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New York’s Medicaid program is the most expensive in the nation, projected to cost $45 billion in fiscal year 2008-09 and to consume nearly one-third of the New York State budget. New York State can provide needy residents with better nursing home care and save about $1.2 billion annually in fiscal year 2008-2009 by changing the way its Medicaid program pays nursing homes. This report explains why the current system is wasteful, perpetuating inefficiencies and inequities without assuring high quality care, and how a better payment system might work.