My Predictions Were Right. That's Not the Good News.

I was about 80% through writing RCM 2030 when the reconciliation bill passed last year.

I put the manuscript down for three weeks.

Not writer's block. I had to rethink the forward-looking sections almost entirely, because the financial environment I was describing for 2027 and beyond was going to arrive faster and hit harder than I'd originally written. The combination of Medicaid eligibility changes, provider tax restrictions, state-directed payment rollbacks, and new CMS program integrity authority changed the timeline on several predictions I'd made.

This week, two things happened that I want to put side by side.

First: the Senate passed S. Con. Res. 33, the FY2026 budget resolution, on April 23. It sets the spending framework through 2035. More importantly, it gives reconciliation instructions to committees that are due May 15. Those committees have to find cuts. The Allowances category in the resolution shows hundreds of billions in negative numbers across the decade. That money has to come from somewhere, and healthcare is where the big numbers live.

Second: this week's news gave us three stories that are all downstream effects of exactly the policy trajectory I described in the book.

Let me walk through what the book said and what's actually happening.

Prediction 1: AI-driven program integrity would become a cost-reduction tool, not just an efficiency play

RCM 2030 said: "Expect audits that run faster, at scale, and in real time. Documentation gaps will turn into take-backs before your team ever files an appeal." It also said the AI-driven program integrity framing from Project 2025 signals a shift toward using technology to find savings in Medicare and Medicaid at scale.

What actually happened: CMS launched the WISeR Model on January 1 in six states. It uses AI to review prior authorization requests for 13 medical services in traditional Medicare, a program that historically had no widespread prior auth. Washington state hospitals reported this week that approval timelines stretched from two weeks to four to eight weeks. The University of Washington Medical System saw same-day urgent authorizations become 15-to-20-day waits. Read the Fierce Healthcare coverage here.

The contractors administering WISeR receive a portion of denied claims that are not overturned on appeal. That incentive structure is doing exactly what incentive structures do.

The book also said: "The reconciliation bill's push for standardized bills and common data formats means every payer and provider will be speaking the same language. That helps claims go through, but it also makes audits cheaper and easier for payers to run at scale."

WISeR is the live example. The infrastructure for faster, cheaper, AI-assisted denial at scale now exists in traditional Medicare. The budget resolution that passed this week creates the financial pressure to use it more aggressively.

Prediction 2: Payers would deploy AI faster than most health systems, and that gap would show up in revenue

RCM 2030 said: "Payers have been doing this longer. Their algorithms review submissions in seconds and kick back anything that does not match a policy template." The AI Billing Arms Race whitepaper I published this month went deeper on the specific mechanisms: automated policy matching, NLP-based encounter review, downcoding in response to AI scribes, bot wars in prior auth.

What actually happened: UnitedHealth Group announced this week that it is investing $1.5 billion in AI in 2026, projecting a 2-to-1 return within 12 to 18 months. A significant portion is going toward making OptumInsight an AI-first company, rebuilding legacy systems around automation. Their digital prior auth tool is showing a 96% approval rate in early months. Read the full earnings coverage here.

For context: UHG posted $111.7 billion in Q1 revenue and beat Wall Street expectations. They are not struggling. They are scaling.

The measurement gap the book described is widening. Most health systems are evaluating their own AI ROI by labor hours saved. That metric tells you what happened inside your building. It does not tell you what the payer did in response to what you sent them. Those are two completely different numbers, and only one of them connects to actual collected revenue.

Prediction 3: The rural hospital situation would get worse before the stopgap money helped

RCM 2030 said: "Stop waiting for Washington to save you. Not with this administration. This administration is all about shrinking federal funding. The $50 billion is a patch, not a fix." The book also said rural hospitals need to treat transformation funding as seed capital, not operating revenue.

What actually happened: This week, the CEO of Scripps Health said publicly that his system expects more than $100 million in annual revenue reductions tied to the reconciliation bill and that hospitals have run out of ways to cut costs. Becker's coverage here. The $50 billion Rural Healthcare Transformation Program exists in the bill, but rural hospital leaders are being clear that grant dollars must be treated as one-time catalysts, not operating income. Meanwhile the budget resolution passed this week has reconciliation cuts due in three weeks, and healthcare is the biggest discretionary target available.

The Paragon Health Institute published a report this week calling for site-neutral payments, tighter DSH oversight, repeal of ACA physician-owned hospital restrictions, and more. Coverage here. Paragon's track record on getting its wish list into legislation is real. Provider tax restrictions and state directed payment rollbacks from their previous work made it into the OBBB. The 12-point list they published this week should be treated as a preview, not a think piece.

What the budget resolution tells us that most coverage missed

S. Con. Res. 33 is not a sexy document. It's a table of numbers organized by functional category across ten fiscal years. But a few things are worth knowing if you run revenue cycle.

The Health category (Function 550, which covers Medicaid and other non-Medicare health programs) is budgeted at roughly $991 billion in 2026 and grows to about $1.28 trillion by 2035. That sounds like growth, but the Allowances category (Function 920) shows massive negative numbers across every year, totaling well over $10 trillion in cuts through 2035 that have no specific source yet. That is the hole that reconciliation instructions are supposed to fill. Committees have until May 15 to submit their proposals.

Here's the plain-English version for anyone not fluent in budget process: Congress has already agreed on how much it wants to spend. It has not agreed on where the cuts come from to get there. Healthcare is where the math is easiest to find. Medicaid eligibility restrictions, provider tax limitations, state directed payment rollbacks, and AI-assisted program integrity are all available tools. The book said they'd be used. The budget resolution confirms the pressure is real and the deadline is soon.

What to do with this

I am not a consultant, and this is not a sales pitch for a strategy engagement. But I can tell you what the organizations that are navigating this well are doing differently.

They are not reacting to policy changes after the cash flow dips. They are modeling exposure before the rule changes. They know how much revenue is tied to Medicaid, Medicare, and supplemental payments, and they update that model when things shift, not quarterly.

They are measuring AI investments against net revenue outcomes at the claim level, not against hours saved. They know what a tool costs per claim and what it collects per claim on the transactions it touched.

And they are watching the Paragon wish list, the reconciliation timeline, and the WISeR pilot results the same way they watch payer contract negotiations: as data that needs to show up in their financial planning before it shows up in their collections.

The full framework for what I think is coming and how to prepare is in RCM 2030. The measurement piece, specifically what to track on the payer AI side and how to know if your own tools are actually helping, is in the free whitepaper.

Both whitepapers are on the resources page here on this website.

Download the AI Billing Arms Race whitepaper here.

The book predicted a lot of this. I'd rather you read it and tell me I was wrong than find out in six months that I wasn't.

-- April E. Wilson

Author, RCM 2030: Strategy and Survival for Revenue Cycle Leaders