for which the cost exceeds $650?
[English]
Dr. Tomkins: Right now, there really is not a mechanism to track that, other than, as I said, with anecdotal reporting from dentists and our members, because we wouldn’t have any way of knowing. When that patient comes in for treatment, the parent may say they only have $650 to spend. That may have been said to the front office staff. The dentist may not even know about what that patient has said. Again, it’s a good question. There is not really an effective tracking mechanism to make sure that the money will go where it needs to go, other than I can tell you that with over 35 years of practice in treating many kids with their parents, parents really want to do what is best for their children. I think this is a tremendous step for those kids who are not currently accessing care because of cost.
Ms. Love: I was just going to clarify that in the technical briefing yesterday, they clarified that there are two benefit periods for this interim program. In the first benefit period, if their expenses are more than $650, they can apply for an additional benefit in the second benefit period. In doing so, they may apply for the new benefit for an expense incurred in the first benefit period to address exactly that concern. Essentially, they could have up to $1,300 to pay for that visit. That was clarified yesterday in the technical briefing.
[Translation]
Ms. Martel: I believe it is very hard to establish a number that is fair for everyone. As stated earlier, each child will have their particular needs. The program prices will probably be much higher in the first years of implementation because we are talking about children who do not have access right now to dental care that is paid for by any of the various public programs. In the first years, the program’s administration will likely be much more expensive while we normalize children’s oral health. As Dr. Burry said, $650 can be enough for some children and completely insufficient for others. Ultimately, it would be difficult to establish a different amount that could meet everyone’s needs.
Senator Dagenais: I believe it was Dr. Tomkins who spoke of a child going to the dentist and being told he needs to have some work done, and the dentist will provide $650 worth of services, after which the child has to go back the next year, when he will be entitled to another $650, to finish the job. Did I understand that correctly?
[English]
Dr. Tomkins: Are you asking me that question?
Senator Dagenais: Yes.
Dr. Tomkins: Theoretically, the parent would come in with the child and have an examination and X-rays taken. The dentist would diagnose what needs to be done and devise a treatment plan. If the parent says, “I can afford to do this amount this year and this amount next year,” then the dental office will work with the person to try to schedule things so that the most acute problems are looked after first and then the other treatment can be done afterwards. We’re accustomed to doing that because patients who have insurance or don’t have insurance want to know how much things will cost.
The Chair: Senators, we have time for a second round, three minutes per senator which includes answers from the witnesses.
Senator Gignac: To echo the question asked by Senator Loffreda, my concern is regarding an employer’s reaction and the possibility of the Canadian economy heading into difficult times with inflation and recession, and in this cost-cutting approach, they will decide to just phase out the private plan. Have you suggested that the government go with penalties or regulations to ensure that employers do not decide to phase out in order to control the cost? It could be a huge price tag for Canadian taxpayers if Canadian companies decide to suddenly cancel or stop their current program.
Dr. Tomkins: Well, certainly, that’s a great question, and it is definitely a concern. You’ve identified the nub of the issue.
For instance, employer-sponsored health plans are not subject to federal or corporate income taxes. That is something we have lobbied. There was at one point a suggestion that maybe they should be subjected to tax as a benefit, and we certainly lobbied at the federal level with the government to not tax benefits, and that would be one way of ensuring that employers kept benefits going. I’m not sure what the policy levers are that the government can employ, but we talked about incentivizing employers to maintain plans or disincentivizing them to drop plans, and that would be something we would look for the government to explore, referring to what’s been done in other jurisdictions, including the reparative legislation they brought in in the United States — Obamacare, the Affordable Care Act.
It is a big concern, because potentially the eligibility criteria of $70,000 to $90,000 captures up 70% of Canadian families that could theoretically fall in there, and in small towns that have one or two single employers, that could encompass the entire town. That is a risk, and we look for government to do what it can. We prefer the term incentivize employers to keep their plans.
Senator Gignac: I think we will have a good question for the minister when they come to the table.
Senator Smith: Thank you to the witnesses. You are doing a great job answering the questions.
I would just like to follow up with asking you a question going back to Senator Loffreda’s initial inquiry about data. You may already know this, but the Parliamentary Budget Officer in his costing of the program used the Canadian Health Measures Survey from 2007 to estimate participation in this new program. When I looked at that, I’m thought I have to get back and ask the question to the people talking with us tonight about the whole thing on data collection. Is the way your industry works that it is singular or regional where you have three or four dentists in an office and it is a highly personalized business, or is it evolving into having small practices with three or four dentists in larger type practices?
For the type of data you need to understand the program, if the program is only going to work until the end of 2023, is it worthwhile for you to do data collection and analysis, or can you use this as a lever to get the government to make a longer-term commitment so you can take a longer-term commitment in doing the type of research you need, especially when you look at Canada and the size of our country and the issues in the North and the issues throughout the rest of our country? What do you think of the reasonableness of really focusing — and maybe you already do this, so excuse my ignorance if I’m off base. Is there enough research or data collection that’s actually going to take place and will there be a plan created to tie in that data with the evolution of your industry, or do you already do it?
Dr. Tomkins: We do surveys at the Canadian Dental Association, but we don’t collect frequency data out of the dental offices. The information that we do have would be based out of the claims transmission that goes on where we do have good data, and that only includes insured patients. We have information on that. We have to be extremely careful how we use data because that comes under the Privacy Act and so on.
In terms of this interim program going on, there isn’t really an effective mechanism for us to collect that data. We have 16,000 dental offices across the country. We like to be helpful, but there isn’t a practical way of finding out from these offices exactly how many patients are coming in accessing this program.
Getting back to the bigger picture, the Canadian Health Measures Survey oral component was done in 2007 and is coming up this year. We would like to see it in there every three years as part of the regular data collection because we would have more robust information about the needs of Canadians and it would be pan-Canadian. Over time, we could predict patterns. Particularly if we’re going to have a government program that will subsidize dental care for up to 6 million Canadians, we certainly need to have the data to see that we’re getting the outcomes we want in terms of oral health and that the money is used wisely. What we’re advocating for is better oral health data collection and research.
Senator Smith: You mentioned countries like Germany and others that are well ahead of us in terms of their dental care programs. Is your association in contact with these countries learning of methods that they use that could be brought into our country? Who is ahead of whom? Who can learn from whom? Is it worthwhile to think there could be information sharing between countries, depending on their sophistication, that could be helpful?
Dr. Tomkins: We do have contacts through the International Dental Federation with other jurisdictions like Australia, the United States, Germany, the U.K. and so on. Dr. Burry is in fairly frequent contact with his counterparts in those other countries. I will defer to him on that question about what kind of data they collect and whether we can use it. Canada is unique country in many ways. It has an extremely diverse population, so it is unlike a lot of countries, and it is a very large country.
Dr. Burry: One of the key advantages some of our partners have outside of Canada is they don’t have all of our provincial jurisdictions. They typically have one national program, one national dental regulatory and one national data collection. In many cases, dentistry is also part of their health care system already, which is way ahead of where we are in Canada. The key thing we can learn in the early days is how they actually fund dental care. It is often funded as part of an overall health care funding and insured through these national benefits. But the government’s commitment is much higher in those countries to health care spending, and particularly to dental care spending, than what we have in Canada. It’s at 6% versus 34 to 40% that other countries are investing. They didn’t start doing that now. They’ve been at this a lot longer. Canada is just starting this journey.
Senator Smith: Doctor, you’re getting me nervous because I have to go to the dentist on Friday. Thank you.
[Translation]
Senator Galvez: My question is for the representatives of the two associations.
[English]
I read your report, and I see there are some things you wish we could have seen in this bill, but they are not there. I don’t know if you are aware that, as senators, we cannot increase or decrease the amount. We cannot move money in the bill, but we can make observations. This is the opportunity for you to tell us how the program can be improved and what things we have to look at so the committee can mention some of these observations in its report. This is an opportunity for you to have input on the gaps or make recommendations to the government.
Dr. Tomkins: I’ll take that and then have Dr. Burry follow up.
The What We Heard report is basically the input directly from dentists. It hasn’t been altered by us, but it’s been collated and put together by us. That is what’s coming out from our grassroots members and members of the provincial and territorial dental associations. It’s a bit of the unvarnished truth coming back on us. What we are doing at the CDA is working diligently on a policy paper that looks toward a long-term solution of an oral health care system. When that policy paper is available, it will be shared widely and publicly, and we would be happy to share it with you.
On the current program, we have what we have. We will work with it the best we can, and we will use the interim measure to give us a bit of time to work on a more ideal, longer-term solution.
Dr. Burry: As an interim program in terms of getting started, this would be a good start. They have started in the right direction. They have avoided some of the pitfalls that dentists identified through that report, particularly not having a lot of additional administration at the moment. I think phase two is a much more difficult and challenging process.
We’re also talking about, at this point, children aged 0 to 12. This is an area where, across the country, the provinces and dentists have a lot of experience treating this age group. Programs have existed in this domain since the 1960s. Some have improved; some are worse at this particular time.
What is going to be critical is discussing what the needs are of particularly two groups going forward, which are the disabled and seniors. This is where there is not a lot of program information. We heard earlier that many individuals, when they stopped working, lost their benefits, and many stopped going to the dentist. There are a lot of unmet needs in the seniors’ group from 65 to 80. There are different needs, and this is where there is not a lot of good program information almost anywhere in the world at this point. We’re looking at new territory that we’re moving into. That is the type of thing where we are moving cautiously forward and looking how to best meet the oral health needs of those groups.
Dr. Tomkins: Just to complicate things, when you’re looking at Canadians with disabilities who are covered under some disability program right now, a lot of them, at age 65, age out of those programs. We’re going to have a subgroup of aged disabled seniors, and they’re going to have very different needs to address.
Senator Yussuff: This is a new program, and it is going to take a lot of effort to get Canadians to appreciate that this program will exist and they need to take advantage of it. Our citizens are not all of the same calibre and knowledge, so the bigger challenge will be, for families who need access to the program, the education and the outreach. In thinking through that challenge, the people we would like to have access to this program may never get access to this program because they don’t know it exists.
How can we work together, recognizing the importance of your association and the reach and capacity that it has, to make sure that education and promotion will happen in a way that will give these families who need access to this program an opportunity to apply and do it? You have to apply for the program. That requires a degree of sophistication. Not all families are the same. They don’t all have access to the internet. We also know from other data that with the Canada child benefit program that despite the fact that it is fairly generous and it will help out poor families, there are a significant number of poor families who don’t access this program. How do we ensure this goes to those who are in need of the system?
My dentist, to a large extent, sends my bill directly to my insurance company, and I get reimbursed. The federal government, obviously, needs families to apply so they’ll reimburse them directly. Is there a system that dentists can get reimbursed directly, if the dentists agree to do so, so the families don’t have to offer the outreach?
The last point I would make applies to the provincial program. When P.E.I. brought in their program, and maybe your association can reveal some of the history here, what coverage disruption happened from private insurance? That is a real example that we know of. It’s a relatively new program in terms of the country, but certainly it changed the lives of many families and children in that province. Did we see a drop-off of private coverage in P.E.I. when that program was brought in?
That is for any of the panellists. I would encourage you to offer whatever knowledge you may have.
Dr. Tomkins: I may start with the first question that you asked. I actually asked the Minister of Health directly, and we asked at committee that there be support from the government to our organization and other oral health organizations — the Canadian Dental Hygienists Association would be included in that ask as well, I would think — so that we can get information out to our members, the dentists and other health providers, about how to help patients access the program. One thing that could happen is that patients or persons who think they’re going to be eligible for the program are going to call the dental office and ask the dental office staff to walk them through the CRA website. As I said before, we are understaffed in dental offices, and now we’re going to add to that administrative workload. We asked if we could have support from the federal government in terms of getting messaging out and the government itself getting direct messaging out to persons who will be able to access the program.
There was a question in between there, which I forgot, but the last question was about what happened in P.E.I. when the children’s program was brought in and what happened to employer-sponsored health plans. I don’t know the answer to that. Dr. Burry may be able to help us with that one.
Dr. Burry: It is still relatively early days, but one of the things that was done in Prince Edward Island was they did bring in income testing. They started it in a more universal position. They’ve moved back to more means testing. Basically, what they’re seeing on the Island, from what we understand, is that individuals without insurance, without benefits, are those who are benefiting from it. It was a good private-public approach that they used in Prince Edward Island, and it got the kind of results that they were hoping for. That is why we hear mostly from them that largely this has been a win-win, a win for the government, a win the employers, and a win for the dentists and the patients in particular.
Ms. Love: I concur with Dr. Tomkins on the first question. On the second question, CRA confirmed yesterday that the dental provider — the dentist or dental hygienist — cannot be reimbursed directly. It must be paid to the parent of the child directly.
Senator Yussuff: I understand the hope that the provincial program and the federal program will be seamless, but our federation has never worked that way. As much as I’m optimistic about your enthusiasm, how can we better advocate? This is also a political question — no disparity to my provincial colleagues — but how can we work to keep the pressure on? I think what’s happening at the federal and the provincial level can be a great complement to the greater good of the country. How do we try to do that? By the way, you are not without influence as an organization. How do we do this in a way that gives us some hope that we can actually bridge this gap? There is a next step, and we need to get that next step properly addressed by both levels of government.
Ms. Love: That’s an excellent question. That’s why CDHA has been a strong proponent of developing a national plan so that eventually, if the provinces decided on providing the services at the provincial level, they would get a federal transfer, the same as the $11 million that was done for mental health and home care. If we had an agreement that they had to comply to receive the funds, to start with the federal plan, have all the dental organizations on board in terms of what that plan is going to look like, make sure it is working, and then if provinces decided that they want the funding to administer the plan at the provincial level, to guarantee delivery at those national standards, then the federal government would do a transfer with the strings attached.
Dr. Tomkins: If we are to have any kind of federal transfers to the provinces, it certainly has to come with strings attached to it to ensure that the money goes to where it needs to go, and there has to be a national standard. This is why, from the beginning, we have been encouraging the federal government to be in close communication with the provincial and territorial governments, and we’re glad to see that this seems to be going on. I think this will be part of the continuing dialogue. It is a political issue, so I will leave the political issue to the politicians to figure that part out.
The Chair: Thank you, Senator Yussuff. We’ll stick with the mandate of our committee.
Senator Duncan: My questions were also related to the federal-provincial angles, but prior to doing that, I would like to follow up on my Non-Insured Health Benefits, or NIHB, questions. You’ve mentioned improvements to NIHB. We started talking about one specific area. I wonder if I could ask for that list of improvements that are necessary in your view to be submitted to the committee in writing. Would that be possible? I’m sure the chair will provide you with a date.
With regard to the federal-provincial transfer of money, there are issues around regulations. Are there issues in implementing this program with different regulations and licensing between provinces and territories? For example, is it possible that some dental hygienists are not licensed in the same way in different areas throughout the country? It may be that you wish to respond to that in writing as well in the interests of time.
Ms. Love: Thank you very much. I will briefly say that many provincial programs have been discussed this evening, and the problem with some of them is that they don’t reimburse dental hygienists — only if a dental hygienist is working under the direct supervision of a dentist. Those dental hygienists who are working in mobile practices or independently in the community cannot be reimbursed by those provincial programs, which is a barrier to access to care. I think those are the kinds of things that have to be addressed if we look at the federal-provincial agreements.
Senator Duncan: If that was a recommendation to us, we could perhaps suggest it.
Senator Loffreda: My question once again — and I think it’s important — is on data collection, which is key. Would the witnesses offer thoughts on what needs to happen to improve data collection? Is it an enhancement of the public health survey, or do they have other suggestions to offer?
While you’re thinking about the answer to that important question, allow me to comment on the displacement risk issue I raised. To your comment on incentivizing or penalizing corporations for dropping plans, I think what we should focus on is to incentivize. It’s not realistic to penalize corporations for dropping plans. I mean even Mark Carney the other evening told us that fiscal responsibility is imperative for the government, and we’re in an era of cost cutting. In my corporate experience and what I saw in the corporate world before my nomination to the Senate — and this was in an era of endless economic growth — corporations were cutting pension plans from defined benefit to defined contribution. I’ve seen dental benefits cut from six months cleaning to nine months cleaning. They were making record profits. I sat on a few boards, and we were witnessing that, unfortunately. I think this is an important issue — the displacement risk. So keep in mind that we have to incentivize, not penalize.
Now that you have given some thought to the important question I asked, maybe we can have some answers.
Dr. Tomkins: First and foremost, we would like to see the inclusion of the oral health component of the Canadian Health Measures Survey on a more frequent basis. Every three years would be ideal. It should be occurring on a regular basis. That is our number one, because it’s disinterested. It’s from the government. It’s collecting actual real data that everyone can use. That would be our number one push: to have the oral health component of the Canadian Health Measures Survey included on a much more frequent basis than it is now.
Dr. Burry: On the next part of this, once they look at the next phase, you also have the option of being able to actually gather much more of the data that you would need related to the program — how it’s working, who is receiving it. Certainly in the next phase, that’s what you would want to see.
In terms of your other area, certainly studies should be done to understand those systems and the financing. At the end of the day, what makes this work in other countries differently, particularly if you want to take Germany as an example, is they have a national scheme that’s working with all the employers. The government is a part of that, but employers in those countries provide the same or better benefits. That’s how they get to opt out of various national schemes. Again, there are a number of different models out there. The government has chosen this particular one for now, but there may be other things into the future, so think of this as the beginning of a journey, not the end of it.
Dr. Tomkins: One survey we did was with the Canadian public. Something like 78% of Canadians, when asked if they were in favour of some sort of government-sponsored national dental care program, said yes. But then when they were asked questions like if this were to affect their current dental benefits, the support dropped by half. Less than 40% are in favour if it affects their dental benefits. You have identified a real risk that two thirds of Canadians might worry about — that if we bring in a national program or federally funded, provincially administered program, whatever we end up with, it could end up taking away benefits from Canadians that value those benefits and that have kept them healthy all those years.
[Translation]
Senator Dagenais: My question is for Ms. Martel.
Ms. Martel, let us put the government insurance program aside and talk about actual costs for parents who are willing to pay to take their children to the dentist.
Can you describe the annual yearly cost for a child who does not present any particular problems? Briefly, what services could a parent obtain for their child for $650?
Ms. Martel: For a child who does not present a high risk of getting cavities or periodontal diseases, we are mostly talking about prevention. There would be one or two annual exams, with a cleaning and a fluoride application. There is sufficient evidence to show that applying fluoride twice a year, on average, helps prevent dental cavities. The children learn about healthy eating, good oral habits to have at home, and plaque removal.
For someone who does not require restorative work — someone with a relatively healthy mouth —, $650 will be more than enough to cover two visits, and there will probably be $200 left for other services, depending on what the dentist finds.
The problem is when people have a lot of cavities. Very often, cavities follow the 80/20 rule, which means 20% of the vulnerable population will have 80% of the cavities. That is the part of the population for which the $650 will not be enough.
However, with a program that starts early, with very young children, there is hope that the future will bring much better results, where children have fewer cavities and reach adulthood without having had any fillings, just by doing prevention.
Senator Dagenais: I want to go back to a comment made by Senator Loffreda. Most insurance companies recommend a cleaning every nine months. When people go to the dentist, it is strongly recommended to them to have one every six months.
What is the best solution? Is it because it would be cheaper for the insurance company to have it done every six months? It does make a difference for the dental plan, does it not?
Ms. Martel: Treatment plans should be made based on the needs of each patient. Some people need to go every two or three months, others every four, six or nine months. For a certain clientele, once a year is enough. The treatment plan should always be based on the patient’s needs, not on the dental insurance plan.
Dr. Burry: I agree with that.
Senator Dagenais: Thank you.
[English]
Senator Pate: So many questions have been asked and answered. Thank you for that.
I want to provide an opportunity, as we wrap up, for any last suggestions you might have. In particular, I’m interested in the national standards issue and the idea of how we encourage jurisdictions to be part of this and how we incentivize these sorts of initiatives rather than disincentivize them. Any final recommendations would be gratefully received.
Dr. Tomkins: We have this interim program right now, so that gives us a little bit of time to talk about the long term and what kind of an oral health strategy we need to have in order to get those 6 or 7 million Canadians to the dentist so they get good oral health care or to the dental hygienist so they get optimal oral health.
Our position really is that the federal government and the provincial and territorial governments have to be engaged in a meaningful dialogue backed up by information from us on what we would consider the elements of essential dental care. It is something that we have been working on at the Canadian Dental Association, and, along with our policy paper which we will be releasing before the end of the year, it will certainly give a very good idea.
The witnesses tonight have spoken about the variation of the population. Some people, perhaps, only need to go to the dentist once a year. Some need to go every three months and have scaling with a dental hygienist and examination by the dentist. I don’t think we should look at private third party insurance plans as the standard for care. They are benefits that have been purchased at a particular price to help patients offset the cost of their own dental care. We need to work with robust data, which is going to be part of the discussion that we are going to be engaging in as we go forward.
Dr. Burry: In terms of looking at this, this is, again, a first step. You’re looking at first steps. In the longer term, what we need to understand is the oral health status of Canadians, how well these programs work and also the conversations between the provinces and the feds in terms of creating that integrated system for Canadians.
This is one of the things that our dentist members are worried about, other programs that come on top of it that are more confusing and having to coordinate things between areas. There are some good things in the short term, like the $650 that can be used to cover out-of-pocket expenses. For those who are on provincial programs, it doesn’t cover that extra service. This is a good news approach, but, again, we need to have better integration between what’s happening provincially, particularly when you have patients who move from province to province so they are not getting all these different levels of benefits. Our systems were largely designed in different times and different eras, and this would bring it up to those national standards of saying a program that was designed in the 1970s may need to move forward.
The Chair: To conclude on that question, Ms. Love, please.
Ms. Love: We totally concur. There are numerous federal programs for dental and dental hygiene care in Canada through NIHB, through Veterans Affairs Canada, through the RCMP, through Correctional Service Canada, and what we want to do is we want to come up with a standard that we can all agree to that would be most beneficial for Canadians and that is fiscally responsible for Canadians. Once we have established that national standard, then if in the future provinces agree to sign on, we can negotiate transfer agreements for the provinces to administer those programs. In the interim, having a national standard and national program would be beneficial.
[Translation]
The Chair: Thank you to our witnesses for appearing today.
[English]
To the witnesses, it was enlightening. No doubt you have provided knowledge, information, understanding and insight into Bill C-31. I would like to remind the witnesses to submit your written responses to the clerk of the committee no later than Wednesday, November 2, 2022. Do we have agreement on that? Thank you.
I would like to take this opportunity before closing the meeting officially, on behalf of all the senators of the National Finance Committee, to thank the entire support team of this committee, those in the forefront of the room as well as those behind the scenes who are not visible. Thank you all for your work which contributes enormously to the success of our work as senators.
Honourable senators, our next meeting will be Tuesday, November 1, 2022, at 9 a.m., to continue our study on the subject matter of Bill C-31.
(The committee adjourned.)