When Thom Tillis Went Rogue

Before his fateful vote, Thom Tillis tried to persuade North Carolina’s top lawmakers that President Donald Trump’s signature bill would severely hurt their state and party.

His own analysis showed the “One Big Beautiful Bill” would cost the state billions of dollars while virtually gutting Medicaid benefits for more than 600,000 people and posing new risks for rural hospitals and health care.

Like a lonely evangelist, Tillis showed his findings to colleagues and state leaders. He shared his concerns with Senate leader Phil Berger and House Speaker Destin Hall several times, including on the morning of a key vote.

“They’re going to have to make some tough decisions,” Tillis told The Assembly. “They simply don’t have the revenue stream to replace it.”

Hours before the Senate’s key June 28 vote to advance the bill, Tillis tried again to persuade his fellow North Carolina Republicans. But national GOP heavyweights also called them urging their public support. The latter won out.

“It was a no-brainer for me,” Berger, who faces a competitive primary next year, said in a statement to The Assembly. “I support the bill and President Trump.”

Hall said he’s “expressed my support for the Big Beautiful Bill for months, and I’m glad it’s now the law of the land.”

That night in late June, Tillis cast the first of two votes against the bill, prompting a series of heated exchanges with the president. According to The Wall Street Journal, when Trump made a final appeal for support, Tillis told the president, “I can’t f—ing do that.”

Trump jumped on Truth Social. “Thom Tillis is making a BIG MISTAKE for America and the Wonderful People of North Carolina,” he wrote.

The next day Tillis announced that he won’t seek reelection in 2026, a decision that could mark the end of a singular political career and, by opening a seat in a purple state, help determine which party controls the upper chamber.

Hours after his announcement, he took to the Senate floor.

“Republicans are about to make a mistake,” he said. “We owe it to the American people–and I owe it to the people of North Carolina–to withhold my affirmative vote until it’s demonstrated to me that we’ve done our homework.”

When the Senate passed the bill on July 1, Tillis was one of three Republicans who voted against it. That resulted in a 50-50 tie broken by Vice President JD Vance. Trump signed it into law on July 4.

Tillis believes the measure will have dire consequences for his state and his party in next year’s midterms, and could cost Republicans the control of Congress. “I told the vice president that if this bill passes, I think President Trump is likely to have two of the most miserable years of his life,” Tillis said. 

Since he won election to the state House nearly 20 years ago, Tillis has been one of state Republicans’ most successful politicians. He quickly rose to speaker just as Republicans took control of both chambers for the first time in a century, and he and Berger injected a new conservative ethos into state policy. Then Tillis was twice elected to the U.S. Senate.

But in this era of MAGA politics, few Republicans can take on Trump and survive politically, even if they think they have the facts on their side. Tillis is just the latest casualty.   

Trigger Law

To Tillis, the Senate version of the bill was a flashing warning sign.

Using data from the General Assembly’s own researchers, state health officials, and the N.C. Healthcare Association, he compiled a seven-page report that said the legislation would cost the state and its hospitals $32 billion over the next decade.

He found the Senate measure (the version eventually signed into law) could strip health care from low-income North Carolinians covered under the state’s 2023 Medicaid expansion. As of this month, that is nearly 670,000 people, including more than one in five residents in some counties. Swain County, which has the state’s highest percentage of beneficiaries at 22.3 percent, voted strongly for Trump last November.

Under expansion, the federal government pays 90 percent of the program’s cost while the state pays 10 percent, or $500 million, covered by a hospital provider tax. That tax also funds the federal Healthcare Access and Stabilization Program, or HASP, which in turn helps hospitals, particularly those in rural areas. 

“Hospitals use these funds towards facility infrastructure needs to keep doors open, preserving maternity services in rural areas, investing in their current workforce and physician recruitment, and investing in services to meet the needs of individuals and of our aging population,” the Tillis report said.

By reducing provider taxes, Tillis’ report says the new law would effectively end the HASP program. “Everybody’s getting angry about hospital systems consolidating and shutting down … in rural America,” Tillis said in an interview, “and we do stuff like this which actually accelerates the pace.”

Because the bill’s changes would reduce the money that pays for Medicaid expansion, a state “trigger” law could end the program. The N.C. Department of Health and Human Services says new work requirements, red tape, and other changes would exacerbate the loss of coverage.

“For that [$32 billion] to come out of the state, there will be consequences,” said former DHHS secretary Kody Kinsley. “There will be closed hospitals, closed providers … and people without prescriptions and checkups they need.”

Tillis spoke with Berger and Hall. He also talked with Dr. Mehmet Oz, Trump’s new administrator for the Centers for Medicare & Medicaid Services. Over the course of three calls with Oz or his staff, he asked them to “poke holes in our methodology.”

“Senator Berger was on the call when the CMS more or less stipulated that, yeah, North Carolina was going to get hit pretty hard,” Tillis said. “There was generally a consensus that our assessment is correct and the legislature’s going to have to contend with it. … If I’m Phil Berger, I’m probably rethinking whether or not I can cut [state] revenue right now.”

The proposed N.C. Senate budget would accelerate planned income tax cuts. Legislative researchers say the cuts would cost the state $2.5 billion in fiscal year 2028-29. The House’s plan does not cut taxes, which is one reason the two chambers are currently at odds over the budget, which was supposed to be enacted by July 1.

“So if I’m the speaker or the Senate leader in North Carolina,” Tillis said, “I’m actually saving as much money as I can to minimize the damage that is going to be done” by the Medicaid cuts.

Then-Gov. Roy Cooper pushed Medicaid expansion for years, but Berger resisted. Finally, in 2023, Berger changed his mind, expressing confidence that the federal government would continue to pay 90 percent of the cost. 

“This is the right thing to do, and it’s not even close,” Berger said then.

In a statement, Berger acknowledged that the Senate bill would create challenges, but that didn’t change his support for Trump’s domestic policy agenda. He said other provisions of the “One Big Beautiful Bill” would reduce those impacts.

“When the legislature expanded Medicaid,” he said, “we put guardrails in place knowing that the federal government could change the financing because the Obama/Biden scheme was unsustainable and racking up a huge debt. I knew President Trump would … rein in spending.”

Hall believes the state can deal with the cuts.

“States like North Carolina can handle the federal changes thanks [to] our fiscally responsible budgeting,” he said in a statement. “The State House budget plan will allow us to continue Medicaid services and fully implement the President’s reforms.”

One thing lawmakers could do, Kinsley said, is eliminate or change the “trigger” law that ends the expansion program if North Carolina has to spend state funds on it.

Tillis said he’s “encouraged because [legislative leaders] are seeing a path forward that’s going to be successful, and I want to see where that’s rooted in analytics. … I just don’t see it. … Happy to be pleasantly surprised though.”

New work requirements will mean extra work for already-stretched counties to make eligibility determinations, said Dr. Shannon Dowler, a Madison County physician and former chief medical officer for N.C. Medicaid.  

Medicaid isn’t the only health care change. As The Assembly reported last month, more than one million North Carolinians who buy private insurance under the Affordable Care Act could see higher premiums with the expiration of some tax credits at the end of the year.  

A report from The Century Foundation, a progressive think tank, found that average premiums for people in North Carolina covered by the ACA would rise by $672. Rural residents would see even higher increases.

In a New York Times op-ed, Larry Levitt, executive vice president for health policy at the nonprofit KFF (formerly known as The Kaiser Family Foundation), said the bill along with other changes could mean 17 million more uninsured Americans. 

“It’s not just the one-third of Americans who get their insurance through Medicaid or marketplace plans that will be hurt,” he wrote. “Changes on this scale will have ramifications throughout the health care system.”

‘They Will Go After You’

Despite his vote, Tillis said nobody should think he’s become a liberal. “I’m the same Republican I was before,” he said.

That’s what some party activists are afraid of.

“This is not a shock to any of us. This is who Tillis is,” said Michele Woodhouse, a former GOP chair of the 11th Congressional District in Western North Carolina. In 2023, she authored a censure resolution against Tillis that was approved at a state convention. “Republicans in North Carolina are counting the days until he is out of office,” she said.

Tillis had come close to flouting Trump before.

In 2017, he voted to protect Special Counsel Robert Mueller’s investigation into Russian interference in Trump’s 2016 election. In 2019, he wrote an op-ed in The Washington Post vowing to oppose Trump’s declaration of a national emergency to build a border wall, only to reverse himself three weeks later and vote with Trump.

During the Biden administration, he worked with Democrats on gun legislation, infrastructure, and immigration.

In January, on the day the Senate was to vote on the confirmation of Pete Hegseth as defense secretary, Tillis told people as late as that morning that he was a “no” vote, The Wall Street Journal reported. But after pressure from the White House and others, he became the crucial 50th vote for confirmation, allowing Vance to break the tie. (This month, Tillis told CNN that Hegseth is “out of his depth” in the job.)

Tillis also has criticized the president’s blanket pardon of the January 6 rioters. He then opposed confirmation of interim U.S. Attorney Ed Martin, a Trump appointee for the D.C. post, because Martin had defended some of the rioters. Trump replaced Martin.

Chris Cooper, a political scientist at Western Carolina University and author of the book, Anatomy of a Purple State, says the reaction to Tillis among the GOP base says a lot about the Republican Party.

“It says that the MAGA wing of the party is less of a wing and more of a center,” he said. “That MAGA is the ideology of the day in the Republican Party, and if you deviate from that they will go after you.”

Tillis’ decision not to run appears to mark the end of a political career in which he quickly rose from Cornelius town commissioner to state House speaker to U.S. senator. Despite concerns from some GOP activists, he believes he would have won again in 2026.

“Absolutely,” he said. “I believe at the end of the day I can win a primary election in North Carolina by reminding people of the body of work, beginning when I first went into the legislature and the promises we kept.”

But Tillis has warned of “enormous headwinds” he believes Republicans will face next year. Though Medicaid changes don’t start taking effect until late 2026, Tillis told CNN’s Jake Tapper he fears the results will compare to the 2010 midterms, after the Affordable Care Act was passed. Republicans captured both the U.S. House and–for the first time in more than a century–the N.C. General Assembly. This time, though, the tide would be in Democrats’ favor.

“I really do believe it could be his Obamacare,” he told Tapper.

Tillis says he’ll use the rest of his term to help Trump, not undermine him.

“I hope that over the course of the next 18 months I demonstrate once again to the president I’m trying to make him the most successful Republican president in history,” said Tillis. “I still feel compelled to do that and to help my colleagues here defeat the threat that liberal progressivism represents to this country.”

On the day of the most consequential vote of his career, Tillis had frequent conversations with his senior staff as well as adviser Jordan Shaw. But he didn’t talk to his longtime political consultant Paul Shumaker.

“If Tillis would have called me,” Shumaker said, “I would have told him he needs to support the bill. The good outweighs the bad. Probably why he did not call me.”