Even the simpliest communication -- "I love you," "How was school?" -- is impossible for many people with degenerative diseases, spinal cord injuries and other ailments. There are technological devices to augment communication, but until recently, they weren't covered under health policies.

Amyotrophic lateral sclerosis robbed Paul Baughman of his ability to speak. So now the 56-year-old former financial analyst relies on a laptop computer outfitted with a straw-like joystick resting against his chin to express his joys, pains, concerns or wants. Baughman can maneuver the joystick with his mouth or subtle head movements and click a switch under the palm of his right hand to type what he wants to say. A voice synthesizer speaks his words aloud.

Medicare refused to cover devices like Baughman's until recently because communication wasn't considered a medical necessity. As a result, severely ill or injured people who couldn't move or speak because of strokes, brain injuries, multiple sclerosis, spinal cord injuries or degenerative diseases had no way to tell doctors that they were in pain, caregivers that they were hungry or family members that they loved them.

"It's difficult to understand the importance of communication until you lose it," said Jeff Edmiaston, a speech pathologist at Barnes-Jewish Hospital who evaluates patients for augmentative communication devices and teaches them how to use them.

Medicare started paying for the devices in January 2000, when rules were changed to pick up 80 percent of the costs. Medicaid programs in Missouri and Illinois cover 90 percent of the expense.

Still, many people -- usually adults -- don't have access to the devices.

Private insurers typically base their payments on Medicare rates, but some have been slow to approve coverage of the specialized equipment, which can range from $300 for a simple calculator-sized gadget to almost $20,000 for a beefed-up laptop loaded with software that allows it to be controlled by a user's brain waves.

Patients who live in nursing homes often fall through the cracks, despite Medicare eligibility, said Mary Riggs, patient services director at the St. Louis regional chapter of the ALS Association. Even though Medicare will pay for the devices, "nursing facilities do not seem to be following through on patients' requests," she said.

Last week, Edmiaston helped to install new software into Baughman's laptop. The speech pathologist at Barnes-Jewish Hospital works with a team of therapists to evaluate the needs of people who can't communicate and match them with appropriate equipment. Barnes-Jewish is the only hospital in the region that offers such a program.

Over the years, the devices have grown more sophisticated. They're smaller, lighter and simpler and boast a wider range of vocabulary and improved voice quality, said Andrea Wieselman, director of clinical services for the Center for Hearing-Speech in St. Louis.

Sometimes, however, it's the simple things that people want to say. One of Edmiaston's patients recently had his computer programmed to ask: "How was school today?" The man hadn't been able to ask his young daughter that question for months.

ALS is a progressive fatal neuromuscular disease that takes away even the simplest movements of walking, speaking and gesturing. Its onset is rapid, with inevitable deterioration and paralysis. Mental abilities, however, are not impaired. The cause of the disease is unknown.

After Paul Baughman was diagnosed with ALS in May 2000, he and his wife, Barbara Baughman, moved from Kansas City back to the St. Louis area.

In the disease's early stages, he continued working for Commerce Bank from a home office. But as the disease worsened, he could no longer type. He also couldn't talk on the phone or interact with visitors at the couple's home in Imperial. His sharp mind was quickly becoming trapped in a stilled body. He stopped working at the end of August.

Baughman maneuvers a straw-like joystick with his chin or mouth.

Without the specially-outfitted laptop, "I would be almost totally isolated," he said, expressing himself with a combination of typing and a series of grunts and groans translated by his wife, Barbara.

The couple sought coverage for the specialized equipment from their private insurance company, but faced a lengthy approval process. They borrowed the equipment from the ALS Association and paid for related expenses out-of-pocket.

"We couldn't wait three to six months," she said. "They (the insurer) said it wasn't a medical necessity. But if a person can't speak or move, how do they communicate? It's been really hard on him."