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OTTAWA -- The clock is ticking for the government to deliver on its ambitious promise to the New Democrats to deliver a dental care program for low- and middle-income uninsured kids by the end of the year, while cost estimates have nearly doubled.

The pledge is a key element of the Liberal government's deal with the NDP to stave off an election until 2025. The Liberals promised to provide coverage by the end of the year for children living in a household with an income of less than $90,000, expanding next year it to include under 18-year olds, seniors and persons living with a disability.

The plan is to fully implement the program by 2025.

The government has just over six months to launch a completely new program, but still appears to be in the consultation phase of the planning and hasn't settled on the most basic question: what form will this program take?

One option is for the program to be delivered as a federal transfer to provinces, who would either administer it alongside existing dental programs and amalgamate them together.

But the NDP have always pitched the program as a stand-alone federal dental insurance plan, administered by federal staff to fill the gaps in the patchwork of provincial and private programs across the country.

A third option to contract the program out to a private company is also on the table, according to several stakeholder groups who've been in talks with government officials but aren't able to speak publicly.

Each available path has its own pitfalls and would likely take more than six months to traverse, and it's not clear what concessions the NDP are willing to accept to get a federal dental-care program in place.

The government's 2022 budget suggested the plan would cost $5.3 billion over the next five years, starting with a modest investment of $300 million this year to kick-start the kids program.

But in a legislative costing note, the PBO says the total cost of the program, if delivered as a transfer to provinces, could be closer to $9 billion, and the government would have to spend $939 million this year to get it going.

The PBO's report underscores just how complicated the government's task is in setting up a new dedicated program, the Canadian Dental Association said in a statement.

"While we fully support efforts by all levels of government to improve Canadians' oral health, we're concerned that the timeline previously announced may be exceedingly ambitious given the complexity of this issue," said Dr. Lynn Tomkins, the association's president.

The government has so far held several one-on-one and roundtable meetings with a large slate of stakeholders, including those with an interest in health care, oral health and insurance.

A task force has been stood up to navigate the various options. The executive director of that task force, Lindy Van Amburg, was not available for an interview.

Instead, Health Canada issued a statement to say that coverage will be provided for children this fiscal year, suggesting the government may be offering itself slightly more breathing room by giving itself until the end of March to fulfil its deal with the NDP.

"The government of Canada is committed to respecting the timelines that have been set out for this program, and will provide more information as the design of the program moves forward," the statement read.

Still, the timeline is ambitious. If, as the PBO interpreted, the government decides to download its dental care ambitions onto the provinces, it will need to get buy-in from 13 provinces and territories with a myriad of existing programs and their own unique industry landscape.

The dental association prefers this option because it would support existing programs that need funding, be less disruptive to the insurance sector and pose a lower risk of people going without coverage during the transition.

The Liberals went through a similar process to realize its cost-cutting goals for child care last year, but it took nearly a year to get all provinces and territories to agree.

The politics of signing new provincial and territorial dental care deals may also be complicated by the fact that several provinces, including Quebec and British Columbia, have emphatically requested more money from the federal health transfer with less political meddling from Ottawa.

Contracting out a federal program comes with its own headaches. Some stakeholders have told the government it could offer best value for money, but transparency and accountability could be lost in the event a private company takes over the coverage.

Awarding a multi-billion-dollar procurement process would normally take upwards of a year. Companies need time to prepare a bid, government officials need to carefully go through each one, and that's all before the winning company is able to start working on the program.

It's anyone's guess how long it would take to launch a federal bureau with dedicated government staff.

The government will need to pick an option before it can even begin delving into the arguably much more challenging and detailed work of deciding which services will be covered, how much reimbursement the plan will offer and how it will impact the industry at large.

It's also difficult to know precisely how much the program will cost. If, as some groups fear, provincial and employee insurance plans drop coverage and refer patients to the federal program, the Liberals' promise to the NDP could become much more costly, very quickly.

This report by The Canadian Press was first published June 16, 2022.