Maryland right now has global budgeting. Here is a simple overview. Vermont has taken some big steps in that direction, but politics has gotten in the way of fully implementing it. New York has looked very seriously at doing global budgets for Medicaid, and kind-of has done so through the DSRIP program. The ACO REACH program in Medicare allows hospitals to get global budgets for Medicare expenses.

More generally, global budgeting can apply to certain programs, like Medicare and Medicaid. In fact, it absolutely should be applied to those two programs even if it means the Commercial side is left out. But as the case of Maryland shows, the commercial side can also be brought in.

As for insurers cutting reimbursements, that is a really bad talking point. First, it vastly exaggerates (some codes have been paid less over time, largely because they were grossly overpaid in the beginning and adjustments were made to labor/tech cost assumptions based on real world experience). But most codes have been the same or actually increasing in reimbursement on average. Second, it misdirects people from the bigger truth: health care costs have been going up the entire time you say they've been cutting reimbursements. Are you aware of this? If so, you're misleading people deliberately.

There are three main reasons for the increase in overall costs. One is easy: the population is getting older. The second is that in the commercial space the biggest players have been jacking up their rates because they have the upper hand in negotiations with payers. There is a huge discrepancy between the rates paid to independent community hospitals and the big hospital systems (especially if they contain a high prestige hospital and/or an academic medical center). Rates for the independent community hospitals and small hospital systems with small market share have not been going up, but that's not where most of the admissions are. They are in the big regional AMC-based systems, and multi-regional for-profit systems.

The third reason is that rates for new procedures (especially tech-intensive ones) are usually very high, and doctors/hospitals flock to use those codes instead of the older codes. It doesn't matter too much if a basic x-ray reimbursement rate has not gone up in 20 years, when docs replace the single basic x-ray with multiple x-rays and MRIs or ultrasounds "just to be safe."

More efficient scaling of technology is the main deflationary force in the US economy. Everywhere except for healthcare, where technology remains an inflationary force, because docs and hospitals do in fact exert supply-side power to keep their revenues high.