U.S. Sen. Thom Tillis says the Senate’s current megabill would effectively end Medicaid expansion in North Carolina — and that’s the main reason he’s opposing the bill.
Tillis’ decision to vote against the bill triggered a primary threat from President Donald Trump, which was followed by the senator’s Sunday announcement that he won’t run for re-election next year.
Tillis explained in a floor speech Sunday evening that he’d reached out to North Carolina legislators, the N.C. Healthcare Association, and Gov. Josh Stein's administration to gather estimates on the bill’s Medicaid impact locally.
He said all agreed that the bill’s cuts to Medicaid funding would mean more than 600,000 people in his state would lose healthcare. That’s because when the Republican-led state legislature enacted Medicaid expansion in 2023, it included a provision that would automatically end the program if the federal government stops covering 90% of its cost.
“So what do I tell 663,000 people in two years or three years, when President Trump breaks his promise by pushing them off of Medicaid because the funding is not there anymore?” Tillis said. He estimates that overall, North Carolina could lose $26 billion in healthcare funding.
Tillis warned his fellow Republicans that the move could damage their party’s election prospects. He argued that a broken promise on Medicaid would be similar to former President Barack Obama’s claim that "if you like your health care plan, you can keep it" under the Affordable Care Act. Tillis says Obama’s statement led to GOP victories.
“Republicans are about to make a mistake on health care and betraying a promise,” he said.
North Carolina’s other U.S. senator, Ted Budd, is supporting the changes to Medicaid. “Nobody is cutting Medicaid,” he said in a post on X. “We're making it sustainable for those it was originally intended for.”
Budd argues that the federal government is paying too much to serve the 663,000 people in North Carolina who qualify for Medicaid under expansion.
“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,” he said.
Other healthcare funding affected too
The N.C. Healthcare Association, which represents the state’s hospitals, is also sounding the alarm about the bill’s impact on another health care program enacted alongside Medicaid expansion.
The Healthcare Access and Stabilization Program, or HASP, unlocked federal funding for hospitals for Medicaid-covered care, which meant that the hospitals could cover the state’s cost to expand Medicaid.
Because the Senate’s bill limits taxes on health care providers, “the benefit of HASP in North Carolina is virtually eliminated,” the N.C. Healthcare Association said Saturday. “This would be a loss of up to $6.5 billion for North Carolina, nearly $5 billion of which is federal funding, that the state is unlikely prepared to fill — and could only do so by deeply cutting from other necessary priorities.” The group urged lawmakers to approve the Medicaid provisions from the House’s version of the megabill.
An analysis released by Tillis’ office says the loss of HASP money would have a devastating effect on rural healthcare.
“At least one rural hospital utilizes the funds to stabilize and recruit OB/GYN and maternity care in their area as their workforce is aging and retiring,” the analysis said. “Additionally, one rural hospital has begun providing oncology services in their area with their HASP funds to ensure cancer care can be provided closer to home. This is key to North Carolinians living in this rural county.”
Budd voiced skepticism of the HASP model in a social media post. “Through a budgeting gimmick, states have required medical providers to pay the state's fair share of Medicaid costs,” he wrote. “Why would they agree to do this? Because providers get this money back — often in spades. States leverage this to receive as much as 9 to 1 federal dollars.”
NC slow to join expansion
For years, North Carolina state legislators refused to expand Medicaid under the Affordable Care Act. One reason Senate leader Phil Berger and Tillis, who was serving as N.C. House speaker, opposed it was because of concerns the federal share of funding could be cut.
Tillis alluded to that history during his floor speech Sunday. "I actually passed a law that made it illegal to expand Medicaid," he said. "Why did I do that? Because I was convinced someday we would be here, and I would have rather found a way to get more people on Medicaid at the standard (system) than having this 90-10 match and watching it disappear and taking away desperately needed health care."
The worry led to the provision in the 2023 Medicaid expansion law that ends health care to people covered under Medicaid expansion as soon as the federal funding share drops below 90%. The legislature could take action to use other funding toward Medicaid, but it's already facing a tight budget year, and House and Senate leaders haven't agreed to a spending plan yet.
Senate leader Phil Berger voiced his support of the Senate's bill on social media Saturday.
I support @realDonaldTrump’s Big Beautiful Bill and the legislature will work through any implementation issues.
— Senator Phil Berger (@SenatorBerger) June 28, 2025
The 600,000-plus recipients of Medicaid expansion are adults aged 18-64 with incomes up to 133% of the federal poverty level. Proponents of expansion said these people fell into a "coverage gap" where they didn't qualify for Medicaid but don't make enough money to pay for insurance on their own.
Former Gov. Roy Cooper spent years of his term advocating for Medicaid expansion. He's now considering a run for the seat Tillis is vacating — and the North Carolina impacts of the megabill could be a key issue in the campaign.
