The counties and City also are required to spend $7.6 billion annually to pay for the state Medicaid program. The counties’ contribution to pay for the state’s Medicaid program is the largest of its kind in the nation and estimated to be larger than all other counties in the country combined are mandated to pay for a state designed and controlled Medicaid program. In addition, counties and New York City provide hundreds of millions more annually in voluntary payments to support publicly owned and operated health facilities.