The Coopérative de Santé de Québec (1944-1945)
The founding meetings provided the cooperative with bylaws and an operating framework that stood the test of time, i.e., after various preliminary versions were considered and following animated debates as the cooperative was being implemented. The first bylaws that mention the "Coopérative médicale de Québec"1 or, later on, the "Coopérative de Santé de Québec",2 are astonishing in terms of the wide-ranging powers assigned to the members. The first version provided for regular meetings in September, December and June, in addition to the annual general meeting.3
Cooperation with a practical approach
According to the bylaws, the annual general meetings would be the final forum for disputes; they would also decide how any surpluses would be used. In addition, a petition signed by 5% of the membership would trigger a referendum on a member-proposed topic. Clearly, despite their highly democratic character, such procedures would have hampered and complicated the cooperative's operations. This shortcoming was quickly corrected: the second version of the bylaws makes no mention of referendums or "regular" meetings,4although it does provide for general meetings. The third and final version, however, did away with special general meetings altogether. The annual general meetings continued to play a decisive role, particularly as regards decisions about how surpluses would be used.
In all of the versions of the bylaws, participants at the general meetings retained the power to elect the cooperative's directors (referred to as "administrators" in the second and third versions) and the members of the monitoring committee. Initially, the election procedure was not completely defined;5 later, secret ballot voting was adopted and proxy voting was prohibited. Directors could be re-elected, while new candidates were required to enter their names in the running prior to the election meeting.
The "social capital" (or share capital) was divided into $5 shares. All shareholders were entitled to call themselves members of the cooperative. Each member was required to acquire at least five shares over a five-year period, although no one could hold more than 40 shares.6
This financial structure facilitated the participation of the less fortunate without preventing the well-to-do from investing more. It was significant, however, that individuals who held a larger number of shares did not exert more power over the cooperative since the "one person, one vote" principle prevailed. This rule was also applied despite the problems it raised in the case of group or family memberships. Initially, the idea had been floated of granting two votes per member family,7 which would have enabled husbands as well as wives to vote. This idea was eventually shelved and the "one person, one vote" principle was upheld for each member.8
The bylaws also set out the powers of the cooperative's various constituent bodies.9 The board of directors was in charge of hiring staff and also had the power to create special committees; it reported to the general meeting and implemented the decisions it adopted. The monitoring committee was responsible for business operations, while the general manager oversaw non-medical personnel and finances (the general manager reported to and served on the board of directors, although solely on an advisory basis). The medical director was in charge of professional relations with doctors and also served on the board in an advisory capacity (the medical committee reported to the medical director).
Based on the above, it is safe to conclude that the board of directors was predominant, although it remained subject to decisions approved at the general meetings.
These bylaws thus enshrined democratic values in line with traditional cooperative principles.
At the same time, medical professionals retained their autonomy. The fee schedule for doctors at the cooperative was proposed by the medical director, who was also a doctor. In addition, a provision in the bylaws formally guaranteed this autonomy: "It is understood that the Coopérative de Santé de Québec does not practice medicine. The cooperative is not authorized to regulate or monitor professional relationships between doctors and patients, nor is it authorized to intervene in said relationships under any circumstances."10 This was an important and delicate issue; the way it was resolved was unequivocal.
The bylaws also stated that employees of the cooperative had to be members.11 This requirement gave the staff a certain measure of control when attending the general meetings. In fact, the employees, due to their small numbers, were unable to form a strong enough lobbying group to single-handedly determine the outcome of decisions adopted at the meetings. Furthermore, the non-medical staff 's pay and working conditions were determined by the board of directors independently of the general meetings.
Focusing on prevention
Prevention was the cornerstone of the services provided to members, adhering to the proverb "An ounce of prevention is worth a pound of cure". Indeed, the fees for an annual medical exam at a member's workplace or home (house calls were restricted for fear of abuse) were the first to be covered.12 The annual contributions were set at $31.20 for families13 and $18 for individual subscribers.
In order to improve the cooperative's financial viability, a number of eligibility restrictions were introduced. For the most part, these covered cases in which the presence of disease was too obvious (this also served to reduce shared risks). It was also clear that many people, despite their relative familiarity with the principles of insurance, only sought help when their state of health was seriously impaired.
Although members of the public remained less aware of health insurance and its practices, they knew where they stood on the question of nationalism. French-Canadian nationalism played a central role within various Quebec institutions, and the cooperative was no exception. The initial bylaws even made explicit reference to that reality. Upon adopting the name "Coopérative de Santé de Québec", the organization declared that it was founded by francophones; French was the only officially recognized language.14 Expressed in such undiplomatic terms, this provision might have raised obstacles for many clients, including some French-Canadian groups employed by anglophone companies; it was thus eliminated from the third version.15 It turned out to be the right decision: for one thing, overly zealous nationalism would have limited the cooperative's range of action. In addition, eliminating the provision did not stop the cooperative from playing the nationalism card in dealings with groups that had such leanings. Indeed, the founders' ties with the Ordre de Jacques-Cartier may have initially shaped the cooperative's support for unilingualism.
A number of key points emerge from an analysis of Dr. Tremblay's proposed project, as well as from the interim committee's proposals and the articles and bylaws governing the cooperative. For example, the broad principles set forth by Dr. Tremblay are visible at each stage of the implementation process. As previously noted, starting with the first meeting of the interim committee, emphasis was placed on democratic oversight, preventive services and doctors' autonomy; these principles are all addressed in the cooperative's bylaws. In fact, the numerous additions to the bylaws (as well as the differences between the three versions) have more to do with practice-related requirements than with a redefinition of the core principles.
It was during the meetings of the interim committee that the group insurance formula was adopted. At the outset, this was designed to ensure a rapid expansion of the client base; it went on to become an important mechanism for improving the living conditions of workers at many different companies.
Flyer entitled "Maintaining your health for 2 cents a day"
When it was founded in April/May 1944, the Coopérative de Santé de Québec was underpinned by strong core principles and democratic structures; however, it was not yet open for business. In order to offer the required services, the technical and administrative components of the organization had to be thought out and put in place. Funding sources were virtually non-existent, notwithstanding the contributions of a handful of families (most of whom were Dr. Tremblay's patients). There is no documentary evidence of funding from any companies or other organizations.16
To make up for these material constraints, the first organizers had to pool their resources. The cooperative itself was set up in the home of treasurer Antoine Verret (90 Rue Boisseau). Various priorities were also identified, with advertising foremost among them. Building a clientele, no matter how small, would provide funding for the initial administrative activities; it was merely a question of recruitment. The advertising committee, made up of Léopold L'Heureux, Ben Morin and Albert Guay, met once a week to coordinate these efforts. The team put together a flyer titled "Maintaining your health for 2 cents a day", which described the services on offer and included an application form.
Due to the tight budget, the advertising campaign clearly relied on word of mouth, which works best when there is a whole neighbourhood centred around a church and a parish. In fact, the local parish premises were often the setting for the study circle meetings. The board members also attempted to raise awareness within their own spheres of influence. Meanwhile, Dr. Tremblay continued to speak out. In late 1944, he hosted a meeting of the Trois-Rivières and Chicoutimi medical societies,17 which had expressed an interest in learning more about the cooperative. He also gave a series of courses on cooperative medicine at Université Laval's Faculty of Social Sciences.
Even though the cooperative only had a small number of members, thought had to be given to the services future clients would require; in addition, essential administrative procedures had to be put in place. Dr. Tremblay made a key contribution in this regard as well. Thanks to his readings, he had become aware of the existence of numerous health insurance companies in the U.S. and Canada. Dr. Tremblay thus set off to obtain as much first-hand information as he could on the health insurance sector and its practices.18
This is why the cooperative's forms were modeled on documents issued by various English-Canadian and American companies, in particular Associated Medical Services and Group Health Coop.
By this time, the cooperative was operating at a cautious pace. As at December 31, 1944, it posted a surplus of $250.93 and had only 11 member families, for a total of 71 members (each family had various dependents).19These families were primarily drawn from Dr. Tremblay's practice, even though (at least theoretically) the cooperative's operating area since June 30, 1944, encompassed the entire Quebec City judicial district. There were only three participating doctors (Dr. Tremblay, Dr. Dorion and Dr. Deschênes). The fact that all three were paid monthly on a "per capita" basis greatly simplified the administrative process. At that time, 75% of contributions20 went directly to the attending doctor, while the remainder was earmarked for administrative expenses and various reserve funds.21
This system, however, was faced with a major problem. Dr. Tremblay, as might be expected, was very busy translating English-language documents into French, as well as leading the advertising campaign. As a result, he had little time left over to attend to his medical practice. And since most of the members were his patients, he was unable to carry the weight single-handedly. Dr. Jules-Édouard Dorion, one of the earliest participants, offered his support and stepped in for his colleague when the patients were willing. Unfortunately, the "per capita" compensation system meant that Dr. Dorion was not paid for the services he provided. Unsurprisingly, despite his dedication to the cooperative's cause, Dr. Dorion could not put up with this incongruous arrangement indefinitely.
Nevertheless, during its first two years of operation, the new cooperative stayed afloat despite its limited financial resources. It did so thanks to the dedication of the board members, backed by Dr. Tremblay's virtually unpaid labour in the areas of education and administration and by Dr. Dorion's work as the only truly active participating doctor.22 At this point, the third doctor, Dr. Deschênes, did not yet have any patients who were members of the cooperative.
The balance sheet as at December 31, 1945, provides a clear illustration of the cooperative's precarious financial position.
Summary balance sheet as at Dec. 31, 1945
|Surplus as at Dec. 31, 1944||$250.93|
|Reserves as at Dec. 31, 1944||38.39|
|Revenues (Jan. 1, 1945-Dec. 31, 1945)|
|Expenses (Jan. 1, 1945-Dec. 31, 1945)|
|Education reserve fund||19.41|
|Loss (Jan. 1, 1945-Dec. 31, 1945)||$31.72|
|Surplus as at Dec. 31, 1945||$257.60|
This table was reconstituted based on the treasurer's report to the board of directors in early 1946. It is not comparable to subsequent balance sheets. It is the only balance sheet from this period that could be found.
Survival at all costs
From the outset, the cooperative unwittingly placed limitations on its effectiveness. Although a streamlined administration helped it to survive, it did nothing to promote growth. And the efforts of Dr. Tremblay and Dr. Dorion, particularly since they were unpaid, could not continue indefinitely. In addition, Dr. Tremblay, who had been consulted by Blue Cross with a view to facilitating the start-up of its operations in Quebec, was well aware which way the U.S. was heading. In fact, Dr. Tremblay's worst fears were confirmed23 when Blue Cross informed him that it would be opening for business in Quebec City on February 1, 1945.24
The arrival of another competitor complicated the cooperative's already precarious position; Dr. Tremblay's initiative appeared doomed. Faced with the threat of failure, the cooperative was forced to change course. In a bid to shore up its position, it changed its name to "Les Services de Santé de Québec" (Quebec City health services) in December 1945.
But to ensure its survival, it would need more than just a new name.
Next chapter : Les Services de Santé de Québec (1946-1949)
- First bylaws of the "Coopérative de santé (médicale) de Québec" (Tremblay archives). Hereinafter referred to as the "first version" (manuscript).
- Articles and bylaws of the Coopérative de Santé de Québec, April 24, 1944, 14 pp., 8½˝ by 14˝ (Tremblay archives). Hereinafter referred to as the "second version". Articles and bylaws of the Coopérative de Santé de Québec, April 24, 1944, 15 pp., 8½˝ by 14˝. Hereinafter referred to as the "third version".
- First version.
- First version, p. 7.
- Second version, p. 4.
- Third version, p. 3. The second version provided for a maximum of 20 shares (p. 4).
- First version, p. 5.
- There is no further mention of this in the other versions.
- See first version, pp. 1, 3-4; second version, pp. 7-9, third version, pp. 5-6.
- Third version, p. 8, section 43 "Professional liability".
- Third version, p. 1, section 7b "Members".
- Minor surgery performed by doctors in their offices or at home was also included.
- First version, p. 11, and third version, p. 7. The second version makes no mention of this.
- Second version, p. 1.
- Third version, p. 1.
- Mention was made during the study circle meeting of a small financial contribution by the caisses populaires. There is no indication that this proposal was followed through on.
- Letters of the Société médicale de Trois‑Rivières to J. Tremblay, October 17, 1944 (1 p.), and October 25, 1944 (2 pp.), (Tremblay archives).
- Although there are no documents confirming the exact dates of these trips to New York and Toronto, they probably took place in March 1946. The correspondence with the companies in both cities dates back to 1945.
- Insofar as it is possible to determine, the initial group of members included Léopold L'Heureux (June 12, 1944), Henri Vallières (August 26, 1944), J.-A. Verret (May 22, 1944), Charles-Omer Dubé (October 5, 1944), Édouard Coulombe (July 1, 1944), Albert Pouliot (May 17, 1944), Gabriel Guimont (May 9, 1944), Arthur Drolet (July 14, 1944) and Henri‑Léon Gagnon (May 9, 1944).
- 80% until February 1, 1946 (minutes of the board of directors' meeting).
- As at December 31, 1944, the contingency reserve fund was $10.51. The education reserve and the statutory reserve were $13.94 each (minutes of the general meeting held on February 12, 1945).
- Hired on May 17, 1944 (minutes of the board of directors, May 17,1944).
- Letter from Duncan Millican, manager of the Association d'hospitalisation du Québec, to J. Tremblay (2 pp., December 16, 1944).
- Minutes of the first meeting of the Quebec City advisory committee, Association d'hospitalisation du Québec, December 14, 1944, p. 4.