Regulations Amending the Canada Student Loans Regulations and the Canada Student Financial Assistance Regulations: SOR/2023-227
Canada Gazette, Part II, Volume 157, Number 24
Registration
SOR/2023-227 November 3, 2023
CANADA STUDENT FINANCIAL ASSISTANCE ACT
CANADA STUDENT LOANS ACT
P.C. 2023-1104 November 3, 2023
Her Excellency the Governor General in Council, on the recommendation of the Minister of Employment and Social Development, makes the annexed Regulations Amending the Canada Student Loans Regulations and the Canada Student Financial Assistance Regulations under
- (a) section 17footnote a of the Canada Student Loans Act footnote b; and
- (b) subsection 15(1)footnote c of the Canada Student Financial Assistance Act footnote d.
Regulations Amending the Canada Student Loans Regulations and the Canada Student Financial Assistance Regulations
Canada Student Loans Act
Canada Student Loans Regulations
1 Section 18 of the Canada Student Loans Regulations footnote 1 is replaced by the following:
18 (1) Subject to subsection (3), for the purposes of section 11.1 of the Act, the Minister may forgive the lesser of the outstanding principal of the borrower’s student loan and
- (a) for the first year in respect of which the borrower qualifies for loan forgiveness, $8,000, in the case of a family physician or $4,000, in the case of a nurse or nurse practitioner;
- (b) for the second year in respect of which the borrower qualifies for loan forgiveness, $10,000, in the case of a family physician or $5,000, in the case of a nurse or nurse practitioner;
- (c) for the third year in respect of which the borrower qualifies for loan forgiveness, $12,000, in the case of a family physician or $6,000, in the case of a nurse or nurse practitioner;
- (d) for the fourth year in respect of which the borrower qualifies for loan forgiveness, $14,000, in the case of a family physician or $7,000, in the case of a nurse or nurse practitioner; and
- (e) for the fifth year in respect of which the borrower qualifies for loan forgiveness, $16,000, in the case of a family physician or $8,000, in the case of a nurse or nurse practitioner.
(2) The maximum number of years in respect of which an amount may be forgiven is five minus the number of years in respect of which an amount referred to in subsection 28(1) of the Canada Student Financial Assistance Regulations has been forgiven.
(3) The amount that the Minister may forgive for a year is to be reduced by any amount that was forgiven for that year under section 9.2 of the Canada Student Financial Assistance Act.
Canada Student Financial Assistance Act
Canada Student Financial Assistance Regulations
2 Subsection 28(1) of the Canada Student Financial Assistance Regulations footnote 2 is replaced by the following:
28 (1) For the purposes of subsection 9.2(1) of the Act, the Minister may forgive the lesser of the outstanding principal of the borrower’s student loan and
- (a) for the first year in respect of which the borrower qualifies for loan forgiveness, $8,000, in the case of a family physician or $4,000, in the case of a nurse or nurse practitioner;
- (b) for the second year in respect of which the borrower qualifies for loan forgiveness, $10,000, in the case of a family physician or $5,000, in the case of a nurse or nurse practitioner;
- (c) for the third year in respect of which the borrower qualifies for loan forgiveness, $12,000, in the case of a family physician or $6,000, in the case of a nurse or nurse practitioner;
- (d) for the fourth year in respect of which the borrower qualifies for loan forgiveness, $14,000, in the case of a family physician or $7,000, in the case of a nurse or nurse practitioner; and
- (e) for the fifth year in respect of which the borrower qualifies for loan forgiveness, $16,000, in the case of a family physician or $8,000, in the case of a nurse or nurse practitioner.
Transitional Provision
3 An application for loan forgiveness that is made in respect of a year that ends before the day on which these Regulations come into force is to be governed by the Canada Student Loans Regulations and the Canada Student Financial Assistance Regulations as they read immediately before that day.
Coming into Force
4 These Regulations come into force on the day on which they are registered.
REGULATORY IMPACT ANALYSIS STATEMENT
(This statement is not part of the Regulations.)
Executive summary
Issues: Among the many factors that contribute to the limited access to health care services in rural and remote areas is the challenge of attracting family physicians, nurses and nurse practitioners to these communities. The COVID-19 pandemic and the lack of a stable and sufficient supply of health professionals has exacerbated health and human resources challenges in rural and remote communities. At the same time, while the Canada student loan (CSL) forgiveness benefit was put in place to help incentivize family physicians, nurses and nurse practitioners to work in rural and remote communities, the benefit is continuing to decline in value given inflation and the rising cost of living. The benefit has not increased in value since its implementation in 2013.
Description: Amendments to the Canada Student Financial Assistance Regulations (CSFAR) and the Canada Student Loans Regulations (CSLR) will allow a family physician to be eligible for up to a maximum of $60,000 in loan forgiveness and a nurse or nurse practitioner to be eligible for up to $30,000 in loan forgiveness over five years. The maximum annual loan forgiven will also increase gradually based on the number of years a family physician, nurse or nurse practitioner works in an under-served rural or remote community. The loan forgiveness will reduce the outstanding CSL balance for eligible beneficiaries at the end of each year of work.
Rationale: The amendments are expected to incentivize a greater number of family physicians, nurses and nurse practitioners to work and remain in rural and remote communities. It is anticipated that approximately 3 000 CSL borrowers will benefit in the first year of implementation (2023–2024) and up to 8 000 per year by 2032–2033. The 50% increase in loan forgiveness is expected to attract 1 196 doctors and 4 001 nurses over a 10-year period. The findings from the literature suggest that this increase in the number of doctors and nurses in rural and remote regions is likely to result in better health outcomes in rural and remote areas of Canada. The cost of the amendments amounts to $22.6 million over 10 years for the Government of Canada. This is also the amount that doctors and nurses receive in exchange for a minimum of 400 hours of service annually to the rural community.
The monetized benefits exclude qualitative benefits to Canadians living in rural and remote communities and Canadian society, such as improved access to health services and, as suggested by the evidence in the literature reviewed, better health outcomes. As a result, the benefits of implementing the regulatory amendments outweigh the costs due to the qualitative benefits.
Issues
In rural and remote communities, the demand for family physicians, nurses and nurse practitioners has historically exceeded supply. As a result, some Canadians in under-served communities need to travel significant distances to receive primary health care or suffer from limited health care services, both of which in turn can contribute to poorer health status. While there are health care shortages in urban areas, shortages are often most acute in rural and remote communities given reduced access for care in some areas. In addition, the COVID-19 pandemic has placed significant demands on health care workers, including an upward trend in overtime worked in the health workforce.footnote 3 Physicians working in rural and remote areas have been identified as a group that is particularly at risk within the health care community with respect to mental health and well-being.footnote 4
While the provinces have primary jurisdiction in the area of health and human resources, the federal government is actively taking steps to work with the provinces and territories (P/Ts) to address health workforce shortages. The CSL benefit was put in place in 2013 in response to the lack of access to health care services that contribute to the poorer health status of residents within rural and remote communities. The objective of the benefit is to help under-served rural and remote communities receive adequate medical services by having more health care providers work in their communities. Nevertheless, since the value of the benefit has not increased since its implementation in 2013, without an increase in funding, it is expected to have declining incentivization effects on the recruitment and retention of doctors and nurses to rural and remote communities. The rising cost of living, coupled with rising interest rates will continue to make repayment challenging for some CSL borrowers.
Background
Canada Student Financial Assistance Program
The Canada Student Financial Assistance (CSFA) Program provides eligible students with Canada student grants (CSGs) and CSLs to help students pay for post-secondary education at a designated college, university or other post-secondary institution. CSGs and CSLs are available to students from nine provinces [British Columbia (BC), Alberta (AB), Saskatchewan (SK), Manitoba (MB), Ontario (ON), New Brunswick (NB), Nova Scotia (NS), Newfoundland and Labrador (NL), Prince Edward Island (PEI)] and the territory of Yukon (YK). In these jurisdictions, students receive both federal and P/T student aid. Meanwhile, Quebec (QC), Nunavut (NU) and the Northwest Territories (NWT) receive alternative payments from the Government of Canada to administer their own student financial assistance programs.
Loan forgiveness for family physicians, nurses and nurse practitioners has been used as a financial incentive since 2013 to help increase the capacity of the health workforce in rural and remote communities. The objective of the CSL forgiveness benefit is to attract and retain health providers in rural and remote communities by offering financial incentives.footnote 5
To expand the provision of primary health care services to Canadians, the Government of Canada forgives a portion of CSLs for family physicians, nurses and nurse practitioners who practise in under-served rural and remote communities. Currently, family physicians are eligible for federal CSL forgiveness of up to $8,000 per year to a maximum of $40,000 over five years. Meanwhile, nurse practitioners and nurses are eligible for federal CSL forgiveness of up to $4,000 per year to a maximum of $20,000 over five years.
The CSL forgiveness benefit applies to the federal portion of a CSL. If a borrower is eligible for the CSL forgiveness benefit, their CSL balance is reduced by the maximum amount of loan forgiveness depending on the category of health profession (family physician, nurse or nurse practitioner), or the outstanding loan balance, whichever is lower.
The eligibility conditions for the CSL forgiveness benefit are prescribed under section 29 of the Canada Student Financial Assistance Regulations footnote 6 and section 19 of the Canada Student Loans Regulations.footnote 7 In order to receive the CSL forgiveness benefit, an eligible borrower must have worked in an “under-served rural or remote community” as a family physician, nurse or nurse practitioner during the year and applied for loan forgiveness in the prescribed form no later than 90 days after the end of that year. Under subsection 2(1) of the CSFAR and CSLR (together, “the regulations”), an “under-served rural or remote community” means any census subdivision, as defined in the document entitled Standard Geographical Classification (SGC) 2011,footnote 8 that does not have census tracts, as defined in that document, and is located outside the capitals of the 10 provinces. Census tracts are located in census metropolitan areas (CMAs) and in census agglomerations (CAs) having a core population of 50 000 or more.footnote 9 As a result, an eligible borrower for CSL forgiveness must have worked in a community with a core population of less than 50 000.
A family physician, nurse or nurse practitioner is also required to practise in an “under-served rural or remote community” for at least 400 hours in order to be eligible for the CSL forgiveness benefit. When the CSL forgiveness benefit was implemented in 2013, a minimum requirement of 400 hours was established as a matter of policy. During consultations on the benefit, stakeholders found basing eligibility on full-time work over the course of a year as too restrictive, as minimum requirements for hours worked over a year differ across P/T programs.footnote 5
Budget 2022 committed to increase the maximum amount of CSL forgiveness by 50% for eligible family physicians, nurses and nurse practitioners in rural and remote communities, starting in 2023–2024. Budget 2022 also committed to expand the list of eligible occupations and review the definition of rural communities.footnote 10
In Budget 2023, the Government of Canada committed to encouraging more doctors and nurses to practise in rural and remote communities by amending the eligibility criteria respecting rurality. Specifically, Budget 2023 committed to amend the eligibility criteria to include more under-served rural communities in need. This measure complements the Budget 2022 commitment to increase the maximum amount of CSL forgiveness by 50% and will be pursued and implemented separately.
Objective
Improving access to primary health care services in rural and remote communities is a complex issue demanding a wide range of financial and non-financial responses with loan forgiveness being one of the many factors influencing an individual’s decision to work in an under-served rural or remote community. The enhancements to the CSL forgiveness benefit are expected to help strengthen health and human resources in rural and remote locations by contributing to the debt reduction of those who work in these designated areas, and therefore incentivizing eligible health professionals to work in those communities. In addition, increasing the generosity of CSL forgiveness could result in some federal CSLs being forgiven faster for some borrowers, and is expected to help improve the retention of health care providers in under-served rural and remote communities. This is because the amount of loan forgiveness will increase gradually each year based on the number of years that a family physician, nurse or nurse practitioner has worked in an under-served rural or remote community.
Description
Under the regulatory amendments, there will be a gradual increase in the maximum amount of CSL forgiveness based on the number of years an eligible borrower receives the benefit. Specifically, the Minister may forgive up to the following amounts based on the number of years an eligible borrower qualifies for the CSL forgiveness benefit:
- Year 1: family physicians ($8,000), nurse and nurse practitioners ($4,000);
- Year 2: family physicians ($10,000), nurse and nurse practitioners ($5,000);
- Year 3: family physicians ($12,000), nurse and nurse practitioners ($6,000);
- Year 4: family physicians ($14,000), nurse and nurse practitioners ($7,000); and
- Year 5: family physicians ($16,000), nurse and nurse practitioners ($8,000).
The loan forgiveness amounts will increase by $2,000 annually for family physicians qualifying for the CSL forgiveness benefit and by $1,000 annually for qualifying nurses and nurse practitioners.
The CSL forgiveness benefit is generally defined by a period of 12 months during which prospective applicants must have been working in an eligible health profession in an “under-served rural or remote community.” Once the regulations are in force, the enhancements will be available to a qualifying health professional who has completed a year of work. Currently, it is the intention to have the regulatory amendments in place for fall 2023.
The eligibility requirements for the CSL forgiveness benefit under the regulations will remain the same over the five-year loan forgiveness period. An eligible borrower must still work as a family physician, nurse or nurse practitioner in an under-served rural or remote community during the year and apply for loan forgiveness in the prescribed form no later than 90 days after the end of that year.
Regulatory development
Consultation
Stakeholder tables
The CSFA Program regularly engages with stakeholders, including student groups, borrowers, and the provinces and territories, through the National Advisory Group on Student Financial Assistance (NAGSFA) and the Intergovernmental Consultative Committee on Student Financial Assistance (ICCSFA). In addition, for this measure, the CSFA Program has also reached out to P/T health ministries with the support of Health Canada and the Committee on the Health Workforce.
From May 17 to May 18, 2022, the CSFA Program met with stakeholders from NAGSFA and the Policy Development Committee (PDC) under ICCSFA. Feedback from these stakeholder tables generally indicated that a higher amount of loan forgiveness than currently available was expected to help provide a stronger incentive for health professionals to work in under-served communities. In addition, some NAGSFA and ICCSFA (PDC) stakeholders commented that financial incentives should build on other P/T initiatives to help increase access to health care services in rural and remote communities. These included incentives targeted to different determinants such as lifestyle preferences, career development, relocation assistance, and student financial assistance that could affect a person’s decision to work in a rural or remote area.
On May 31, 2022, the CSFA Program also met with P/T ministries of health through the federal-provincial/territorial (F-P/T) Committee on the Health Workforce. The Committee on the Health Workforce reports to the Conference of Deputy Ministers. Membership consists of the federal and provincial co-chairs plus one senior-level delegate from each federal, provincial and territorial Ministry of Health. Its mandate includes providing policy and strategic advice to the Conference of Deputy Ministers on health workforce issues and identifying emerging issues in the health workforce and health delivery.footnote 11
At the meeting, representatives from P/T health ministries were supportive of increasing the maximum amount of CSL forgiveness by 50%. However, some P/T health ministries commented on the high cost of a medical education and the need for medical students to take out additional loans through lines of credit while in medical school. In addition, one stakeholder commented on the potential challenges of retaining health professionals after the loan forgiveness period ends under the CSL forgiveness benefit.
Fall 2022 engagement
In fall 2022, the CSFA Program also engaged stakeholders on Budget 2022 commitments respecting CSL forgiveness. These commitments included increasing the maximum amount of CSL forgiveness by 50% for eligible doctors and nurses working in rural and remote communities, expanding the list of eligible occupations and reviewing the definition of rural communities.footnote 10 As part of the engagement, a discussion paper and a questionnaire were sent out to 102 stakeholders. These stakeholders included associations representing health care occupations, professional associations, P/T health ministries, Indigenous stakeholders, organizations representing the community interests of rural and remote communities and NAGSFA and ICCSFA members.
In an effort to limit the scope of the engagement exercise to the current regulatory amendments, the CSFA Program focused on input from the following stakeholders: professional associations representing physicians and nurses, P/T health ministries, organizations representing the community interests of rural and remote communities, Indigenous stakeholders and NAGSFA and ICCSFA members. These groups represent 75 of the 102 stakeholders invited to provide input as part of the fall 2022 engagement. Meanwhile, 12 responses were received from these 75 stakeholders.
Most stakeholders that submitted responses supported the enhancements to the CSL forgiveness benefit. However, a number of stakeholders had concerns respecting the retention of health professionals in rural and remote communities beyond the five-year loan forgiveness period. In particular, one organization representing Indigenous health professionals was concerned that financial incentives could lead to a revolving door of health care providers with no ties to Indigenous communities in rural and remote areas.
As a way to help increase the retention of family physicians in rural and remote communities, one professional association representing physicians recommended extending the CSL forgiveness benefit beyond the five-year loan forgiveness period. CSFA Program data shows that most beneficiaries pay off their federal CSLs in three to four years and would therefore not benefit from extending the benefit beyond the five-year loan forgiveness period. As a result, the amendments do not extend the loan forgiveness period beyond five years.
In addition, one professional association also recommended imposing a multi-year service commitment on CSL forgiveness recipients of at least two to three years to help increase retention. Imposing a return of service commitment was not universally supported by all stakeholders and partners. According to one professional association representing nurses, requiring graduates to remain in a community could impact their mental and physical well-being. Additionally, one provincial health ministry commented that imposing a multi-year service agreement may lead to higher instances of absenteeism and sick leave for health professionals working in extremely challenging circumstances (e.g. the COVID-19 pandemic and the illicit toxic drug supply crisis).
One professional association representing nurses also recommended the benefit be extended to health professionals working in urban communities. In addition, another professional association representing physicians advocated for comprehensive student loan debt relief to support the retention of health care workers in areas of urgent need, including rural and remote areas. Increasing the supply of health professionals in rural and remote communities was suggested by the professional association representing physicians to help increase retention by reducing burnout and high staff turnover. Currently, many physicians reportedly quit isolated communities because of overwork and burnout. Under-resourcing in rural and remote areas was seen as a self-perpetuating problem leading to high staff turnover and heavy workloads for existing staff.
One NAGSFA member and three provinces also suggested that there was a lack of awareness of the benefit and an absence of coordination between F-P/T governments. Moving forward, the CSFA Program anticipates it will use existing stakeholder tables (e.g. ICCSFA, NAGSFA, F-P/T Committee on Health Workforce) to raise awareness of the enhancements to the CSL forgiveness benefit and to foster greater collaboration with its P/T partners. In addition, social media and web platforms, and news releases could also be used to communicate the new measure to student borrowers and other interested stakeholders.
One NAGSFA member and one province also commented on the complexity of the application process for the CSL forgiveness benefit. The CSFA Program is reviewing the application form to find additional efficiencies, such as allowing applicants to upload scanned copies of the application form electronically with the service provider to avoid having to mail in applications. As volumes increase, the CSFA Program will also be looking into options with respect to web-based applications.
Prepublication in the Canada Gazette, Part I
The regulations were published in the Canada Gazette, Part I, on June 24, 2023, followed by a 30-day comment period. A total of three comments, from the Denturist Association of Canada, the Canadian Dental Hygienists Association, and the Association of Canadian Faculties of Dentistry were received through the Government of Canada’s Online Regulatory Consultation System. All three comments requested that the CSFA Program consider expanding the list of occupations eligible for the CSL forgiveness benefit and did not provide any feedback specifically on the regulatory amendments. While these comments will be considered in the context of future CSFA Program amendments, they are beyond the scope of the present regulatory amendments and did not result in any changes to the regulations.
Modern treaty obligations and Indigenous engagement and consultation
The regulatory amendments are not expected to have differential impacts on Indigenous peoples or negative implications for modern treaties, as per Government of Canada obligations in relation to rights protected by section 35 of the Constitution Act, 1982, modern treaties and international human rights obligations. The regulatory amendments was assessed for modern treaty implications, as per the Cabinet Directive on the Federal Approach to Modern Treaty Implementation. The assessment found no immediate impacts on modern treaty obligations.
Instrument choice
Increasing federal CSL forgiveness for doctors and nurses in rural and remote communities could not be addressed by means other than regulatory amendments. The Canada Student Financial Assistance Act footnote 12 and the Canada Student Loans Act footnote 13 only allow for loan forgiveness with the conditions to be prescribed by the regulations. As a result, non-regulatory options were not considered.
Regulatory analysis
Benefits and costs
A cost-benefit analysis was conducted to assess the incremental impacts to stakeholders of increasing the maximum amount of CSL forgiveness by 50% for eligible family physicians, nurses and nurse practitioners working in under-served rural and remote communities. The cost-benefit analysis was compared to a baseline scenario in which these regulatory amendments are not made. The complete cost-benefit analysis is available upon request.
The stakeholders that will be most directly affected are eligible family physicians, nurses, or nurse practitioners who are CSL borrowers and the Government of Canada. The residents of designated under-served rural and remote communities and Canadian society will also be affected directly given that there will be an increase in the number of primary care providers in rural and remote communities.
The key data source for this cost-benefit analysis is CSFA Program administrative data, specifically the amount of federal debt at the time of leaving school for CSL forgiveness beneficiaries, the amount of loan forgiveness, and the number of recipients of the CSL forgiveness benefit. In addition, a review of research literature also helped to identify the impacts of debt forgiveness and increased access to health care services on individuals who reside in rural or remote communities.
It is anticipated that approximately 3 000 CSL borrowers will benefit in the first year of implementation (2023–2024) and up to 8 000 per year by 2032–2033. The 50% increase in loan forgiveness is expected to attract 1 196 doctors and 4 001 nurses over a 10-year period. The findings from the literature suggest that this increase in the number of doctors and nurses in rural and remote regions is likely to result in better health outcomes in rural and remote areas of Canada. The cost of the proposal amounts to $22.6 million over 10 years for the Government. This is also the amount that doctors and nurses receive in exchange for a minimum of 400 hours of service annually to the rural community.
Cost-benefit statement
Number of years: 10 (2023–2024 to 2032–2033 academic years)
Base year for costing: 2023
Present value base year: 2023
Discount rate: 7% (Canadian Cost-Benefit Analysis Guide: Regulatory Proposals)
Monetized costs
The cost to the Government of Canada for providing increased loan forgiveness under the amendments is based on estimates using CSFA Program administrative data.
The monetized cost is the cost of providing increased loan forgiveness to CSL forgiveness beneficiaries (3 000 CSL forgiveness beneficiaries in 2023–2024). The total monetized costs are estimated at $22.6 million (present value) over the next 10 years.
|
Impacted stakeholder |
Description of cost |
Base year |
Second year (2024–2025) |
Final year (2032–2033) |
Total |
Annualized value |
|---|---|---|---|---|---|---|
|
Government of Canada |
Cost of increasing loan forgiveness |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
|
All stakeholders |
Total costs |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
Monetized benefits
The regulatory amendments will provide increased loan forgiveness for CSL forgiveness beneficiaries. These benefits were monetized by attributing the estimated costs incurred by the Government related to direct program costs for the amendments.
|
Impacted stakeholder |
Description of benefit |
First year |
Second year (2024–2025) |
Final year (2032–2033) |
Total |
Annualized value |
|---|---|---|---|---|---|---|
|
Borrowers |
Increased loan forgiveness |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
|
All stakeholders |
Total benefits |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
The regulatory amendments will forgive the federal student debt of family physicians, nurses and nurse practitioners who work in rural and remote communities. Research demonstrates that loan forgiveness and loan repayment programs are strong incentives that may influence medical residents’ career choices and recommend financial incentives that reward physicians who provide care to at-risk populations.footnote 14 Family physicians, nurses and nurse practitioners have significant federal debt loads when compared to the average CSFA Program client. This is especially true for family physicians who utilize the CSL forgiveness benefit, as they have more than double the CSL debt when compared to the average CSFA Program client.
The regulatory amendments will also allow these borrowers to repay their loans faster. This will enable them to service other educational and non-educational debt, increase their savings and have increased disposable income. Research demonstrates that having a high level of student debt is directly linked to financial difficulties and hardship, even for individuals who manage to make regular payments.footnote 15 In terms of medical student debt, individuals with higher amounts of student loan debt were more likely to report high levels of stress from their educational debt and are more likely to delay major life decisions, such as getting married, having children and buying a house.footnote 16
|
Impacts |
First year |
Second year |
Final year |
Total |
Annualized value |
|---|---|---|---|---|---|
|
Total benefits |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
|
Total costs |
$1.4M |
$3.0M |
$4.1M |
$22.6M |
$3.2M |
|
NET IMPACT |
$0 |
$0 |
$0 |
$0 |
$0 |
Quantified (non-$) and qualitative impacts
Positive impacts
For designated under-served rural and remote communities outside of provincial capitals, CMAs and CAs with a core population of less than 50 000:
- Increased number of doctors, nurses and nurse practitioners working in rural and remote communities
The regulatory amendments are expected to increase the number of family physicians, nurses and nurse practitioners working in rural and remote communities. While there are many reasons for doctors and nurses to work in rural and remote areas, research demonstrates that monetary incentives are an important factor in recruiting doctors and nurses to these communities.footnote 17footnote 18 Research also demonstrates that providing financial incentives has allowed communities to strategically recruit healthcare providers and that financial incentives have a positive effect on the recruitment of doctors and nurses when compared to communities that did not provide financial incentives.footnote 19footnote 20
- Improved access to healthcare providers
Increasing the number of health care providers working in rural and remote communities is also expected to help improve access to health care services. Rural and remote communities face unique challenges across the various social determinants of health.footnote 21 In particular, lack of access to healthcare providers results in unmet healthcare needs, including lack of preventive and screening services, and treatment of illnesses. Access to a regular primary health care provider is generally associated with better health outcomes and providing local access to health care helps address the health problems of the local population.footnote 22footnote 23 By increasing incentives for family physicians, nurses and nurse practitioners to work in rural and remote communities, the regulatory amendments will result in better health care services and continuity of care.
The literature examined suggests that the increased number of doctors and nurses in rural and remote regions could have an influence on health indicators. Research from the United States shows that increasing the supply of primary care physicians by one unit per 10 000 people is associated with improved health outcomes in the range of 0.66% to 10.8% and an average mortality reduction of 5.3%.footnote 24 Similarly, research on Canadian health expenditures finds that increases in health spending can positively impact a variety of health indicators.footnote 25
The monetized benefits exclude qualitative benefits to Canadians living in rural and remote communities and Canadian society, such as improved access to health services and, as suggested by the evidence in the literature reviewed, better health outcomes. As a result, the benefits of implementing the regulatory amendments likely outweigh the costs.
Small business lens
Analysis under the small business lens concluded the regulations will not impact Canadian small businesses.
One-for-one rule
The one-for-one rule does not apply to these regulatory amendments, as there is no change in the administrative burden on businesses.
Regulatory cooperation and alignment
The regulatory amendments are not related to any commitment under a formal regulatory cooperation forum. The CSFA Program has consulted with P/T stakeholders and they have been supportive of the measures. In addition, while QC, NU and the NWT do not currently participate in the CSFA Program, these P/Ts could still benefit from the CSL forgiveness benefit for family physicians, nurses and nurse practitioners. Eligible health professionals that received a CSL from a participating P/T in the CSFA Program are still permitted to benefit from CSL forgiveness if they worked in an under-served rural or remote community in QC, NU or the NWT.
Increasing the generosity of the CSL forgiveness benefit is aligned with P/T strategies to increase health care capacity in rural and remote communities. In 2022 provincial budgets, AB,footnote 26 SKfootnote 27 and ONfootnote 28 each committed to making significant investments in the recruitment and retention of physicians and nurses in rural and remote areas.
In addition, the provinces of SK and BC also have loan forgiveness programs in place that target health professions. Under SK’s loan forgiveness program, nurses and nurse practitioners receive forgiveness of one fifth (20%) of their outstanding SK student loan debt, up to $4,000 annually, for up to five years, to a maximum of $20,000. Eligible communities in SK must also have a population of less than 10 000. Meanwhile, BC’s loan forgiveness program forgives student loan debt for eligible professionals working in an under-served community to a maximum of 20% of the BC portion of a Canada-BC integrated student loans for up to five years. Under BC’s program, eligible occupations include nurses and physicians, as well as other professions, such as midwifery, occupational therapy, physiotherapy, and respiratory therapy. In addition, loan forgiveness is available to certain occupations that work with children, such as school psychologists and teachers of the deaf, hard of hearing or visually impaired.
Meanwhile, several P/Ts, such as NL, NS, PEI, QC, NU and the NWT, also offer broad loan forgiveness programs not targeted at specific occupations.
Strategic environmental assessment
In accordance with the Cabinet Directive on the Environmental Assessment of Policy, Plan and Program Proposals, a preliminary scan concluded that a strategic environmental assessment is not required.
Gender-based analysis plus
The regulatory amendments will support eligible borrowers and in a broader sense the greater Canadian population. The gender-based analysis plus (GBA+) did not identify any unintended adverse, disproportionate or differential impacts resulting from the regulatory amendments.
Women are expected to particularly benefit from the enhancements to CSL forgiveness. In 2020–2021, approximately 83% of CSL forgiveness recipients were female and program data from the same year found 90% of nurses receiving the CSL forgiveness benefit were women. In 2020–2021, family physicians and residents in family medicine only made up about 18% of CSL forgiveness recipients; of this 18%, 54% were women.
In addition, the enhancements to the CSL forgiveness benefit are expected to particularly benefit borrowers between the ages of 18 to 29 years old. According to program data, 74% of individuals with outstanding CSLs are under 35 years of age. Literature examined suggests that financial incentives can play a greater role in motivating younger physicians (i.e. younger than 45 years of age) to move to a rural area than in the case of older physicians.footnote 29 Therefore, the regulatory amendments are expected to benefit more borrowers under the age of 35 compared to other age groups, as these beneficiaries are more likely to be repaying their loans and more likely to be influenced by financial incentives than older physicians.
Rural and remote communities in Canada are also expected to particularly benefit from the enhancements to the CSL forgiveness benefit. Rural and remote communities have historically faced barriers to health care access, including a shortage of primary care providers, increased travel time to health care facilities and economic hardship. These barriers existed before COVID-19 and have worsened since the pandemic.footnote 30 In conjunction with other initiatives to increase health care capacity in rural and remote communities, the enhancements are expected to help support increased access to primary health care services in these communities.
Implementation, compliance and enforcement, and service standards
Implementation
The regulatory amendments will come into force upon registration.
The assessment of eligibility for the CSL forgiveness benefit will remain unchanged. Applicants will continue to be required to submit an application for the CSL forgiveness benefit within 90 days of the completion date of their service (one year after the starting date).
Once the regulations are in force, the enhancements will be available to a qualifying health professional who has completed a year of work. For example, if the regulatory amendments come into force on November 1, 2023, a qualifying health professional will be eligible for the benefit if they started a year of work in an under-served rural or remote community on or after November 1, 2022.
Existing F-P/T and stakeholder forums will be used to notify all stakeholders of the changes. Social media, web platforms and news releases will also be used to communicate the new measures to student borrowers and other interested stakeholders.
The effect of the enhancements to the CSL forgiveness benefit will be incorporated into existing performance measurement and evaluation mechanisms. ESDC’s Evaluation Directorate recently completed an evaluation of the CSFA Program in March 2021.footnote 31 In addition, the ESDC Evaluation Directorate is completing an evaluation of the CSL forgiveness benefit that is expected to be released in 2023–2024.
Compliance and enforcement
To support effective management and accountability to students, the CSFA Program will continue to be monitored to ensure effective program performance and integrity. The Canada Student Financial Assistance Act (CSFAA) requires the Minister of Employment, Workforce Development and Official Languages to table an actuarial report at least once every three years. This report provides an estimate of program costs and revenues, a 25-year forecast of future program costs and revenues, and an explanation of the methodology and actuarial and economic assumptions used to produce the figures presented in the report. The CSFAA also requires the Minister to table in Parliament an annual report on the CSFA Program, which provides detailed statistics on the program (including the value of the portfolio) and outlines key objectives, initiatives, and accomplishments achieved over a given academic year.
The CSFAA provides authority for the CSFA Program to ensure that loan forgiveness is not granted to student borrowers who are not eligible. Subsection 17(1) of the CSFAA provides for a fine of up to $1,000 for student borrowers who knowingly provide any false or misleading information, including by omission, in an application or other document. Also, section 17.1 of the CSFAA allows for any such student borrower to be denied additional student financial assistance, as well as certain other CSFA Program benefits, including, but not limited to, interest-free periods or repayment assistance periods.
Contact
Erin Hetherington
Director
Program Policy Division
Canada Student Financial Assistance Program
Learning Branch
Employment and Social Development Canada
200 Montcalm Street, Tower II, 7th Floor
Gatineau, Quebec
K1A 0J9
Email: Erin.Hetherington@hrsdc-rhdcc.gc.ca