Sen. Susan Collins said she told the White House and Republican leadership weeks ago that President Donald Trump’s signature policy bill would have to be overhauled for her to vote “yes.”

The changes that Collins wanted were never made.

Collins, R-Maine, voted “no” on Tuesday, joining all Democrats and Republican Sens. Rand Paul of Kentucky and Thom Tillis of North Carolina to oppose the bill that slashes health care and green energy funding, and extends the 2017 tax cuts. The bill — which would add $3.3 trillion to the national debt over the next decade — is now before the House, which passed a similar bill in May.

The bill passed by one vote, after the last Republican holdout, Sen. Lisa Murkowski of Alaska, voted in favor. Vice President J.D. Vance had to vote to break the tie, and it passed 51-50.

In an interview with the Press Herald on Wednesday, Collins said the cutbacks to Medicaid were especially problematic for her considering that several rural hospitals in Maine are “teetering” financially.

“I had made it clear weeks ago that I would have to see substantive, major, significant changes in the bill in order for me to support it,” Collins said. “I had made this clear to the White House, to (Republican leadership), to everybody.”

Collins had also voted against an earlier version of the bill in April because it included Medicaid cutbacks.

Collins said rural hospitals are in a precarious financial position, and she’s worried that the Medicaid cutbacks will make it difficult for them to stay open if the bill passes. Northern Light Health’s Inland Hospital in Waterville closed this year.

The Senate version of the bill contains $900 billion in cutbacks to Medicaid and the Affordable Care Act, including work requirements and changes to eligibility that makes it more difficult to maintain Medicaid eligibility.

Collins proposed a $100 billion provider relief fund to help soften the blow to rural hospitals, but that was pared to $50 billion in the final version of the Senate bill.

“I am very eager to get funding to them as quickly as possible,” Collins said.

Collins said she reduced her request to $50 billion, to be offset by increased taxes on the ultra-wealthy, hoping that would pass, even knowing that it would be insufficient to address the revenue losses to hospitals caused by the Senate bill.

“I was trying to hit the sweet spot and come up with a fund that would pass,” Collins said. “There would have been no provider relief fund in the bill if not for my efforts.”

Collins’ amendment was defeated by a coalition of Democrats and more than half of Republicans. But the $50 billion relief fund was included in the final version of the bill, although the tax on the ultra-wealthy was removed by Republican leadership.

Collins said she supports work requirements for able-bodied Medicaid recipients, but would have liked to see changes to the provisions that would allow more people to not become uninsured.

For instance, Collins said, seasonal workers who may not meet work requirements to receive Medicaid and do not have employer-provided coverage should be able to sign up for insurance through the Affordable Care Act marketplace. However, the Senate bill prohibits those who fail to qualify for Medicaid because they failed the work requirement provisions from signing up for the ACA.

“I don’t want them to fall through the cracks,” Collins said. “They should be able to get heavily subsidized insurance through the ACA.”

The Medicaid cutbacks — fueled in large part by work requirements and changes that make it harder to maintain eligibility — and cuts to ACA subsidies would result in a projected 16 million Americans becoming uninsured, including about 40,000 in Maine.

Collins said she’s also in favor of changes to the Medicaid eligibility rules that would allow more people to seamlessly maintain their Medicaid eligibility.

James Myall, economic policy analyst for the Maine Center for Economic Policy, a left-leaning think tank, said even with changes to work requirements that Collins is suggesting, it would likely still leave millions uninsured. And that would be detrimental to the financial well-being of hospitals, patients and the entire health care system.

“You can soften the blow, but the blow is still there,” Myall said.

Myall said when uninsured people become sick or injured and it makes it difficult for them to work, they can’t get the health care they need to get back to working.

“Of the millions projected to lose their Medicaid from the work requirements, the vast majority of those are already working,” Myall said. “A lot of the losses in the insured will be from paperwork errors.”

Collins also voted against the bill because she was opposed to the fast elimination of green energy credits in the energy industry.

Collins said she would have preferred a two-year phaseout of green energy credits for projects like windmills and solar panel farms. Collins said she also wanted to see federal tax credits maintained for household energy efficient heat pumps and rooftop solar panels.

Myall said the U.S. is set to lose ground to China and other countries in the clean energy industry.

“Phasing out the credits reduces some short-term harm, but over the long term we will still see the same negative effects,” Myall said.