Text-to-Speech Technology Reaches an Inflection Point

Chester Higgins Jr./The New York Times
Kara Lynn uses an iPhone with special software, costing less than $500, to speak to family, friends and doctors.

Update | 9/19/09 10:10 p.m. Kara Lynn, who was featured in a Times article because she was using an iPhone for text-to-speech service, offers her own comment about the technological curve.

Moore’s Law is a funny thing. Computing gear ticks along, getting faster and often cheaper at a steady rate. But, every now and then, we hit an inflection point where things change in a drastic fashion. Such is the case with the iPhone from Apple and with netbooks -– products that nailed the right recipe of horsepower, size and cost at the right time.

In an article published Tuesday, I took a look at how iPhones and netbooks have disrupted not only the consumer electronics market but also health care.

People with speech-impairing conditions like A.L.S., autism, Down syndrome and strokes have started to discover that general-purpose devices, equipped with downloadable text-to-speech software, can in many cases help them communicate better and more cheaply than the proprietary speech devices covered by Medicare and private health insurance.

Most of the interviews for the article were with people who have A.L.S. or help treat people suffering from the condition, which over time severs connections between the mind and muscles. On average, people with A.L.S., or amyotrophic lateral sclerosis, live for two to five years after their initial diagnosis.

About 20 percent to 25 percent of the people with A.L.S. have a form of the illness called bulbar onset. Such people tend to lose control of the muscles around their mouth and throat first, harming their ability to speak and swallow. This group of people has seized on the iPhones and netbooks, since the devices solve some obvious problems.

Most insurance companies will cover only one speech-generating device about every five years. The more basic devices cost $5,000 to $10,000, and complex devices can shoot past $20,000.

People with bulbar onset are often forced to forgo one of the lower-end devices that can help them deal with their early loss of speech in favor of saving their health insurance money for a time when their condition will worsen. At that point, people tend to gravitate toward far more sophisticated systems, like those that can turn head and eye movements into computer commands.

“In many cases, people will save their insurance money for a time when the need a bigger device, like one that sits on a wheelchair,” said Lisa Bruening, a patient services coordinator at the ALS Association in Cleveland, Ohio. “No one has a crystal ball about how their disease will progress.”

But as my article pointed out, many of those suffering from bulbar onset A.L.S. can now take matters into their own hands and purchase a cheap iPod or netbook to help them through the early stages of their multiyear battle.

A number of people who read the article seemed to think I was suggesting that everyone with a speech-impairing condition could benefit from an iPod or netbook instead of a specialized device. That is, of course, not true.

As the article mentions, the specialized products have features like tougher construction that make them different from off-the-shelf computers. Children with Down syndrome, for example, often throw their devices around and need something that can survive many drops.

But for people with bulbar onset A.L.S., iPhones and netbooks have opened up new ways for them to try to come to terms with their conditions while functioning out in the world. In addition, disease experts say that children with Down syndrome often prefer to have a standard computer or something with some cachet like an iPhone rather than a stigmatizing, specialized device.

And so the question at hand is whether insurers need to be more flexible to deal with the wider range of hardware and software that’s now available on the market.

A number of people, via e-mail and comments on the Times’ Web site, requested more information about the text-to-speech products on the market. Here’s a list of some of the available software. (My thanks to Alisa Brownlee, a clinical manager at the national office of the ALS Association, for doing the heavy lifting on this.)

Free Software: ChipSpeaking (PC), Etriloquist (PC), MyFTC (PC), MyVoiceX (PC and Mac), NaturalReader (PC), pVoice (PC) and ReadPlease (PC).

$30 to $300 Software: ByteCool ($30/PC), NextUpTalker ($100/PC), GhostReader ($40/Mac), Proloquo ($300/Mac and $200/iPhone), TextSpeechPro ($60/PC), UniversalReader ($80/PC) and Read the Words (Web service that costs $35 a year).

Hardware: The leading makers of text-to-speech devices are DynaVox Mayer-Johnson and Prentke Romich. I’ve also been pointed to Zygo Industries as a producer of lower-cost text-to-speech devices.

Netbooks are widely available, while the iPhone can be purchased from Apple or AT&T.

Lastly, some people asked how they can help. A.L.S. centers and other groups say they will take donations of your older devices. (You can find the nearest chapter of the ALS Association online or by calling 800-782-4747.)

Comments are no longer being accepted.

The text-to-speech feature is built-in on Apple computers. There is no need to download free software. Just select the text you wish to speak then go to the application menu on the top left corner, choose Services, then click Start Speaking Text. You can select among a dozen voices or even make a custom voice.

Strange title. Do you know what an inflection point is?

Such text-to-speech converters aren’t only for ALS patients. I’ve been affected by thyroid cancer and have had problems with my voice for months as a result. I use the free Etriloquist mentioned in the article along with AT&T Natural Voices as the quality of the synthesized voice is much better with them than with the Microsoft free offerings.

I absolutely agree with #2. What the article describes is a rapid increase in usability, which is precisely the opposite of an inflection point.

This is almost as bad as when journalists talk of quantum leaps, not realizing that a quantum is actually the smallest possible jump, not a large one.

We used the term “inflection point” in terms of a sharp turn. Text-to-speech technology has taken a sharp turn on the price-performance graph.

Vindu Goel
Deputy Technology Editor
The New York Times

. . . and a “quantum leap” is a categorical, rather than an incremental, leap.

This implies a dramatic, noticeable and/or measurable change or shift, as opposed to an incremental change.

For example, having functional devices available for $200 instead of $5000 makes them dramatically, noticeably and measurably more affordable for the people who need them.

And having the text-to-speech feature readily at hand, rather than in a large, single-use device, makes them dramatically, noticeably and measurably more useful for the people who need them.

Similar to the change from teletypewriters to texting for speech and/or hearing-impaired people.


Thanks for the insightful article, a great example of what the Times does best.

#1 is correct — Macs have had free text to speech for well over 20 years. MacInTalk was used to introduce the original Macintosh back in 1984, and was a supported product starting in 1988.

So far as the article, it neglects to mention that the Apple’s current iPodTouch will also run iPhone test-to-speach software.

Yes, but did you see Monday’s article about how insurance providers are refusing to pay for such mainstream devices, no matter how much sense they make?


It’s not really relevant that Macs have had text-to-speech for years. The technology to produce the speech isn’t really the hard part. Nearly all of the work on a technology like this is on the user interface. Taking into account the abilities of the user base and crafting an interface that allows users to express themselves both fluently and quickly is extremely difficult.

I agree with the dissenters. There is a problem with the title as the iPhone was the inflection point not the Text2Speech technology.

if these devices are generalized (e.g. a phone), it seems unnecessary for insurance to cover their costs.

i’m liberal, but influenced by the thoughts in this atlantic article:

we don’t submit gas receipts to our auto insurance companies. why should we assume that a phone that has some text-to-speech software on it, should be also?

i think it’s great that these people are saving their insurance claim for larger items, and just paying for the phone themselves.

Marian, I’m not sure that the gov’t needs to pay for something as cheap and multi-functional as an iPhone or netbook for people. While I think the previous article did a good job of showing how ridiculous it was to pay $5,000 for ‘specially-made’ (read: functionally inhibited) devices; it didn’t make a good argument for buying cheap, ubiquitous electronic devices for people, especially when they are likely to buy them themselves. Just another example as to why a government-run or government-overseen healthcare system is scary to me.

WRT #4, Ivan: It’s been 30 years or so since my last quantum mechanics course, but I believe you are mistaken. When electrons make quantum jumps, they are not necessarily the smallest quantum jump possible at that instant.

Aside, from that, when used in nontechnical talk, writers are often referring to the abrupt, sudden nature of a change — as in a quantum leap — not necessarily the size of the change. Theres nothing wrong with that usage.

Larry: The article notes that private insurers also refuse to buy multifunction devices.

And it’s not safe to assume most people will be fine getting text-to-speech systems on their own if the medical system won’t help. Patients will probably know less than doctors and caretakers about what’s available and how to set it up. And for some patients it might be a hardship to get even a relatively cheap and useful device: A.L.S. treatment can be expensive even with insurance, plus the paralysis quickly makes many patients unable to work in most jobs. Some patients in the article worked out systems of their own, but that doesn’t represent everyone.

It’s great that lower-cost text-to-speech tech is available and that the tools are useful for other stuff. But that doesn’t mean insurance suddenly gets a pass on paying for the devices to treat patients’ conditions.

An inflection point is one after which curvature changes direction. In this case the existing direction of curvature is merely accelerated.

If text to speech per $ spent is generally getting better and suddenly gets much better it did not hit an inflection point.

What this really illustrates is the magnitude to which the health care industry is subject to market failure.

Since health care output per $ is getting worse, it would indeed hit an INFLECTION POINT if health care per $ got better!

I’ve written a free, large font reader for OS X that speaks text files aloud and displays the text stanza-after-stanza, simultaneously. I wrote it to aid visually impaired people, but it is useful to anyone. It’s only for the mac desktop.


My daughter has CP – she uses a Dynavox V – about $14,000 Australian. The touch screen interface and custom software is essential, and up until the iphone, alternatives were just not good enough. Even with iphone/iPod Touch, there are still equipment limitations – infrared control, speaker volume, screen size; but the potential and hugely less expensive potential of iphone/itouch devices warrants development of affordable solutions. The vastly superior touch screen technology is great, and the reduction in social stigma by using a “normal”/cool device is also important.

I hope Apple do release a notepad touch device – the iphone interface and development environment is ideal and the potential cost savings are huge for families that are often faced with so many challenges with limited resources. Then, even now, we just need the likes of Dynavox to get on board with affordable hardware enhancements (batterypack, speaker, IR cradle like the TomTom iphone mount) and affordable well engineered speech software.

Text to speech can be useful for people who still have use of their fingers. If the ALS progresses and the person loses his/her fine motor coordination then the Text to speech becomes useless, for instance Stephen Hawkins can’t use a simple text to speech devices. Also cognitively impaired people, who cannot spell correctly cannot use text to speech and need picture based systems, or Unity Based systems as those from Prentke Romich. Also people with CP have an inability to use their fingers in many cases and need to use switch based technology. this doesn’t let the insurance companies off the hook for coverage of people who have speech problems, just it is a much more complex problem, hopefully cheaper computers will bring down the prices in general.

Anything equivalent software for Linux ? Thank you for the info.


So this article is intended to count as a clarification ???
Health care tries to rely on science as a way to weed out competing claims of successful treatments from the mundane (placebo effect) to the criminal (people selling fake cures).
As a result, medical insurers, both government and private,take a conservative approach when consumers of medical care want payments to cover what are novel treatments or multi use devices.
It is true that multirole devices are becoming more and more powerful, more and more useful and increasingly common.
Despite this, insurers have to take a prudent approach and ask not just for anecdotal stories, they need to and should continue to rely on medical case studies and experiments to prove the value of these new techniques.
The prior article really did seem to suggest that are insurers are just luddites, rather than caught in a dilemma, how do you know that the funds being disbursed are for the betterment of the medical condition in question.
Why did the prior article not identify the name of the software used by ms lynn?? Was her choice of iPhone based on the fact that it was the only way to run the software?? or was there in fact a different piece of hardware, less expensive, without a cell contract, which could do the job. What is an insurer to do??
Its not quite so cut and dried is it ??

Another emerging technology in Text-to-Speech (TTS) specifically of interest to ALS patients is the ability to capture or “bank” a person’s voice for later use as a synthetic speech voice. I direct an NIH-funded project to develop one such system: //www.ModelTalker.com/.


The story did identify the software. It’s called Proloquo2Go.

That particular software only runs on the iPhone. But, as this post points out, there’s a wealth of software available for PCs.

I think that that, inflection points and other phrases aside, the main tech trend as integration increases and cost decreases is that programmable general purpose devices crowd out more expensive, purpose-built devices. You can see this with cell phones, as they become music players, cameras, and portable Internet devices. Software and maybe a couple of smart peripherals running on a standard platform eventually deliver most of the function of specialty devices at a fraction of the specialty device cost. The interesting thing about iPhones and iPod Touch devices is that they are really pocket computers that happen to make phone calls or play music, expandable in function through an apps store. The newer Android and WebOS devices are similar in using standard software components running on portable versions of mass market hardware with their own versions of an app store to add new functions.

First, I have to say the title is perfect. With mainstream hardware proving to be more functional, more portable, more desirable, more financially and physically accessible, and able to do everything a dedicated speech generating device does as well, the technology is indeed at an inflection point, and change is bound to happen. If the makers of the dedicated devices don’t want to lose a very large portion of their users, they need to exam what the users need, want, and ultimately WILL use.

My $8,000 device (which, for $45, I did unlock after Medicare and Empire BC/BS paid for it) is very heavy, has very difficult to reach ports for anyone with fine motor problems, has a touch screen that does not function well, has very limited hard drive and memory, and was built with a low end processor that is not even compatible with Vista. Besides not loving the hardware, I dislike the software even more. I worked many years running many sophisticated computer applications. I have been known to be very good on any computer, so I don’t think the problem in my case is computer illiteracy. The software that came on my SGD was a real turn-off. It reminded me of the clunky DOS programs of the eighties.

As someone with ALS, my journey is expected to lead me to a state where I am completely paralyzed, head to toe. I will spend my days in a power wheelchair. My means of communicating, running my household, paying my bills, interacting with the world, being helpful to others, being my son’s mother, will be via whatever computer is mounted on my chair. Right now, my Mac Powerbook works just fine, but it I lose absolutely all ability to activate an alternative access switch, an eye tracking system will be needed. To my knowledge, these systems are not sold as add-ons to consumer computers. Will my only choice then be to give up a good computer for a very limited one that also does eye tracking? I hope not.

I am fortunate to still be somewhat ambulatory. It is not at all practical to carry a heavy device around, especially since I have very weak hands, arms, and shoulders. The iPhone with the AAC app Proloquo2Go has changed my life. I hear so many parents reporting the same life-changing stories about their children with autism, down syndrome, cerebral palsy, and other conditions that make speech difficult.

Sure, I bought my iPhone, and I bought an iPod for my son. Two of the best purchases I’ve ever made. Until recently, I could do that, but since my disease has progressed, I now need to hire a live-in caregiver for my son. I don’t know how I will be able to afford her, but buying iPods will no longer be an option.

There are so many people with speech impairments whose lives can be changed with such an unobtrusive, truly portable, and socially normal device, yet not all can afford this. It’s just ridiculous that insurance will pay thousands of dollars for a device that may very well become an expensive paper weight. What should matter in the end is “will the patient use it?” From what I hear, the AAC-enabled iPhones and iPods ARE being used, while bigger dedicated devices gather dust.

Many people commented on the original story with concerns
that any old Joe would fake speech impairment for a free iPod. It’s just not that easy. No speech generating device is ever approved by Medicare or insurance without a prescription by an MD for a speech evaluation by an SLP, a very lengthy and detailed justification based on the evaluation, written by the SLP, agreed with and signed by the MD, and reviewed and finally approved by the insurance company. You won’t find licensed providers willing to do all that so you can get a free iPod.

As for kids with Down syndrome throwing things. Not all do, and certainly as they grow up, as with any child, behavior usually improves with maturity. My son is five. He throws everything, but he rarely lets his iPod out of his proud grip. He will, on occasion, throw it to an adult when he is done with it, and it usually is never caught. I use only an easy to grip silicone skin on his device, and have had no damage. It’s not as fragile as I thought it would be. You can get more protective covers.