America’s fragile mental health safety net all too often leaves people nowhere to turn but the police when a loved one is in the midst of a behavioral health or suicide crisis. The 988 system, a new alternative to calling 911, could change that, but states are lagging behind in implementing it.
Calling 911 for people having mental health breakdowns has led to deaths that were avoidable, especially among people of color. Between 2015 and 2020, 1 in 4 people who were shot and killed by police had a mental illness; 1 in 3 were people of color.
A new federal law mandates that, as of July 16, 2022, every U.S. state must have in place a call system to make it easier for people to seek immediate and appropriate for mental health or substance use crises. The National Suicide Hotline Designation Act of 2020 adds a complement to 911. The 988 system will be the dedicated call-in line for dispatching trained staff to respond to the mental health and substance use emergencies now met primarily by law enforcement with sometimes tragic consequences, particularly for Black, Latino, and Indigenous people, as well as immigrants, LGBTQ youth, and military veterans.
Establishing an easy-to-remember crisis phone line in every state that’s staffed 24 hours a day every day comes at a critical time for a nation grappling with a behavioral health epidemic. Suicide is the second leading cause of U.S. deaths for people between the ages of 10 and 34; more and more Black youths are dying by suicide. Mental health issues among youths have become so dire, made worse by the toll of the Covid-19 pandemic, that three leading pediatric groups have declared kids’ mental health to be a national emergency. Drug overdose deaths are also at record levels.
In research my colleagues and I are doing with racial/ethnic minoritized populations, we see alarming levels of participants reporting they have had suicidal thoughts. In one incident, a police officer was sent to a house of such an individual; that experience retraumatized the person, who had experienced a previous police encounter, and escalated his anxiety, making him reticent to seek care.
There’s no question that the country needs a system like 988. But putting in place a system to address the colossal demand with a well-prepared workforce ready to effectively support and serve people in need is not where it should be.
Congress left it up to states to design 988 to allow for innovation. But states need help to move along — and move along more urgently — to put a universal crisis-response system in place by the July 2022 deadline.
To date, only a handful of states have passed or introduced legislation for building a 988 system. According to the most recent data the American Foundation for Suicide Prevention shared with me, Colorado, Nevada, Virginia, and Washington have enacted legislation that includes user fees for the 988 system. Four states have enacted 988 infrastructure legislation without calling for fees. Three states have created commissions or task forces to study implementing a 988 system. Other states are still debating legislation and California has appropriated limited funds. In short, more than half the states haven’t made any progress at all.
To move things along, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) must increase public awareness of available supplemental mental health and substance use disorder block-grant funding that could be applied to implementing 988, as well as Medicaid’s newly enacted opportunities to implement crisis stabilization systems funding. The National Suicide Hotline Designation Act allows states to raise funds for administering and staffing the 988 system by levying a surcharge on monthly bills for mobile and landline phone service. This money can support the dedicated call centers, pay for trained mobile-response teams, and bolster stabilization services for people in crisis. Federal funding and grant opportunities also exist to hire mental health and substance treatment providers to boost crisis stabilization programs and services.
The federal government must offer guidance on how to build this infrastructure and connect personnel to resources for states struggling to get moving.
The 988 call system holds great promise for offering all people facing mental health or substance use emergencies the appropriate support, services, and responses to get care and treatment. But that can’t happen until states roll it out effectively. If some states aren’t prepared to roll out 988, or have weaker infrastructure or support for it, the country could end up with a system that perpetuates inequities in mental health access rather than reduces them.
States must convene relevant stakeholders, including police departments, hospital emergency providers, community mental health and addiction service providers, and people with lived experiences, to help construct culturally responsive, equitable, and well-coordinated 988 systems. States that are struggling would benefit from seeing models for how to train crisis responders and staff 988 centers, like those in Washington state and New Mexico. SAMHSA should share with states forums offering technical assistance on how to expand crisis stabilization services so they can see what infrastructure supports are needed to make a 988 system work across the cascade of care.
The U.S. learned the hard way from Covid-19 what happens by waiting for a crisis to respond, and experienced in real-time the tragic consequences of not being prepared. Let’s not repeat these mistakes with the 988 system and perpetuate a mental health system that works for some people but not for others.
The 988 system must be designed right, and all states need to move with urgency to get it in place in time. Lives, especially the lives of young people, are at stake.
Margarita Alegría is the chief of the Disparities Research Unit at Massachusetts General Hospital in Boston and professor of medicine in the departments of medicine and psychiatry at Harvard Medical School.
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