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    A voice for everyone

    A voice for everyone: A voice for everyone who can't rely on their own.

    About 5 million Americans, and 97 million people worldwide, may benefit from a way to communicate that doesn't depend on speech. A speech device with an evaluation and training costs about $10,900 at Medicare's rates, our arithmetic.

    Try it in the sliderTalk to Ryan

    Ryan K. Hertel · heyitskenton

    The problem

    What we're up against.

    • Millions without a reliable voice.

      About 5 million Americans and 97 million people worldwide may benefit from augmentative and alternative communication, from picture boards to speech devices.

    • A handful of conditions.

      In the UK, 97.8% of the people who could benefit have one of nine conditions, among them dementia, Parkinson's, autism, stroke, cerebral palsy and motor neurone disease.

    • When speech goes.

      More than 80% of people with motor neurone disease, which Americans call ALS, develop problems with speech, and one in four children with cerebral palsy can't talk.

    • Many autistic children.

      Between 25% and 30% of autistic children don't develop functional speech, or speak very little.

    • Most of the world goes without.

      More than 2.5 billion people need assistive products, communication apps among them, and in some countries access is as low as 3% of the need.

    What works

    Proven, and ready to grow.

    • A device from the start.

      In a randomized trial with 61 autistic children who spoke very little, therapy that began with a speech-generating device led to more spontaneous speech and more new words.

    • It helps toddlers talk.

      In a randomized trial with 68 toddlers who had fewer than ten words, those taught with symbols and devices built much larger vocabularies, and the devices helped their speech rather than holding it back.

    • Large effects.

      Across studies, aided communication had large effects for autistic people, and showing someone how to use their device, by using it with them, works at every age.

    • Tablets work too.

      Across 31 studies, tablet-based speech devices improved communication, and for young children learning to ask for things, picture exchange worked as well as a device.

    • Eye gaze for ALS.

      Eye-tracking devices reduce communication disability and improve quality of life in late-stage ALS, and in one small study, people used them about 9.1 hours a day.

    What a family could fund

    Where the money goes furthest.

    • Try before you buy.

      Every state runs an assistive technology program that lends devices, so families can try one before they commit. In 2025, 14,003 of the 56,451 devices lent were for speech and communication, by the states' own counts.

    • Help for people with ALS.

      Team Gleason has given more than $65 million in help since 2011, by its own count, including co-pays and loaner devices for communication.

    • Free, open apps.

      Cboard, a free, open-source app that works offline, was piloted with UNICEF's support with 125 children in Croatia, Montenegro and Serbia, where about 840,000 children could benefit.

    • Banking a voice.

      People can record their own voice before they lose it, through programs like the Nemours lab's ModelTalker, and newer neural voices sound clearer and more natural. One AI company now offers free voice cloning to people with ALS, by its own account.

    • Training the people who help.

      Many new speech-language pathologists don't feel ready to work with communication devices, and those with more varied training feel better prepared. At Medicare's rates, a training session costs $102.60.

    Honest limits

    What money can't promise.

    • Many devices go unused.

      About a third of communication systems end up abandoned, by an older estimate, most often for lack of training, support or a good fit.

    • The trials are small.

      A Cochrane review found only two eligible trials, of very low quality, and the gains in communication faded within ten months.

    • Voice banking is underused.

      In one service review, fewer than half of clients had been told about voice banking, and only one in ten were using a banked voice on a device.

    • Costly, with gaps in coverage.

      A top-tier device costs Medicare about $9,646, and an eye-gaze device can cost more than $16,000. Medicare doesn't pay for tablets that can do the same job, and may not cover devices in some settings, such as hospice.

    • New risks, thin evidence abroad.

      AI-generated voices can be misused, and US regulators now count them as artificial voices under robocall law. Only 18 studies have looked at communication devices in low- and middle-income countries.

    Hard questions

    Asked and answered.

    1. You might ask

      Won't a device stop my child learning to talk?

      Ryan

      No. In the best evidence, none of 27 cases lost speech, and 89% gained some. The gains are modest, so expectations matter.

    2. You might ask

      A third of devices go unused. Isn't the money wasted?

      Ryan

      Most abandonment comes from missing training and support, which is exactly what lending libraries and well-trained therapists fix.

    3. You might ask

      Won't brain implants or AI soon make all this obsolete?

      Ryan

      They're remarkable but early: a speech implant restored conversation for one man with ALS, and AI typing help was tested with two users. Devices help people now.

    In the slider

    See what your fortune could do here.

    A voice for everyone

    The slider prices this cause with these numbers:

    • A speech device with an evaluation and ten training sessions costs about $10,900: our arithmetic from Medicare's rates.
    • The whole need here is everyone in America who may benefit from a way to communicate beyond speech, about 5 million people.
    • Many people do well with a tablet setup of $500 to $800, so this price is cautious, and without training and support, about a third of devices go unused.
    Try it in the sliderTalk to Ryan

    More of the Blueprint

    Keep reading.

    23 more chapters on the way

    Back to Keep 100

    Sources

    Every number in this chapter, and where it came from.

    1. Source 1: Augmentative and Alternative Communication (Practice Portal) (opens in a new tab)

      American Speech-Language-Hearing Association. Checked 16 October 2026.

      The profession's own guidance. Its estimate of need comes from a 2020 textbook, and its abandonment figure from an older study.

    2. Source 2: DMEPOS Fee Schedule: DME26-D (October 2026) (opens in a new tab)

      Centers for Medicare & Medicaid Services, October 2026. Checked 16 October 2026.

      Medicare's national fee for a new, top-tier speech-generating device.

    3. Source 3: Prevalence of people who could benefit from augmentative and alternative communication (AAC) in the UK (Creer and others) (opens in a new tab)

      International Journal of Language & Communication Disorders, 26 April 2016. Checked 16 October 2026.

    4. Source 4: Voice banking for people living with motor neurone disease: Views and expectations (Cave and Bloch) (opens in a new tab)

      International Journal of Language & Communication Disorders, 22 December 2020. Checked 16 October 2026.

    5. Source 5: Clinical prognostic messages from a systematic review on cerebral palsy (Novak and others) (opens in a new tab)

      Pediatrics, 8 October 2012. Checked 16 October 2026.

    6. Source 6: Communication interventions for autism spectrum disorder in minimally verbal children (Brignell and others) (opens in a new tab)

      Cochrane Database of Systematic Reviews, 5 November 2018. Checked 16 October 2026.

      A Cochrane review that found two eligible randomized trials.

    7. Source 7: Almost one billion children and adults with disabilities and older persons in need of assistive technology denied access, according to new report (opens in a new tab)

      World Health Organization, 16 May 2022. Checked 16 October 2026.

      With UNICEF, on the Global Report on Assistive Technology.

    8. Source 8: Communication interventions for minimally verbal children with autism: a sequential multiple assignment randomized trial (Kasari and others) (opens in a new tab)

      Journal of the American Academy of Child & Adolescent Psychiatry, 12 March 2014. Checked 16 October 2026.

    9. Source 9: Randomized comparison of augmented and nonaugmented language interventions for toddlers with developmental delays and their parents (Romski and others) (opens in a new tab)

      Journal of Speech, Language, and Hearing Research, April 2010. Checked 16 October 2026.

    10. Source 10: A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders (Ganz and others) (opens in a new tab)

      Journal of Autism and Developmental Disorders, January 2012. Checked 16 October 2026.

    11. Source 11: Effects of Interventions That Include Aided Augmentative and Alternative Communication Input on the Communication of Individuals With Complex Communication Needs: A Meta-Analysis (O'Neill, Light and Pope) (opens in a new tab)

      Journal of Speech, Language, and Hearing Research, July 2018. Checked 16 October 2026.

    12. Source 12: Tablet-based speech-generating devices for individuals with autism spectrum disorder: a meta-analysis (Muharib and others) (opens in a new tab)

      Journal of Autism and Developmental Disorders, 29 November 2023. Checked 16 October 2026.

    13. Source 13: Comparing Interventions With Speech-Generating Devices and Other Augmentative and Alternative Communication Modes: A Meta-Analysis (Pak and others) (opens in a new tab)

      American Journal of Speech-Language Pathology, 22 February 2023. Checked 16 October 2026.

    14. Source 14: Eye tracking communication devices in amyotrophic lateral sclerosis: impact on disability and quality of life (Caligari and others) (opens in a new tab)

      Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 8 July 2013. Checked 16 October 2026.

    15. Source 15: Usability of eyetracking computer systems and impact on psychological wellbeing in patients with advanced amyotrophic lateral sclerosis (Linse and others) (opens in a new tab)

      Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 1 November 2017. Checked 16 October 2026.

      A small study of eleven patients.

    16. Source 16: State Data Summary: Device Loan, All States, 2025 (opens in a new tab)

      National Assistive Technology Act Data System. Checked 16 October 2026.

      The states' own reports, compiled nationally.

    17. Source 17: Team Gleason (opens in a new tab)

      Team Gleason. Checked 16 October 2026.

      The organization's own account.

    18. Source 18: Technology & Equipment (opens in a new tab)

      Team Gleason. Checked 16 October 2026.

    19. Source 19: Giving every child a voice with AAC technology (opens in a new tab)

      UNICEF Office of Innovation, 23 July 2020. Checked 16 October 2026.

    20. Source 20: ModelTalker (opens in a new tab)

      Nemours Speech Research Laboratory. Checked 16 October 2026.

    21. Source 21: A large-scale comparison of two voice synthesis techniques on intelligibility, naturalness, preferences, and attitudes toward voices banked by individuals with amyotrophic lateral sclerosis (Hyppa-Martin and others) (opens in a new tab)

      Augmentative and Alternative Communication, 4 October 2023. Checked 16 October 2026.

    22. Source 22: Our Impact Program aims to empower 1 million people through AI voice technology (opens in a new tab)

      ElevenLabs, 20 August 2024. Checked 16 October 2026.

      The company's own account.

    23. Source 23: Graduate Students' Perceived Preparedness to Work With Individuals Who Use Augmentative and Alternative Communication (Barman and others) (opens in a new tab)

      American Journal of Speech-Language Pathology, 17 March 2023. Checked 16 October 2026.

    24. Source 24: 2026 Medicare Fee Schedule for Speech-Language Pathologists (opens in a new tab)

      American Speech-Language-Hearing Association, 13 November 2025. Checked 16 October 2026.

      National Medicare rates for a device evaluation and for training sessions.

    25. Source 25: Perspectives of speech language pathologists regarding success versus abandonment of AAC (Johnson and others) (opens in a new tab)

      Augmentative and Alternative Communication, June 2006. Checked 16 October 2026.

    26. Source 26: Voice banking for individuals living with MND: A service review (Judge and Hayton) (opens in a new tab)

      Technology and Disability, 2 June 2022. Checked 16 October 2026.

      A review of one UK service's records.

    27. Source 27: Finding & Funding AAC (opens in a new tab)

      Pennsylvania Department of Human Services. Checked 16 October 2026.

      Practitioners' cost estimates, in slides hosted by the state.

    28. Source 28: Medicare Coverage Policy on Speech-Generating Devices (opens in a new tab)

      American Speech-Language-Hearing Association. Checked 16 October 2026.

    29. Source 29: FCC Makes AI-Generated Voices in Robocalls Illegal (opens in a new tab)

      Federal Communications Commission, 8 February 2024. Checked 16 October 2026.

    30. Source 30: A scoping review of augmentative and alternative communication (AAC) interventions in low- and middle-income countries (Muttiah and others) (opens in a new tab)

      Augmentative and Alternative Communication, 15 March 2022. Checked 16 October 2026.

    31. Source 31: The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: a research review (Millar, Light and Schlosser) (opens in a new tab)

      Journal of Speech, Language, and Hearing Research, April 2006. Checked 16 October 2026.

    32. Source 32: Effects of augmentative and alternative communication intervention on speech production in children with autism: a systematic review (Schlosser and Wendt) (opens in a new tab)

      American Journal of Speech-Language Pathology, August 2008. Checked 16 October 2026.

    33. Source 33: An Accurate and Rapidly Calibrating Speech Neuroprosthesis (Card and others) (opens in a new tab)

      New England Journal of Medicine, 15 August 2024. Checked 16 October 2026.

      One participant.

    34. Source 34: Using large language models to accelerate communication for eye gaze typing users with ALS (Cai and others) (opens in a new tab)

      Nature Communications, 1 November 2024. Checked 16 October 2026.

      A pilot with two users.