Thom Tillis is leaving the Senate over Medicaid cuts. Here's what they'll mean for NC

The U.S. Senate’s budget proposal backed by Republican President Donald Trump could cause hundreds of thousands of North Carolinians to lose their health insurance — a scenario that could also fuel a new round of rural hospital closures.

That presented U.S. Sen. Thom Tillis, R-NC, with a political choice: Vote for the bill and risk losing his 2026 reelection bid due to backlash by angry voters, or oppose the bill and risk losing the GOP primary for daring to oppose Trump.

He took the second option but didn’t make it to the primary. After Tillis made his opposition known, Trump quickly announced he’d support a Tillis challenger in the upcoming primary. A Trump endorsement is make-or-break in the modern Republican Party. Tillis acknowledged that reality by saying he wouldn’t seek reelection after all, lamenting that Congress values “political theatre” over governing.

“In Washington over the last few years, it's become increasingly evident that leaders who are willing to embrace bipartisanship, compromise, and demonstrate independent thinking are becoming an endangered species,” Tillis wrote in announcing his decision not to seek reelection.

In a previous statement about the budget plan itself, Tillis had said he “will always do what is in the best interest of North Carolina, even when that puts me at odds with my own party.”

He invoked the estimated $1.1 trillion in cuts to Medicaid the bill would make, which Republicans proposed to help pay for the trillions of dollars more in tax cuts it also proposes. The bill will grow the national deficit by $3.3 trillion if it becomes law, according to the Congressional Budget Office.

“I cannot support this bill in its current form,” Tillis wrote. “It would result in tens of billions of dollars in lost funding for North Carolina, including our hospitals and rural communities. This will force the state to make painful decisions like eliminating Medicaid coverage for hundreds of thousands in the expansion population, and even reducing critical services for those in the traditional Medicaid population.”

What would the bill do?

Tillis had told fellow Senators in the days before the vote that the budget plan will kick more than 600,000 North Carolinians off their health insurance if it becomes law. That’s based on the language of the Senate bill, as well as an assumption that Republican leaders in the state legislature are unlikely to change state law to avoid the cuts.

Health care industry representatives say Tillis is right to be worried about what happens to North Carolina if Trump’s budget — or at least the Senate version, which still needs to pass the U.S. House of Representatives — becomes law.

“Six hundred and seventy thousand people, whose lives have been made better because of expansion, will lose their coverage the minute the president signs that bill,” Josh Dobson, a former Republican politician who now leads the North Carolina Healthcare Association, said in an interview. “So the stakes couldn’t be any higher for the people of North Carolina.”

Tillis has estimated that the bill would pull as much as $39 billion out of the state economy over the next decade, in the form of health care spending that’ll no longer happen.

Dobson said the number could actually be higher.

“That’s not waste, fraud and abuse,” Dobson said. “That’s direct services to the people of North Carolina, in danger, if the Senate version holds up.”

The key factor for North Carolina is a proposal to make state governments pitch in more money toward the portion of people on Medicaid who wouldn’t qualify under old Medicaid rules but do qualify under new rules, called Medicaid expansion, passed as part of the Affordable Care Act in 2010 under President Barack Obama. The law is more commonly called Obamacare.

The changes in Medicaid expansion opened the program up not just to people in deep poverty and their children, but also to people who are working — but just in low-wage jobs that don’t offer benefits, and which pay slightly too much to qualify for traditional Medicaid but too little to afford private insurance: Workers like waiters or people in the retail or construction industries.

When GOP state lawmakers passed Medicaid expansion into law in 2023, they wrote in language that will end the state’s expansion if the federal government ever stops paying for less than 90% of the cost. That’s exactly what the U.S. Senate budget would do, putting health insurance at risk for the hundreds of thousands of North Carolinians who have been able to buy coverage since that law passed.

The state’s other U.S. senator, Republican Sen. Ted Budd, voted for Trump’s budget and later said he was in favor of ending Medicaid expansion in North Carolina. Budd said the 600,000 people in that program aren’t who the program was originally intended to help in the 1960s, and removing their coverage will lower government spending a substantial amount.

“For patients who Medicaid was intended to serve—single mothers, disabled folks, and children—the federal government is required to cover a significantly lower portion of the cost compared to patients added to the program under Medicaid expansion,” Budd wrote on social media, adding: “We're implementing responsible reforms to Medicaid to make sure that when Americans fall on hard times, they can access Medicaid funds as intended.”

Tillis disagreed with Budd's assessment, as does Dobson.

“What the U.S. Senate is proposing will have catstrophic consequences for many years to come,” Dobson said.

Democrats in the state legislature have spent months asking their Republican colleagues to undo the language in the state Medicaid expansion law that would repeal the program if federal funding changes. They’ve cited fears that a budget plan exactly like this would be proposed by Trump.

Republican state leaders have so far resisted those calls, but it’s unclear if the U.S. Senate vote to approve the cuts could spur action.

The state legislature is currently adjourned for a summer vacation of indefinite length, and spokespeople for Speaker Destin Hall and Senate leader Phil Berger didn’t immediately respond to requests for comment.