Advocates see a chance to transform mental health crisis services. But with deadlines looming, so is a fight with the telecom industry.

It’s 12 pm EST, and almost 300 people are gathered for a weekly Wednesday video call. The number “988” is displayed prominently on the screen. Unlike most weekly meetings, there’s an intensity to the call, known to those in attendance as The Crisis Jam

The call’s urgency and its fast, almost fevered pace, are driven by another number that weighs heavily on the callers’ minds: 7/16/22, as in July 16, 2022. That’s the deadline, mandated by Congress, for states to implement a sweeping change that shifts emergency mental health calls from 911 – the traditional police, fire and medical emergency line – to a new, easy-to-remember three-digit phone number: 988. 

Barnhill-Hubbard and Hawks of CAHOOTS attend to a man who needs help, later taking him to a local sobering station. Credit: Thomas Patterson

The people on the Crisis Jam call, a collection of crisis workers, mental health advocates and local officials, see the changeover as an historic opportunity to dramatically remake the nation’s system for responding to mental health emergencies from one handled primarily by law enforcement to one handled by trained crisis counselors and responders. Simply put, their goal is a system that provides people in need with someone to call, someone to come, and somewhere to go. (See story on the Cahoots program in Eugene, Oregon for a look at the workings of one city’s pioneering crisis response effort.)

But with the deadline for launching the 988 line just 9 months away, only a few states have enacted legislation to create and fund call centers and other services. Advocates are concerned that states are paying little attention and will lose the opportunity to create safer, more compassionate responses to such crises.

On one recent call, progress reports came in rapid-fire updates. Oregon has become the eighth state to pass legislation to implement 988. A new law in Washington state will fund 988 and double the number of crisis call counselors. Washington State’s American Indian Health Commission is rolling out a 988 suicide-prevention line serving Native Americans. A Colorado crisis line is increasing its use of peer supporters – people with personal experience as mental health consumers – to handle crisis calls.

Credit: Shasta County California

The staccato delivery reflects the need for states and localities to put into place a dizzying array of logistics in order to implement a transition that some see as the biggest change in social medicine since the rollout of Obamacare. 

“The idea that we’ve got to do something radically different is weighing on all of us,” says David Covington, president and CEO of RI International, a Phoenix-based nonprofit that provides a range of crisis and recovery services across the country.

The National Suicide Hotline Designation Act of 2020 passed Congress unanimously and was signed into law by former President Donald Trump last October. It requires telephone carriers to enable calls to 988 for suicide prevention and mental health emergencies by July 16, 2022. It also enables carriers to charge customers a monthly fee – as they already do to support 911 calls – and allows states to use the revenue to fund call centers, phone counselors and related services and “the provision of acute mental health, crisis outreach and stabilization services” triggered by calls to the 988 line. The law imposes no limit on the fee, leaving that to the states.

The sense of urgency is driven by the sharp rise in mental health symptoms and needs during the COVID-19 pandemic, as well as the growing awareness of racial injustice in policing and incarceration brought to the fore by the murder of George Floyd. Since 2015, 1,486 people with a history of mental illness have been killed by police in the US, according to the Washington Post—almost a quarter of all fatal police shootings. 

More commonly, thousands of mentally ill people get arrested and held in jail or brought to hospital emergency departments, which are ill-equipped to handle crisis care. Many also languish in jail for months while awaiting trial. On average, 10% of law enforcement agencies’ total budgets and 21% of staff time are spent responding to and transporting persons with mental illness, according to the Treatment Advocacy Center, a Virginia-based nonprofit.

Even children in crisis run the risk of being arrested or brutalized. In January, a parent in Rochester, New York, called 911 because her nine-year-old daughter was talking about suicide. The mother repeatedly asked for mental health intervention, but instead police officers restrained her daughter, forced her into a snowbank and handcuffed her while she called out for her father. After she resisted getting in a police cruiser and defied an officer’s order to “stop acting like a child,” an officer pepper-sprayed her, the New York Times reported, citing body-camera footage.

Credit: Shasta County California

State of Play

Advocates are asking states to take advantage of the user-fee provision in the federal law and levy charges on telephone consumers of less than $1 a month. The same kind of monthly fee brought in $3 billion in 2019 to support 911 services. These fees could then be combined with other state and federal funds, as well as reimbursements from Medicaid, Medicare and private health insurers, says Hannah Wesolowski, director of field advocacy for the National Alliance on Mental Illness, or NAMI, the nation’s largest mental health advocacy organization. 

“​The best system is a hybrid system not just relying on the tax, not just relying on healthcare but ensuring we have everything we need to save lives,” says Jonathan Goldfinger, chief executive officer of Didi Hirsch Mental Health Services, a Los Angeles nonprofit that operates one of the nation’s largest crisis hotlines.

As of September 2021, only four states – Nevada, Colorado, Washington and Virginia – have passed 988 implementation measures that set monthly fees on phone users and define how the funds can be used. Each has its own system, ranging from Nevada’s fee, which is capped at 35 cents and covers a full scope of services, to Virginia’s, which is capped at 12 cents per line and funds only crisis call-center operations.

Three other states — Utah, Indiana and Oregon – have passed legislation that defines the crisis services that should be provided in those states and identifies short-term funding mechanisms, but doesn’t establish a fee. Texas, New York, Alabama and Nebraska have passed legislation to study how to fill existing gaps in their crisis services. Illinois passed a bill focused on procedures, ensuring that law enforcement will not be the primary response to a crisis call.

Three states have pending legislation and in five states it has been killed or stalled. Most remaining states have set up committees to plan their 988 implementation strategy but have not yet taken concrete action or designated a source of funds.

After months of debate, a California proposal that would have authorized a fee of up to 80 cents on the monthly bill of each cell-phone user to fund call centers and other services stalled out, with a vote postponed until at least January. For now, the state will be able to use $20 million that Governor Gavin Newsom has set aside to fund call center operations. 

911 vs. 988 

To set a standard for a new mental health crisis system built around 988, the National Association of State Mental Health Program Directors drafted a model bill for state legislatures to comply with the National Suicide Hotline Designation Act. The bill provides support for three stages of response – call centers, mobile crisis teams and stabilization services. 

First, callers would be connected to trained crisis counselors who would work to de-escalate the situation. In Phoenix, with one of the most developed systems in the country, more than 70% of crisis calls received each month are resolved on the phone, without the need to send medical or law enforcement personnel to the scene, according to Matthew Moody, director of contact center operations at Solari Crisis & Human Services, an Arizona nonprofit.

Second, a mobile crisis team would come to the scene if needed, avoiding police dispatch. Phoenix has 27 mobile teams, each with a mental health professional and trained crisis worker. Planners there are also developing a system to pair officers with mobile crisis teams on occasions where both are needed.

“The idea is to utilize law enforcement services strategically and only at times when their presence is warranted,” says Ron L. Bruno, executive director of CIT International, a Salt Lake City-based training institute which teaches officers to respond to people experiencing mental health issues and redirect them to social services.

The third stage is the place to go – ensuring that there are appropriate facilities where people in crisis can stabilize and get support and treatment ranging from non-clinical sobering and respite centers to residential treatment centers and psychiatric hospitals. Those services are key, advocates say, and they are pushing states to create a system that provides them all as a continuum of care.

Ready or not

When July 2022 arrives, operators of mental health lines believe call volume to 988 will rise far beyond the 2.2 million calls the National Suicide Prevention Line received in 2018. The number can now be dialed from 95 percent of cell networks and connect callers to the National Suicide Prevention Lifeline, according to CTIA, the Washington, D.C.-based telecommunications association. What’s missing in some states are funds to ensure that crisis counselors will be on the other end to answer the call – and that a range of other crisis services can also be marshalled. 

If all the pieces are not in place, calls to 988 might simply be routed back to law enforcement, says NAMI’s Wesolowski. 

The use and amount of fees on phone users to support 988 and crisis services have emerged as a sticking point. California’s proposed legislation, AB 988, now shelved until next year, would allow a fee of up to 80 cents per customer, the same limit imposed on 911 fees. 

The Steinberg Institute, the nonprofit advocacy group that sponsored the bill, estimates that a monthly fee of 30 cents per customer would bring in $195 million annually, while an 80-cent fee would generate $514 million. (Tom Insel, a donor to MindSite News and chair of its editorial advisory board, is board president of Steinberg Institute.)

The telephone industry – whose members will have to enable the new national call line and whose customers may pay a monthly fee to support it – is pushing for the lowest possible charge. 

“The 988 fee should be limited to funding equipment, communications services, and direct costs for crisis hotline center personnel for 988 call taking and appropriate call routing,” Gerald Keegan, CTIA’s vice president of state legislative affairs, wrote in an April 14 “letter of concern” to California legislators. Surcharges to support 911 “do not fund police, fire, or EMS,” which are paid for by state and local general funds. Likewise, the 988 fee shouldn’t pay for mobile crisis teams, stabilization and other follow-up services.

That analogy is rejected by California Assemblymember Bauer-Kahan, the author of the state’s 988 bill. “Comparing 988 to 911 is not an apple-to-apples comparison,” she told MindSite News in an email. “988 is a new service, so an entirely new workflow and care system needs to be built.” 

Industry groups have taken a similar position in testimony before state legislatures, a stance that prompted pushback from three Democrats on the Senate Finance Committee, Ron Wyden and Jeff Merkley of Oregon and Chris Murphy of Connecticut. In July, they wrote a letter expressing concern that “telecom lobbyists appear to be pressing state legislators” to reduce the fees and “limit the states’ implementation of this critical lifeline for Americans in crisis.”

One way or another, 988 is coming. Come next July, residents in all states will be able to dial that number, but the services they receive when they do are likely to differ greatly. If states fail to act by then, call centers might not have the resources to meet an expected increase in call volume. And that could mean longer wait times for those in crisis. 

As the clock ticks down to July 2022, advocates are concerned that a vital opportunity could slip away. On one recent Crisis Jam call, Margie Balfour, a psychiatrist and chief of clinical innovation and quality at Connections Health Solutions in Tucson, delivered a rally-the-troops message. “We have less than a year to implement 988,” she said. “Now’s the time.” 

Julianne Hill is an award-winning reporter, producer and educator who specializes in mental health coverage in Chicago. She is a former Rosalynn Carter Mental Health Fellow.