RALEIGH, N.C. — U.S. Sen. Thom Tillis writes in his new memoir that before he broke with President Donald Trump on the so-called Big, Beautiful Bill, he first checked the numbers with the two most powerful Republicans in the North Carolina General Assembly.
In How to Lose Friends and Antagonize Presidents, Tillis says the first people he phoned were Senate leader Phil Berger, R-Rockingham, and House Speaker Destin Hall, R-Caldwell. According to his account, they told him the federal changes would leave North Carolina nearly $2 billion short every year for a decade.
Tillis voted no on the bill in June 2025, pointing to the risk to rural hospitals and Medicaid patients. He writes that he understood his Senate career was effectively over once he saw how the plan would squeeze the provider-tax system states use to help pay for Medicaid and push costs onto state taxpayers. Trump went on to look for a primary challenger against him, and Tillis did not seek another term.
The measure passed anyway, trimming federal Medicaid spending by $1 trillion to help cover tax cuts. Medicaid covers more than a quarter of North Carolina residents, and as many as 250,000 people in the state could lose coverage when the cuts begin in January.
Tillis also writes that he consulted Democratic Gov. Josh Stein and his administration, along with the North Carolina Healthcare Association, the state hospital group. Stein had sent Congress a letter urging a no vote. Hall and Berger, by contrast, praised the bill in public posts after it passed in July 2025, and their offices did not answer requests for comment on the book.
The book, released Oct. 6, goes well beyond Medicaid. Tillis calls his vote to confirm Defense Secretary Pete Hegseth the worst call of his career, counts federal recognition of the Lumbee Tribe in 2025 among his proudest achievements and says he backs about 90% of the policies the White House favors.
Tillis, a former speaker of the state House, also warns in the book that Republicans are on course for heavy losses in the November midterm elections.
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