Most States Have Not Yet Acted to Support New 988 Behavioral Health Lifeline

Whom do you call for help when you or someone you know is dealing with a mental health or substance use crisis? The answer can depend on whom you ask.

Most call 911, though some call-takers and dispatchers lack the training and resources to properly identify a behavioral health emergency and respond accordingly. More than 2 million call the National Suicide Prevention Lifeline each year, while others dial state-run suicide hotlines. Separately, calling 211 can provide nonemergency services that vary from region to region.

To make it easier for people to get help from trained health professionals safely and quickly, Congress recently enacted laws to create 988, the first nationwide telephone number to help people with any behavioral health crisis 24 hours a day, seven days a week. The Federal Communications Commission issued regulations in July 2020 on how 988 should operate once it launches in July 2022.

States are now largely responsible for implementing the number—including building the infrastructure, training staff, and integrating it with 911 and other emergency services—but the federal government has given them little funding or guidance to do so.

To provide help, The Pew Charitable Trusts assessed legislation enacted so far in the nation’s statehouses. Pew also commissioned a report from the Technical Assistance Collaborative (TAC)—a Boston-based nonprofit that develops policy solutions for communities dealing with housing, mental health, substance use, and other issues—to give policymakers a comprehensive framework to ensure that the 988 system is effective.

As of Oct. 12, nine states had passed binding legislation, taking a variety of approaches:

• Seven—Illinois, Nebraska, Nevada, Oregon, Utah, Virginia, and Washington—created advisory groups charged with some or all aspects of implementation. These panels typically consist of representatives from various state agencies, health providers, law enforcement, emergency medical services, and others. Separately, Colorado already had a 988 planning committee operating under the state Department of Human Services.
• Four—Colorado, Nevada, Virginia, and Washington—authorized or imposed a surcharge to support 988 operations, typically to be collected by telecommunications companies from customers as they do to support the 911 system. In states where the legislation authorized but did not specify the exact fee, advisory groups have been charged with making recommendations to the governor or legislature.
• Indiana and Utah directed their Medicaid agencies to submit waiver applications or Medicaid state plan amendments to the Centers for Medicare & Medicaid Services that, once approved, will allow for federal reimbursement of a portion of crisis services delivered to Medicaid beneficiaries.

As part of a broader 2021 budget measure, California allocated $150 million for “mobile crisis infrastructure” but did not specify how much to spend on 988. The state’s Department of Health Care Services later designated $20 million to support the new emergency mental health line.

Two other states passed resolutions with no force of law. Alabama created a commission that will “study and provide recommendations” for implementing 988, while Idaho simply recognized 988 as the “universal mental health and suicide prevention crisis phone number.”

For the states still considering action, the TAC report outlines several priorities, providing comprehensive lists of stakeholders to engage, design issues to consider, scenarios to anticipate, and problems to troubleshoot. The report’s authors recommend:

• Systems-level planning. Diverse stakeholders within and beyond state agencies should be involved in planning each 988 system, including people who have used the suicide prevention lifeline, mental health counselors, 911 administrators, and law enforcement. Listening to a variety of voices will ensure that 988 works as well as possible for everyone, regardless of who or where people are or why they are calling.
• Coordination with crisis responders and care providers. 988 staff must be trained and have the technology and relationships to communicate with 911 (and vice versa). They also must be able to connect with “upstream” services such as mobile crisis teams, outpatient treatment centers, intensive in-home care, and housing providers who can offer on-the-ground support immediately and over the longer term.
• Sustainable financing. To pay for 988, local call centers, and the support services that callers may need after they hang up, states should diversify the funding sources—looking at the use of telecommunications surcharges, Medicaid reimbursements, and federal block grants, for example.
• Marketing and communications. When 988 is operational, states must invest in communications that educate residents about the new number, including its text and chat options.
• Evaluation. States will need to evaluate their 988 systems regularly to ensure that they continue to be funded appropriately and managed effectively, perhaps via partnerships with a state academic institution or center of excellence.

As many states continue to contend with the COVID-19 pandemic, political gridlock, tight budgets, environmental catastrophes, and other priorities, it is understandable why only nine have enacted legislation to implement 988. Fortunately, there is still time to act, but not much. State lawmakers, regulators, and other stakeholders can get further guidance from the TAC framework. State officials also can contact Pew’s mental health and justice program for more resources to help manage the transition to 988.

If you or someone you know needs help, please call the National Suicide Prevention Lifeline at 800-273-8255 or text TALK to 741741 to reach a crisis text line counselor.

Tiffany Russell directs The Pew Charitable Trusts’ mental health and justice partnerships project, and Josh Wenderoff is an officer with Pew’s health programs.