Despite the huge Medicaid expense, the state hasn't done enough to see that the money is well spent, critics say.

"I always thought we had a bad Medicaid policy, but I discovered we have no policy,'' said Sen. Raymond Meier, R-Oneida County, co-chair of a Senate task force that explored the issue last year. "That's the problem. There's no coherent set of principles and policies that guide the system."

Meier has seen the budgetary impact up close. He wrestled with Medicaid as a county executive before being elected to the Senate.

"We decide a whole bunch of people are going to be eligible, we decide they can access a whole bunch of services,'' he said. "So we set up a system that provides those services. But no one asks questions about who's using services or why there are more hospitalizations in one county as opposed to another.''

It's no mystery where the money is going.

New York spends by far the most in the country on nursing homes and other kinds of long-term care, like home visits from nurses. It also spends the most on hospitals, in part because New York City is the doctor-training capital of the world.

Almost 10 percent of New Yorkers over 65 are either in nursing homes or getting services at home, according to an analysis by the Center for Governmental Research, a Rochester-based think tank. That's more than double the rate for the other large states the center used as points of comparison.

But those costs have been going up relatively slowly in the past several years, as new services have diverted thousands of seniors away from the homes.

What has led to the current crisis is a huge runup in the overall number of recipients, which has exploded from 2.7 million four years ago to 3.7 million now. In addition, like other states, New York has had to deal with a rapid escalation of prescription-drug costs.