Beyond Reimbursement Rates: A Liquidity-Sensitive Household Capacity-to-Pay Framework for Reimbursement-Based Health Insurance in Morocco

Abstract Formal health-insurance coverage may fail to translate into effective access when patients must pay providers before reimbursement. This paper develops a liquidity-sensitive household capacity-to-pay framework that complements conventional ex-post financial-protection measures with an ex-ante measure of the resources required at the point of care. The framework distinguishes residual capacity to pay (RCTP), liquidity burden, final out-of-pocket burden, effective reimbursement, and the immediate financing gap. Because linked Moroccan household, health-need, provider-price, and claims data are not publicly available, the framework is illustrated through a calibrated synthetic simulation rather than used to estimate population prevalence. Sixteen household profiles combine four net-income levels with four household compositions, while sensitivity analyses vary essential expenditure, housing costs, debt service, transfers, and financing arrangements. Under baseline assumptions, a MAD 18,000 hospital bill represents 4.39 months of RCTP for a single adult earning MAD 8,000 per month and 18 months for a two-adult household with one child at the same income. Final burden after reimbursement is substantially lower, showing that ex-post protection and ex-ante affordability can diverge. Direct payment reduces the financing gap even when the final reimbursement rate is unchanged. The framework is intended as a transparent stress-testing and empirical-design tool, not as an estimate of unmet need in Morocco. It identifies testable implications for future linked household-and-claims research and for the evaluation of reimbursement versus third-party-payment arrangements.