November 1, 2022
Honourable senators, I rise today as opposition critic to speak to second reading of Bill C-31, An Act respecting cost of living relief measures related to dental care and rental housing.
The objective of this legislation is twofold.
Part 1 of the bill enacts the dental benefit act and authorizes the Minister of Health to make payments out of the Consolidated Revenue Fund in relation to dental care services for children under 12 years of age.
Part 2 enacts the rental housing benefit act and authorizes the Minister of Housing and Diversity and Inclusion to make payments out of the Consolidated Revenue Fund in relation to a one-time $500 payment to eligible individuals.
I will speak first to the new dental benefit act.
Oral disease is one of the most common chronic diseases of childhood, according to the Centers for Disease Control and Prevention in the U.S. The science that has developed over the last 20 years shows a growing body of evidence that links oral health with overall health and well-being. In fact, if you look at the scientific peer-reviewed journals, you will see studies that show a causal relationship between oral diseases in children and increased risk of diabetes and cardiovascular and respiratory diseases in adulthood.
A paper entitled “The effects of oral health on systemic health,” published in the journal General Dentistry in 2017 by Dr. Shawn Kane of the Department of Family Medicine at the University of North Carolina, best sums up the many studies on this subject, and I quote:
“A shared trait of periodontal disease and these medical conditions is that they are chronic conditions that take a long time to develop and become clinically significant. Primary prevention—treating the patient prior to the onset of symptoms, myocardial infarction, stroke, diabetic complications, or significant periodontal disease—is the challenge. Complications associated with these conditions cause significant morbidity and mortality and are incredibly costly to the healthcare system. Unfortunately, a lack of access to primary medical or dental care prevents some patients from engaging the system until a negative event has occurred.”
Dental care is a critical element in caring for one’s overall health, and we understand that preventative care is important. A 27-year follow-up study of 8-year-olds found that poor oral health in childhood was associated with poor heart health in adulthood. The Finnish study’s lead author was clear: “This emphasizes how important good oral hygiene and frequent check-ups with a dentist starting early in life are for general health.”
Furthermore, studies show that the use of dental care in childhood influences use of dental care in adulthood. In fact, childhood developmental literature indicates that early childhood experiences have a profound influence on later life. Pediatric dental textbooks emphasize that children learn from their experiences and are socialized toward oral health behaviours by their parents. There is support in the literature that having a childhood dental visit was associated with positive attitudes and beliefs about dental care in adulthood and with preventative and restorative dental visits later in life.
Honourable colleagues, I fully agree with the principles that govern this legislation, but I do not agree with the design of this benefit, as I shall explain.
Part 1 of Bill C-31 provides for the establishment of the new dental benefit, which will provide up to $650 a year for dental care per child under 12 for parents with adjusted family incomes under $90,000. This application-based, interim benefit will be administered by the Canada Revenue Agency.
I have three main concerns with Part 1 of this bill. The first is the jurisdiction and the exacerbation of existing inequities among provinces and territories. The second is the administration and design of the program. The third is the potential impact on services currently in place.
On jurisdiction, dental care is not within the federal one: It falls squarely within provincial jurisdiction. This is why the government should have had agreements in place with the provinces before it proceeded with a dental plan.
Honourable senators, most provinces and territories already provide dental care coverage programs for children, primarily those from low‑income households, but there is a wide variation in existing dental coverage for children across the provinces.
I did review existing dental coverage for children in Canada. To the best of my knowledge, the following information is up to date, but if there has been a change in the province or territory that you represent, please do share that information with me.
In Newfoundland and Labrador, all children under the age of 13 are eligible for the Children’s Dental Health Program, which covers examinations at 6-month intervals, cleaning treatments at 12-month intervals, routine fillings and extractions and sealants.
In Prince Edward Island, the School Oral Health Preventative Program provides preventative services to children from a dental hygienist, including an annual oral health risk assessment, oral health instructions, topical fluoride application, placement of sealants, cleaning or polishing of teeth and referral to a dentist if necessary. Further, the provincial dental care program offers sliding-scale coverage for families who are receiving social assistance or who meet certain financial thresholds. Children are eligible for an annual exam, annual cleaning, sealants, fillings and extractions.
In Nova Scotia, children under the age of 15 are covered once per year for a routine dental exam, two routine X-rays, a preventative service such as brushing and flossing instruction or cleaning appointments, fillings, necessary extractions and nutritional counselling.
In New Brunswick, the Healthy Smiles, Clear Vision program provides regular exams, X-rays, extractions, and some preventative treatments such as sealants and fluoride treatments for children under the age of 19 of low-income families that do not have private insurance.
In Quebec, all children under the age of 10 are eligible for annual examinations, emergency examinations, X-rays, local or general anaesthesia, fillings, extractions, endodontics, prefabricated crowns and oral surgery.
In Ontario, children under the age of 18 from low-income households are eligible for the Healthy Smiles program. The program covers check-ups, cleaning, fillings, X-rays, scaling, tooth extraction and urgent or emergency care.
In Manitoba, the Employment and Income Assistance Program provides families with income support, including support to cover the costs of basic dental services. Eligibility is based on the cost of a family’s monthly basic needs compared to their financial resources. More services are available for children in the Winnipeg health region specifically.
In Saskatchewan, children in low-income working families who meet the standard of an income test or are receiving the Saskatchewan Employment Supplement are covered for most dental services. Children from families receiving Saskatchewan income support are eligible for supplementary health coverage, including a range of basic dental services.
In Alberta, children under the age of 18 from low-income households, and 18- or 19-year-olds who are living at home and attending high school, are eligible for the Alberta Child Health Benefit. The benefit covers basic and preventative services like fillings, X-rays, examinations and teeth cleaning.
In British Columbia, children from families with annual adjusted net incomes of $42,000 or less are eligible for the Healthy Kids Program. The program covers $2,000 of basic dental services every two years, including exams, X-rays, fillings, cleaning appointments and extractions.
In the Yukon, the government provides diagnostic, preventative and restorative dental services to all children, from newborn to Grade 12. Children receive dental exams, X-rays, oral hygiene instruction, cleaning and scaling, fluoride application and sealants. Many of these services are provided in schools. If necessary, fillings, crowns, extractions or other emergency dental services are also covered.
In the Northwest Territories, infants and children aged 0 to 4 years are eligible for primary oral health services in Fort Smith, Fort Simpson, Inuvik, Fort McPherson and Norman Wells at no cost. These services include oral health assessment, oral health screening, oral health education, fluoride varnish application and referral to an oral health professional. Children in junior kindergarten to Grade 12 in these communities are eligible for the school-based Oral Health Program at no cost. Dental hygienists or dental therapists complete oral examinations, offer preventative and therapeutic treatments, provide oral health education and make referrals to dentists.
In Nunavut, children enrolled in the children’s Oral Health Project are eligible for free dental screenings. Following the initial screening, sealants, temporary fillings, extractions, fluoride varnish and referral for additional treatments are made available. Services are provided in a variety of settings, including health centres, schools, daycares and community centres.
Honourable colleagues, I include all this information to demonstrate that existing dental benefits throughout the country are detailed, specified and diverse. While I understand that the new Canada dental benefit is said to act as a top-up to existing benefits, my concern is that it ignores the provinces’ existing programs.
Unlike the provincial and territorial plans, there are no specifications around the dental procedures that the federal benefit is to be used for. The federal benefit can be used for preventative care, diagnostic care or restorative care — essentially anything that the parent and the practitioner determine is needed for the child’s oral health. An additional benefit of $650 will go a lot further to top up care in Quebec — where basic dental services are already covered for children under 10 years old — than in provinces without such coverage, highlighting potential inequities among provinces.
In regard to the administration of the program, the government has told us that the Canada Revenue Agency, or CRA, will administer the program through CRA’s My Account online portal. Parents of eligible children will be required to log in to their CRA account to attest to their child’s eligibility and to claim the benefit. Once the application is complete, the benefit will be paid within three to five days, and the attested details will be verified later. Random income tax audits will likely be part of compliance checks.
Honourable senators, parents will be subjected to uncertainty and costly errors if this benefit’s application process is confusing or faulty.
These are the challenges of a benefit that is application-based and attestation-based. There are built-in risks. Parents will be out-of-pocket after paying the dental expenses upfront in a crisis, or parents will anticipate the dental needs of their children, along with the cost, and apply for the benefit before going to the dentist. Undoubtedly, there will be those who thought they were eligible for the benefit, but discover later that they were not.
Also, the amount of the dental benefit varies significantly, depending on the family net income. The briefing note provided by the government states:
“The benefit provides $650 per child per year for parents with adjusted family net incomes under $90,000 for dental services received by their children under 12 years of age.”
In practice, however, the benefit declines quickly from $650 per child — if the family net income is less than $70,000 — to $390 if the net income is greater than $70,000 but less than $80,000. And then the benefit goes down to only $260 per child if the net income is greater than $80,000 but less than $90,000.
This pay-now-and-verify-later program design lends itself to problems and misunderstandings. Just last week, at the Finance Committee’s pre-study of Bill C-31, the Parliamentary Budget Officer, or PBO, Mr. Yves Giroux, cautioned that because the benefit is attestation based and I quote: “administration will need to be tight. Otherwise, it could lead to abuse. That’s one of the concerns that I personally have as a taxpayer.”
Furthermore, proactive reimbursement of anticipated costs may lead to situations in which parents, who are already stretched financially, take a risk and use the benefit cheque for rent, groceries, heating or other essential expenses. It may also lead to confusion about which expenses are eligible. At the Finance Committee’s pre-study, Senator Anderson raised a very important point, and I think our colleague Senator McCallum raised the very same point today: Indigenous Canadians who have coverage under the Non-Insured Health Benefits program have to travel sometimes to access dental care, though the care itself is covered. Will transportation or food expenses incurred while travelling to access dental care be considered eligible? It is not clear.
The administration of this program could have been greatly simplified had the federal government collaborated with provincial and territorial governments, many of whom already have direct billing agreements with dental care providers in place. At the Finance Committee’s pre-study, Senator Omidvar asked the PBO, Mr. Giroux, whether it would have been more efficient to transfer money to the provincial governments. He replied: “It certainly would have been better tailored to provincial realities and needs to transfer this money to provinces and territories. However, it would have required what would probably be lengthy discussions and negotiations with provinces.”
Furthermore, according to the Canadian Dental Association, regardless of whether they have dental benefits or not: “Canadians with lower household income were less likely to go to a dentist than those in higher income households.” Although the government is providing this benefit, the need to make a cash payment at the time of treatment may remain a barrier. In creating this benefit, did the federal government consider the social determinants of health, or the causes of health outcomes? Did they consider whether a benefit thus designed will actually improve the health outcomes of Canadian children?
Another barrier is the need to file a tax return. As Jennifer Robson and Saul Schwartz at Carleton University have shown — and our colleague has repeatedly helped us recognize — about 10% to 12% of Canadians do not file a tax return and, therefore, do not receive the benefits for which they are eligible. In their article, “Who Doesn’t File a Tax Return? A Portrait of Non‑Filers,” Robson and Schwartz note: “Low income is clearly related to the likelihood of not filing. Persons in families with a disposable income below the official Market Basket Measure of poverty were much less likely to file than those whose family income was above the threshold.” As our PBO, Mr. Giroux, remarked at the Finance Committee’s pre-study, more and more benefits rely on the tax system, but in his words, “the government is not as proactive as you would think it could be in 2022, for example, in reaching out to these individuals who fail to file taxes.”
I find these vulnerabilities concerning, and they demonstrate the downfalls of cobbling a benefit together in a hurry rather than taking the necessary time to put a proper plan together.
It is also a concern that the government and the Parliamentary Budget Officer have different estimates for the cost of this program. A briefing note shared by Senator Gold notes that Budget 2022 provides $300 million in funding for dental care in 2022-23, and $600 million in 2023-24. The Office of the Parliamentary Budget Officer, however, puts the projected costs for this program at $247 million in 2022-23 and $372 million in 2023-24. That is a difference of $281 million. At the Finance Committee’s pre-study, Senator Boehm asked the Parliamentary Budget Officer, Mr. Giroux, whether — as we project into the future and with consideration of inflation — the sum that the government has planned to spend on this program is realistic. Mr. Giroux said, ” there are too many unknowns as to the format and program designs to say whether or not it’s enough money.” Honourable senators, many of you have more expertise in finance than I do, but I ask: Is this quality of program design acceptable? This is an interim benefit. I sincerely hope that if the government introduces a permanent national program, its design is more robust so that we can provide a proper review.
The need for a robust program design is especially relevant given the state of the Canadian economy. On October 20, 2022, the Toronto Star reported that Finance Minister Chrystia Freeland told her cabinet colleagues that submissions for new programs must demonstrate how existing departmental resources can be used to fund at least 25% of new operating costs. As this bill demonstrates, the government must improve their program design to ensure that new programs and benefits can be budgeted for appropriately.
Finally, in regard to the potential impact on services currently in place, Canada’s premiers are calling on the federal government to rebalance the health care funding partnership. Earlier this year, Premier John Horgan of British Columbia called for increased health transfers for existing health programs, “Do I think it would be grand to have a national dental care plan? Absolutely. But we need to start with first principles, and that is stable funding so that we can do the hip replacements, so we can have a human resource strategy for our primary care sector.” In August, when asked about a potential new federal dental benefit, Premier Blaine Higgs of New Brunswick said, “we’ve been spending a lot of energy over the last number of months and years talking about a crisis in our current health care system”. Because right now, we have a health care service that is not providing what was intended. So my focus would be on our current situation and let’s get it fixed first.
The Canadian Dental Association has also flagged concerns about how this benefit may impact existing dental coverage. In a brief, they note that two thirds of Canadians have dental coverage, and half of Canadians have employer-sponsored coverage. They say, “It is vital that this dental care ecosystem not be disrupted; the focus needs to be on gaps in coverage, particularly for underserved populations”. Will employers stop providing dental insurance to employees? Will the system that now works well for many Canadians and dental care providers be compromised?
Honourable senators, it is a considerable concern that provinces and territories with real dental programs in place will discontinue them so that the funds allocated to their existing programs can be reallocated to their strained provincial health care systems. Employers may see this as an opportunity to cut costs on private dental insurance as well. The dental benefit act is a poor substitute indeed for many of the existing programs and insurance plans in this country. Hopefully, the Finance Committee will hear from the provinces and territories regarding potential impacts to their existing dental programs.
Now, for Part 2 of Bill C-31, the rental housing benefit act, which provides a one-time, tax-free benefit of $500 for rent paid on a principal residence in 2022.
This benefit will only be available to renters with adjusted net incomes below $35,000 for families or $20,000 for individuals. But it, too, is an attestation-based application process.
Those who apply must have filed an income tax return in 2021 and then attest that they:
- Are paying at least 30% of their adjusted net income on shelter.
- Are paying rent for their own primary residence in Canada, which would include the address of a rental property; the amount of rent paid in 2022; and the landlord’s contact information.
- Lastly, they must consent to the CRA verifying their information to confirm eligibility.
One might legitimately ask how many Canadians even know what “adjusted net income” means — I’m looking to Senator Marshall, because I’m sure she knows — never mind what their own “adjusted net income is.
Subsection 2(3) of the bill states:
“In section 4, adjusted income has the same meaning as in section 122.6 of the Income Tax Act, except that the reference to “at the end of the year” is to be read as a reference to “on the reference day.”
There you have it — or do you?
If we next look to section 122.6 of the Income Tax Act:
QUOTE: adjusted income, of an individual for a taxation year, means the total of all amounts each of which would be the income for the year of the individual or of the person who was the individual’s cohabiting spouse or common-law partner at the end of the year if in computing that income no amount were:
(i) under paragraph 56(1)(q.1) or subsection 56(6),
(ii) in respect of any gain from a disposition of property to which section 79 applies, or
(iii) in respect of a gain described in subsection 40(3.21), or
(b) deductible under paragraph 20(1)(ww) or 60(y) or (z) UNQUOTE
Honourable senators, does this sound straightforward? You cannot simply look up your earnings for the last year to see if you qualify. You will be better served by going back to your 2021 income tax return to look up Line 23600 — “Net income”.
But if you have a spouse, you must add your partner’s net income to your own. But then, you will still have to subtract the Universal Child Care Benefit or Registered Disability Savings Plan benefit in order to obtain, finally, your adjusted net income.
The risk here is not that Canadians will apply for the benefit when they don’t qualify, but that they will not apply even though they do qualify. When one hears on the news that, with the income of $35,000 or less, you may qualify for the rental housing benefit, most would immediately think of gross income, not net income, and definitely not adjusted net income.It is entirely possible, and even likely, that people with a gross family income of just over $35,000 will not even bother to apply for the benefit because they will assume they do not qualify. This would be regrettable.
Indeed, it appears that the government itself is not very clear on how many Canadians will be eligible for this benefit. The government initially committed $475 million for this benefit in Budget 2022. It has since updated the proposed funding to $1.2 billion for 1.8 million recipients. The Office of the Parliamentary Budget Officer, meanwhile, has estimated that the program would cost $940 million for 1.7 million recipients.
Honourable senators, in closing, we must consider how well these programs will serve Canadians. Important questions about the new dental benefit act include: Were premiers consulted; and will this new benefit change the administration of current programs in provincial jurisdictions? Will those who are eligible apply? Will this program cost what the government suggests in their briefing note, or what the Office of the Parliamentary Budget Officer estimates in their legislative costing note? Will the dispersed funds be used as intended? How will compliance checks work? And, most importantly, will more Canadian children ultimately go to the dentist because of this benefit, or will existing disparities in care persist?
Important questions regarding the new rental housing benefit act include: Will those who are eligible apply? Will the application process be straightforward? Does the government have a more comprehensive housing strategy than this one-time payment?
Honourable senators, I look forward to clarifying witness testimony at committee hearings, along with debate on these issues in the chamber.