When, in the 1990s, Emily Lengen chose a career working with babies and toddlers with disabilities, it felt like a chance to earn decent money while doing important, challenging work that she loved. Lengen, who lives near Rochester, New York, travels in person to the families’ homes — sometimes logging up to nine visits in a day — teaching children with developmental delays and disabilities how to play with toys and socialize with siblings and peers; and coaching their parents in how to help the babies grow and thrive.
Yet as her 30th anniversary working as a special education teacher for the New York State Early Intervention Program approaches, Lengen increasingly feels disillusioned: still happy in her work, but distraught about remaining in what may be the only profession in New York that hasn’t gotten a substantive raise — in absolute terms, much less adjusting for inflation — in three decades. Any modest rate increases the state’s early intervention providers (which include teachers like Lengen and a range of therapists) have benefited from, were generally counterbalanced by cuts. “As a 30-year veteran with a master’s degree, I am working twice as hard as when I started in early intervention, and making less now,” Lengen said.
Over the same time period, New York’s hourly minimum wage has more than tripled, from $4.25 in the mid-’90s to more than $15 now. The average salary for public school teachers jumped from about 48,000 in the mid 1990s to about $95,000 in 2023-24, according to the National Education Association. And, while New York state data is elusive, nationally the average compensation package for chief executives climbed from nearly $6.4 million in 1995 to more than $20 million in recent years.
The Economic Policy Institute’s Elise Gould, who researches wages and economic inequality, said she knows of no precedent for a job where the absolute pay hasn’t risen in 30 years. “It’s a little hard to believe,” she said.
Early intervention providers deliver critical services including speech, physical and occupational therapy to children from birth through age 3 who have a range of developmental delays and disabilities. When done well and promptly, research shows that it can reduce the need for costly special education services, as well as other public assistance down the road, and improve life outcomes.
Early intervention systems are state-led and designed, and the mix of specific funding sources can vary considerably across states. New York relies on a combination of private insurance dollars and county, state and federal funding, including Medicaid, to serve approximately 70,000 children.
Emily Lengen, a veteran special education teacher working in New York’s early intervention program, on a recent visit to one of her clients in her home. (Emily Lengen)
Many of the therapists, special education teachers and others who provide early intervention services are not salaried employees. In New York, they are paid a fee for service rate that is set by the state. After providing the service, they submit a claim for reimbursement and are paid either by Medicaid if the child is eligible, or by the state, which draws from a combination of funding streams.
For many services, including the specialized therapy and support that Lengen provides, that rate was higher in the 1990s when early intervention began in New York state, than it is today. For instance, a 2024 report published by The Children’s Agenda, a Rochester-based group which has advocated for increased pay for providers over the years, found that a standard visit — at least 30 minutes — was reimbursed at a statewide average of $79 in 1994, compared to $69 in 2022. Brigit Hurley, chief program officer at the group, said that according to a recent staff analysis, “reimbursement rates would need to increase by 240% to have the same spending power as it did when the early intervention program began.”
People in the field say it’s typical for therapists, who all have at least a master’s degree, to earn between $50,000 and $70,000 a year — far less than they could make doing the same work in a different, often less stressful, setting.
“If you were a governor or a legislator and were stuck at your 1995 salary, would you stick around for that job?” said Amanda Wilbert, the regional director of Step by Step Pediatric Services in Rochester, an agency that coordinates early intervention services. Two of the young occupational therapists Wilbert oversees left earlier this year for jobs doing the same work in a nursing home. The positions came with an approximately $30,000 raise, bringing their pay from about $60,000 to $90,000, and better benefits, Wilbert said.
Partly because of that pay-induced exodus, advocates say that New York ranks last of all states in terms of timely delivery of early intervention services to kids. In the spring of 2024, after a long, hard battle by advocacy groups, a pay boost appeared to be on the horizon. The state approved a 5% rate increase for in-person early intervention services, plus an additional 4% for those working in rural and underserved parts of the state. But so far, therapists have yet to see that bump, with final approval pending with the federal Centers for Medicare & Medicaid Services. (In late September, federal officials did approve the 4% for those working in underserved areas, but it’s unclear when it will be implemented, or how many providers it will reach.)
How Medicaid Cuts Could Impact Early Intervention for Young Children
Meanwhile, with the Trump administration having recently slashed Medicaid by trillions of dollars, the long-delayed full increase might not get the federal stamp of approval for the indefinite future, according to advocates, and the system will likely continue to bleed providers. Said Lengen: “In the end these kids are losing out, and it’s a very vulnerable population.”
New York is hardly an anomaly. Other states — both red and blue — report similar challenges, including Texas, Rhode Island and Illinois. In Illinois, a 2024 deep dive into the finances and pay in early intervention found that the median annual income for independent contractors in the field was about $71,000, which is significantly lower than typical incomes for similar roles in the state. According to the Bureau of Labor Statistics, the median annual wages for a speech and language pathologist in various settings in Illinois is about $88,000 and for physical therapists, it’s about $104,000. As in New York, that disparity has caused many early intervention professionals to leave the field, with the number of speech therapists in the program dropping 13% between 2018 and 2023, and physical therapists falling 16%, according to the 2024 report.
The problem is only likely to worsen nationally, said Elisabeth Burak, a senior fellow at Georgetown’s Center for Children and Families. States will struggle to raise rates for any service that’s funded partially through Medicaid, she said.
No one knows exactly what the fallout from the Medicaid cuts will be, but untold numbers of families with children could be booted off the program. At the same time, the amount of money states get for Medicaid-eligible families could shrink, forcing state policymakers to make tough decisions about how to make up the losses. “States are already having a hard time but it has the potential to get a lot worse,” said Burak.
New York’s early intervention program was created in 1993 and it’s had a rocky history with compensation. The first significant rate decrease occurred in the late 1990s, according to the state data compiled by The Children’s Agenda. Rates stayed the same for over a decade. And then in 2010 and 2011, there were two cuts, said Brigit Hurley, chief program officer at the group.
A few years ago, in 2022, some providers in New York, including physical and speech therapists, saw a 5% increase. But that “didn’t bring the pay above when the program started,” said Hurley. And the across-the-board pay bump that the state legislature and governor authorized for in-person services in 2024 brought hope to many providers, but without final approval at the federal level for the 5% bump, they still haven’t seen the increase.
“I’ve had providers tell me they are getting paid less now than when they graduated 30 years ago with a master’s degree,” said Hurley. “It’s a really dire situation.”
I’ve had providers tell me they are getting paid less now than when they graduated 30 years ago with a master’s degree.
Brigit Hurley
Much — and on particularly bad days, most — of early intervention professionals’ work is uncompensated: travel time to homes; “no shows” when the families aren’t available; lesson planning and other preparation for the sessions; communication with families between visits; equipment and supplies; mandated annual continuing education sessions; extensive reporting that’s required on each case.
“This year and last year … I come home after seeing four to nine kids and I’m at the computer for two to three hours doing reports,” Lengen said. “With [26] kids on my caseload, that’s a lot of reports to do.”
Lengen, 62, graduated in 1985 with a bachelor’s degree in special education and, a few years later, earned a master’s in reading. She worked for nearly a decade in K-12 classrooms, and then shifted to early intervention around the time the program debuted in New York in the 1990s. Initially, she worked for an agency and made a full-time salary. But she left the staff position in 2004 when the agency stopped providing early intervention services. “The pay was decent, but it was a big learning curve on my part,” she said.
Today, Lengen works in homes and child care programs, supporting kids and their caregivers, often coaching the latter on how to manage challenging behaviors. She also winds up filling gaps left by other holes in the intervention system, like supporting children with autism in their sensory development. “I end up doing a lot of sensory play since most of the kids don’t have occupational therapists — there aren’t any available,” she said.
Since she began working independently over 20 years ago, the demands of the job — including higher caseloads and increased reporting requirements — have increased but the stagnant pay hasn’t come close to keeping up with inflation and the rising cost of living. There were the two pay cuts across the board — 10% in 2010 followed by another 5% in 2011 — and, nearly a decade later, special educators were overlooked when some therapists got the modest bump in 2022. “At that point, I was really thinking long and hard about leaving early intervention,” Lengen said.
Despite her financial advisor’s recommendation that she at least consider working in a school district, Lengen decided to stick around, noting that she loves the work and didn’t want to start over late in her career. But many other early intervention providers have left the field.
When Sandra Ribeiro started providing physical therapy through early intervention in 2000, she said, “we were some of the highest paid across our profession, and we had support.”
At that time, all of the early intervention providers involved in a child’s case would gather monthly with each family to coordinate services and brainstorm what could be changed or improved. But that practice began to erode more than a decade ago when the state stopped paying professionals for the time spent in those meetings.
Ribeiro has a doctorate in physical therapy, and is fluent in five languages (Portuguese, French, Italian, Spanish and English). That’s a huge asset in the many multilingual homes she’s visited. She points out that providing in-home therapy to an incredibly diverse group of families — some cooperative and supportive of her efforts and others less so — is a complicated assignment.
“It requires a high skill level to be able to work with a very young child to start with,” she said, “and then you have to be able to incorporate the family.” Still, she found it deeply rewarding to see the progress a child could make when delays and challenges were addressed early in life. One grateful family still sends her a Christmas card every year, even though the “child” she helped is now 24 years old. “I don’t think you can get that in other settings — you’re not a fixture of the home,” she said.
Over the years, not only did Ribeiro’s pay fail to rise significantly, but it also became much more difficult to get reimbursed for her work at all. “If you forget to do one little thing on your paperwork it gets kicked back and it can be months before you get paid,” she said. Over the last decade, there have been some isolated but significant cases of fraud in the program, and that has led to stepped up reporting requirements and auditing for all.
A lot of therapists have been so demoralized they shy away from early intervention even though in our hearts we would love to still be in those homes.
Sandra Ribeiro
On weeks when everything went very smoothly — and there were no last-minute cancellations or no shows — Ribeiro would clear $1,500. But many weeks there were hiccups beyond her control that cut into that income. Two and a half years ago, she decided she had had enough and left early intervention for a job teaching physical therapy at LaGuardia Community College in New York City. Most experienced therapists she knows have also left the state-run program over the years, Ribeiro said.
“We all know that when you go into health care it’s not for the money,” she said. “But you have to be able to say to yourself, ‘My work is worth something.’ And a lot of therapists have been so demoralized they shy away from early intervention even though in our hearts we would love to still be in those homes.”
Since Ribeiro left the field, the payment issues have only gotten worse. Over the last year, scores of New York providers have faced delayed or missed payments because of glitches with the state’s new data and payment portal, the EI Hub.
Meanwhile, across New York state, countless families no longer have access to critical therapies because of the steady attrition from the field. Rural families have been especially hard hit. In the remote Tri-Lakes region of northern New York, Katie Wheeler’s 3-year-old daughter missed months of early intervention services that she was entitled to because of a shortage of providers.
Katie Wheeler’s daughter looks at a book with the special education teacher.(Katie Wheeler)
Diagnosed with autism around the age of 2, the child qualified for in-home special education services and speech therapy. In early 2024, she was assigned a special ed teacher who came to her home two or three times a week, but a few months later, when the state dissolved the agency providing those special education services, the toddler lost access to that support for about a year. She received speech therapy virtually last winter; in-person early intervention sessions weren’t an option due to the lack of providers in the region. The virtual sessions went surprisingly smoothly for the toddler. “It worked so well, I was surprised,” said Wheeler. “They really pour their heart into what they are doing, and she grew immensely.”
At the start of 2025, however, New York’s virtual early intervention providers learned that they would be getting a sizable pay cut. Ironically, the rate cut for telehealth services, as they are officially known, was initiated to free up funds for the pending 5% increases for in-person services in the state, which is still awaiting approval from the federal Medicaid office.
Wheeler’s daughter’s speech therapist, along with most other virtual providers in her county, promptly quit, which Wheeler says she entirely understands. “We were not given anyone else because there was no one else to be given,” she said. The family did pay out of pocket for some speech therapy, but in the six months that her daughter went without early intervention services over the winter and spring, Wheeler said she could see significant regression. When she was in speech therapy, the child could name an animal when shown a picture, and make its sound, for instance; but without services, much of that language slipped away.
Katie Wheeler’s daughter meets with her special education teacher at the family’s home. Finding consistent early intervention services was a huge struggle for the family given the shortage of providers.(Katie Wheeler)
When the girl became old enough to receive special education services through school, there was another months-long delay to get services set up. In an effort to access more robust special education services, the family recently moved to nearby St. Lawrence County. Wheeler knows that most families would not be able to take such an extreme and expensive step.
With the recent loss of virtual providers, she said, “there are going to be so many kids without anything.”
Research has shown that timely receipt of early intervention, in the years when the brain is developing far more rapidly than at any other point, is critical to child development, and can improve life outcomes far down the road. Many children who receive early intervention do not require special education services in kindergarten, including slightly less than half of those with developmental delays, according to one 2007 study.
When delays and challenges aren’t addressed in the early years, they show up — often aggravated — in schools, where there’s rarely the time and resources to address them. “Kids are going to preschool and kindergarten with lower skills than ever,” said Amanda Wilbert. “They’ve never gotten services, and they desperately need them.”
There are many reasons, advocates say, that it’s been such a long struggle to increase pay for early intervention providers in New York. The isolated instances of fraud have been cited by some state officials as a reason for not investing more, said Hurley.
But the unprecedented rate freeze — which long predates the fraud — also speaks to the societal and political invisibility of babies with developmental delays and disabilities, according to early childhood advocates. And it speaks to the invisibility of an overwhelmingly female labor force whose work occurs largely in the private space of the home.
For now, with the slashes to Medicaid, the push to increase rates in New York is on the back burner, although it is not totally off the table. Hurley and others say they remain committed to advocating for changes that will improve the system, including studying alternative models for delivering services.
Lengen said that many months ago, she stopped looking for the 5% rate increase promised a year and a half ago to finally provide a small boost to her income. “At some point, you stop believing that it’s going to come,” she said.
But unlike so many others, she has no plans to go anywhere. “I hate the fact that the state and county don’t think we are worth giving money to,” she said. “But I love the job and the families,” she added, noting the joy that comes from teaching and playing with the littlest learners on their level.
“I will work in early intervention until the day I can not get up off that floor.”
