In his first State of the State message, in 1995, Pataki said, "The Medicaid system has grown far beyond its original intent as a provider of care for the needy. Its costs have become staggering and the quality of care it provides leaves much to be desired. … Today, New York's Medicaid system costs three times as much per recipient and often delivers a quality of care inferior to the programs run by other states. We can do better and we must.''

When he made that speech, nine years ago, the cost of the program was $23.5 billion — compared to more than $42 billion this year.

That's not to say he's had no success in reining in costs. Between 1997 and 2000, when the state's economy was booming, welfare rolls were shrinking and managed-care plans were squeezing hospitals to lower rates, the number of Medicaid recipients actually fell, from more than 2.9 million to 2.73 million, and the cost went up a not-unmanageable rate of about 4 percent a year.

But then the economy turned down, the World Trade Center disaster happened, hospitals and doctors started to demand higher payments from HMOs, the cost of prescription drugs started to take off — and the state as well as New York City started to actively push people to enroll. Costs have jumped from $32.5 billion to $42.1 billion in just three years.

When the state was facing a potential budget gap of more than $11 billion a year ago, Pataki proposed $1.3 billion in health-care cuts that would have led to the loss of 38,000 health-care jobs. In response, health-care unions as well as hospital and nursing-home executives led a throng of 25,000 people to the Capitol, who in a snowstorm marched and chanted against the cuts. The Legislature rejected most of the reductions Pataki proposed.

The demonstration was led by Dennis Rivera, president of one of the most politically powerful unions in the state, the 250,000-member Local 1199 of the Service Employees International Union, who uses a huge political war chest and the energy of his members to push government leaders for more government spending on health care.

"There is no effective opposition to him,'' said McMahon of the Manhattan Institute.

Part of what makes Rivera such a powerful political figure — and Medicaid such an important issue for him — are two key facts: Medicaid accounts for about one-third of all health-care spending in the state; and the 1.17 million-worker health-care industry, where employment grew by 1.7 percent last year, is one of the few areas of the state economy that is adding jobs.

So any substantial cuts in Medicaid would mean the loss of thousands of jobs that are protected by powerful labor unions.

One of those jobs belongs to Natalia Mhlambiso, a South African native who is a registered nurse and works for the Visiting Nurse Service of New York.

One recent afternoon, she traveled to East Harlem to look after a 72-year-old man suffering from emphysema and a 70-year-old woman who, after a series of strokes, has lost the use of her legs and most use of her arms.

The woman whom Mhlambiso visited, Doris Hasell, a mother of seven, spent some time in a nursing home after her first stroke about five years ago but, as Mhlambiso cleared her breathing passages in her apartment, she talked about how much more content she is now.

"There's no place like home,'' she said.

New York has by far the largest Medicaid-financed home-care program in the country. Taxpayers are spending about $3.7 billion on it this year. But at an average cost of $120 a day, it is far cheaper than nursing homes.

One of the major challenges for those who want to reform the state's Medicaid system is to care for more people at home, like Hasell, and fewer in institutions, like DeWitt. It would be both cheaper and better for the patients, advocates argue.

"We need to deliver more services at home," said Daniel Sisto, head of the Healthcare Association of New York, a lobbying group.

Sources: Business Council of New York State, state Association of Counties, Attorney General Eliot Spitzer, staff research