Governor Spitzer’s battle with the state’s largest health care workers’ union and a major hospital association began in earnest yesterday, as the groups took to the airwaves to criticize the governor’s proposal to slow Medicaid growth. Mr. Spitzer returned fire by accusing the union and the hospitals of relying on “distortion, scare tactics, and mischaracterization.”

Facing the first large-scale attack by a major special interest group in his young administration, Mr. Spitzer went on the offensive, casting the Greater New York Hospital Association and the 275,000-member 1199 SEIU as enemies of change who suck up billions of dollars in state subsidies and deliver substandard health care.

In 2002, Governor Pataki, who was running for re-election, approved a Medicaid package that gave 1199 SEIU employees $1.8 billion in raises and benefits over three years.

“These groups — 1199SEIU and Greater New York Hospital Association — receive billions of dollars in state subsidies without proper measures of accountability for how they spend taxpayers’ hard-earned money,” Mr. Spitzer said in a statement. “Their goal is to block any attempt to reform the system.”

Mr. Spitzer is proposing to increase Medicaid spending by more than $1 billion, to $47.5 billion, and extend insurance coverage to 400,000 children. As part of his long-term plan to change the reimbursement system to direct more revenue to hospitals that treat a greater percentage of Medicaid patients, Mr. Spitzer is also proposing a freeze on fee-for-service rates and other cost-saving measures that slice about $1 billion out of the budgets of hospitals and nursing homes — equal to about 1% of their operating revenues.

He described the groups’ campaign —which includes two 30-second spots airing statewide, mailings, and door-to-door canvassing — as a “predictable response from groups dedicated to maintaining a status quo that does not work for anyone but them.”

Mr. Spitzer in his statement also made an appeal to lawmakers, whose leaders in both the Republican-controlled Senate and the Democrat-controlled Assembly are likely to try to negotiate for more Medicaid money in the final budget due April 1. The union and the association have contacted lawmakers directly, asking them to pledge to oppose Mr. Spitzer’s budget.

The governor said the Legislature faced a “simple” choice: “Will you side with the same old demagoguery of ‘everyone but me.’ … Or will you push for real reform that fundamentally restructures the health care delivery system to finally put patients first and control exploding costs that have led to our unsustainable tax burden and the highest health care spending in the nation?”

The union, led by Dennis Rivera, and the hospital association, led by Kenneth Raske, are expected to spend millions of dollars on the campaign, tapping a $60 million joint fund called the Healthcare Education Project.

In their confrontation with the Democratic governor, the groups are using a different, less direct attack strategy than the one employed against Mr. Pataki, a Republican. In both ads, the chief target is not the governor but profit-happy HMOs and pharmaceutical companies, which are personified as content, white males lounging in a limos and staring at a computer screen displaying a bar graph of escalating revenues. The argument is that Mr. Spitzer is siding with the HMOs and the drug companies over the hospitals and their employees. The ads cleverly co-opt Mr. Spitzer’s slogan for his Medicaid budget by instructing viewers to tell the governor “to put patients first.”

The ads also acknowledge the public’s general dissatisfaction with the Medicaid program, saying Mr. Spitzer is “right to want to reform health care but he’s doing it the wrong way.”