Bill C-31 - An Act respecting cost of living relief measures related to dental care and rental housing - Second Reading
Honourable senators, I rise today to speak to Bill C-31, An Act respecting cost of living relief measures related to dental care and rental housing.
I would like to thank Senator Yussuff, Senator Seidman, Senator Omidvar and Senator Simons for their previous speeches, which have increased our awareness and knowledge about dental care in Canada.
As many of you will know, I have been invested in the provision of dental care for 48 years of my life. Dental care is near and dear to my heart, and through my work I have given dentistry the worth that it deserves.
As it pertains to this bill, colleagues, I have concerns regarding the lack of adequate responses to questions raised by me and by other dental health professionals. I’m concerned about this short‑term approach when the effective prevention and management of most dental disease requires a long-term view. Moreover, we have provincial models of public health dentistry that provide care already. These clinics need to be better supported and funded to enable them to provide continuing additional care.
Most dental care systems are still structured around acute care service delivery, including emergency care such as pain relief. This traditional approach based on high-risk individual treatment is costly and research has proven its weak effectiveness.
Honourable senators, I have witnessed the children’s dental programs that existed in the provinces of Manitoba and Saskatchewan in the 1970s and 1980s. They were successful in completing school-based dental care on school-aged children, mainly in rural areas. The majority of children in the rural towns in Saskatchewan were eventually placed on maintenance, costing the government and taxpayers approximately $80 a year per student. Despite the success stories in these two provinces, the programs were phased out due to pressure from the provinces’ dental associations. Here, we can see the struggle between the public health model of dentistry and the business model. Which model will be encouraged to flourish in the proposal before us?
Colleagues, I further noticed in the bill that dental therapists are not included in the bill’s definition of “dental care services.” The dental therapists both federally and provincially trained in Saskatchewan and Manitoba are licensed health professionals who today provide the majority of services to children in dental offices. However, there are some federally trained dental therapists in Manitoba who are not recognized by the Manitoba Dental Association, or MDA. They continue to work on reserves without licences and without malpractice insurance, to their detriment. These federally trained therapists were trained through the dental faculty at the University of Toronto. I approached the MDA to question why the licensing of these two groups differed, but I did not receive an answer.
There are also Children’s Oral Health Initiative, or COHI, workers hired under a federal program who are trained at the community level but work without a diploma. They are allowed to provide treatment of fluoride application even though trained dental assistants are forbidden to do so through their provincial standard of care. It’s unimaginable that we have unrecognized, unlicensed providers without malpractice insurance permitted to work on children simply because these children live on-reserve. This is what we call geographic and systemic health racism.
As such, one big question lingers: Will this act be amended to include dental therapists, especially since they license and regulate their own profession in Saskatchewan and are looking at doing the same in Manitoba?
Honourable senators, one example of the fallout from decommissioning the children’s dental program was the closing down of the federal dental therapy school in Prince Albert, Saskatchewan, in 2011. The federal dental therapy school, supervised by dentists from U of T, was originally situated in Hay River, Northwest Territories. Yet, because the dental therapists had successfully completed treatment of all the citizens in the town, they had to move the school in Prince Albert. I understand that a new dental therapy school will be ready to start in La Ronge through the faculty of the University of Saskatchewan. I also understand that there are talks ongoing with different schools about dental hygienists who will be trained to be dental therapists.
This issue of a sustainable workforce continues with the other dental health professions. There are existing challenges with the recruitment and retention of oral health clinicians to provide care. When I was in Winnipeg, I asked dentists how they would be able to absorb the influx of children that this bill will result in, and who would be advising these children which offices would provide care. There are over 650 offices in Winnipeg but adequate infrastructure is not in place to handle this increased workload, which they are expected to absorb. I also do not know who would head such an initiative. Many dentists are already booking with their own patients months in advance. Will dentists be willing to displace some of their own patients for an interim program with unknown levels of bureaucratic involvement?
Colleagues, under the heading “Application” in section 8, it states that the application must include the name, address and telephone number of the dentist, denturist or dental hygienist — this is where dental therapists are missing — the applicant intends to have provide dental care services for the person for whom the application is made. The application also requires the month during which the services were provided, or when the applicant intends to have the services provided.
Based on what I have seen working in the field, I can say that very few dentists will provide care while expecting payment at a later date, despite what was said last night at the Finance Committee meeting. Furthermore, many First Nations are refused service due to an inability to prepay.
There are other situations at certain times where insurance companies will inadvertently send cheques to the patient instead of the provider, and then the provider has no recourse to payment when the patient doesn’t return the cheque to the office.
What happens if the applicant chooses to go to another provider — which is their right — or if they receive that cheque but don’t spend it on the intended care? This is a very profound possibility, as many of these individuals may have to decide if the money they receive is better spent on food or clothing so that their children can have basic living needs.
As we saw, the same situation occurred with the CERB where ineligible individuals sought the benefit because they needed it to meet basic needs. These are profound concerns to be addressed.
Honourable senators, I would like to speak to another successful dental program that is offered for children in Grades 2 to 6 at participating schools in the Winnipeg School Division, which has a high proportion of low-income households. This program is delivered by dental students in the college of dentistry at the University of Manitoba in concert with Variety, the children’s charity of Manitoba.
The third- and fourth-year dentistry students, who number 70, work with dental hygienists, dental assistants and supervising dentists to educate and screen children at school. Typically half of those screened require treatment. I was one of the instructors in the early 2000s, and I saw first-hand the extensive needs of children in these urban populations.
In their 2021-22 report, 17 schools were involved and 2,053 students were screened with 21% treated. Dental students administered 733 treatments, improving the lives of 199 children altogether.
Marsha Missyabit, the vice-principal of the Niji Mahkwa School stated:
This year, our school felt very supported by the dental outreach program. Students that attended the program were very comfortable and had pleasant things to say. Communication was effective and we were accommodated with respect. Thank you for all your support!
In 2019, Variety began supporting SMILE plus, a partnership between the University of Manitoba and the Winnipeg Regional Health Authority that provides free dental care for children in kindergarten and Grade 1 at select schools. These are done through private donations.
Honourable senators, I call attention to these successful programs as they can be used as models for implementation. The universities themselves are great sites for public health model delivery of dental care.
Yet, colleagues, a large concern I have with Bill C-31 arises from discussions I have held with various groups and individuals who are concerned about the inadequate amount of $650. It was quoted these children only require $650 worth of treatment. This amount would allow for an exam, radiographs and only two to three restorations. If this is all they require, then truly these children do not need a lot of work, but I don’t believe this to be the case. These children will need full-mouth comprehensive care, especially for groups that have had very little to no access to oral care, as has been stated by some senators.
When I appeared as a witness at the House of Commons Health Committee back in 2003, the committee looked at the amount offered in the Non-Insured Health Benefits program. At the time, it was $800. The committee indicated that this was inadequate, and they were instrumental in raising that amount to $1,000, a number that was still indicated to be inadequate.
Many health professionals have acknowledged that dental care is out of reach for many, including all age groups across the country. Who is most at risk and what is going to be done to provide some equality and equity to these groups?
Many people don’t have appropriate and timely dental care for reasons stated by the college of dentistry at the University of Manitoba, which include accessibility, availability, accommodation, awareness and acceptability.
I have said this before: That span between the $70,000 and $30,000 income brackets is huge and has the possibility of negative implications for the $30,000-to-$40,000 income group. In this group, they lack resources like the internet, phones, child care, transportation and the skills to navigate the new, incoming bureaucratic system, which already limited access to care when I was delivering dental care 20 years ago. It still continues to limit access today.
To add to the bureaucracy, the Canada Revenue Agency will be yet another major obstacle, especially if they do not have direct deposit accounts or access to computers.
What I heard in yesterday’s speech is that for Canadians to be able to receive their benefit payments swiftly, they will receive an upfront payment. That alleviates some of the burden for those who cannot prepay.
However, how will we assist those parents who do not have bank accounts or financial literacy? How will the government further ensure that this group will be able to access dental benefits equally with the $70,000 income group, who will have more resources?
Honourable senators, I would like to state my serious discomfort with the rushed manner with which this critical bill has proceeded. Is this because there has been a threat to trigger an election if this bill is not passed by December, or that the Canada Revenue Agency wants it passed by November 18?
It needs to be said that working under duress is no way to start this public health dental program. Spending public funding is a responsibility that we must consider diligently, not hastily.