This article is adapted from an episode of Tradeoffs, a health care policy podcast. It’s the first of several episodes Tradeoffs is doing on the rollout of 988, the new mental health emergency hotline coming this summer. Over the course of a year, Tradeoffs will be chronicling the debut of 988, checking in with national experts, and closely following the journeys of two local crisis care organizations, and State of Mind will be publishing adapted versions of the episodes. Subscribe to Tradeoffs here.
This July, America is getting a new phone number. It’s a hotline for mental health emergencies—thoughts of suicide, erratic behavior, addiction issues—that anyone anywhere can dial with just three digits, 988. For people hallucinating, hurting themselves, or on the edge of overdosing, a 911 response can be dangerous, if not deadly. For instance, in January 2021, 52-year-old Patrick Warren was killed by police after his family called 911.
Other people in crises simply go without help, and the consequences are devastating. Roughly 46,000 Americans died by suicide and more than 90,000 died from drug overdoses in 2020. Mental health advocates hope 988 can offer people a fast, safe alternative to 911.
The law creating the new line passed on Oct. 17, 2020, and converts the existing National Suicide Prevention Lifeline from 10 digits down to three. But Congress wants this phone number to be more than an “easier-to-remember” hotline. Lawmakers see it as a front door for people in all kinds of mental health crises—not just acute ones.
In 2020, the current suicide lifeline received roughly 3 million calls and texts. As many as 12 million may come through this wider 988 door starting in July, according to federal health officials. Mental health advocates see that as 12 million opportunities to greet people with better, safer crisis services than they’ve had before. Thanks to 988, some communities across the country are now hustling to remake their local mental health care systems, adding new places to send people and new staff to help.
Forty-six-year-old Andrea Harrison used to being one of the roughly 30 million Americans whose mental illness goes untreated. Childhood trauma had led her to pills, then crack, and then heroin. Andrea’s story illustrates how a crisis can be a rare chance to get someone the help they need, or a missed opportunity that could cost someone their life.
One June morning in 2012, Andrea found herself in an alley in Huntington, West Virginia. She’d just been revived by paramedics after overdosing on heroin. All her usual thoughts tumbled through her mind: “Am I going to be arrested? How am I going to get my next fix?” But what stuck out was a new idea: “I could choose to not be here.”
Her sons were 10 and 12. Andrea had vowed to never take her life. That’s how her mom, Dina, had died. Andrea had never forgiven her mother for that, but today the idea of suicide seemed to fit. “That scared me,” she says. “It scared me to death.”
Andrea’s life had ended up a lot like Dina’s in nearly every other way: poverty, addiction, homelessness, drifting in and out of her kids’ lives. Andrea wandered all day, haunted by thoughts of her mom and scared she might harm herself. She camped out that night in an abandoned house, where, exhausted, cold, and shaking from withdrawal, she made a decision. She would kill herself.
But as much as Andrea’s life mirrored Dina’s, Andrea knew something her mom didn’t: the long tail of suicide, the guilt, the hurt, the unanswerable questions: “I didn’t want that to be the story of their life. … I knew I had to do something to save them. And by saving them, I have to save myself first,” she says.
And that was that. Andrea changed her mind, but she knew she needed help fast. She considered calling 911 but worried she’d end up in jail. But she thought of another number, too, for a place in town where she could detox. She says everyone in the crowd she ran with had memorized that same number for the local detox center. It was the help she could find, not the help she needed. She did detox for 48 hours but remained addicted to heroin for five more years. Andrea got sober in 2017. She was 41, the same age as Dina was when she died by suicide.
Andrea is 46 now and deeply involved in the local recovery community.
Providing people the help that they need in the moments they need it most—that’s the highest hope for this new 988 number. But as is so often the case with health care programs and policies, the difference between high hopes and disappointment will be in the details. Who will provide that help, how, where, and at what cost?
There’s a popular phrase out there: “988 could be the 911 for mental health crises.” The hotlines have a lot in common: They’re both national numbers, but the help you get depends on where you live. When you call 911, it matters how far you live from a fire station or how much you trust the local police. And every 911 call really has two key elements: There’s the people who respond and the places they take you. Those two elements will also determine the success of 988. But there’s another problem: Even though Congress created 988, Congress didn’t fund it.
There is some money coming from the Biden administration. But at least initially, what 988 becomes will depend largely on what states, cities, and counties do.
The first people 988 callers will encounter are the crisis counselors who staff the National Suicide Prevention Lifeline—the 10-digit hotline that Congress has repurposed as the foundation for 988.
That lifeline is staffed locally by counselors and more than 180 call centers around the country. They all look and operate pretty differently. But at their core, they provide the same basics: emotional support, possibly some referrals to local mental health services. And research out of Arizona suggests that for a big chunk of callers, about 80 percent, that’ll be it. The phone will be enough.
For the other 20 percent, ideally, the call center would dispatch some type of first responder to the caller’s location, just like 911. And here is where communities are starting to make some pretty different choices, because a lot of those first responders are police. And police scare a lot of people.
“If 988 is executed the way 911 is executed, people will die,” says Madhuri Jha, who directs the Kennedy-Satcher Center for Mental Health Equity at the Morehouse School of Medicine. As the Washington Post reports, police have fatally shot more than 1,500 people with mental illness in just the past six years. And we know that Black people are already more than twice as likely to be fatally shot by police than whites. Add mental illness into that mix, and a Black person’s risk of being killed by police quadruples.
Communities are experimenting with who should respond to these emergencies. Chicago is piloting police-free options, such as staffing mobile crisis vans with social workers and paramedics, even people who have lived through their own mental health struggles. Richland County, South Carolina, is still using police but pairing them up with mental health workers. Arizona has embraced a kind of short-term facility, literally called the Living Room, with recliners and couches where people in crisis can rest and make a recovery plan.
Right now, when people experiencing a mental health crisis call 911, most of the time they end up in a hospital or in jail. “More than 2 million people each year with a mental illness are booked into our nation’s jails and prisons. It’s a huge number,” says Hannah Wesolowski, who directs policy for the National Alliance on Mental Illness. Advocates like her see 988 as a chance to significantly shrink that number.
Keeping people out of the hospital and jail could result in savings, which would have obvious appeal to policymakers. But delivering on that promise will be tough.
It’s clear 988 is a rare national opportunity to welcome many more people in crisis into care. With no clear blueprint of what to actually build, though, and a lack of resources, there’s a lot of concern that this opportunity may slip away. Mental health experts say they can easily imagine 988 services will look a lot like the status quo: long wait lists, inadequate services. And they know better than anyone else what more of the same means: more suicides, more overdoses, more lives lost.
“This does represent a chance to get it right from the beginning. And I don’t want us to be coming back 10, 15 years from now trying to fix what we are about to roll out,” says Ben Miller. He runs Well Being Trust, a national mental health philanthropy. “My biggest fear is that we’re going to have 51 versions of bad. People are not necessarily going to have the comprehensive vision that they’re going to need for this to be meaningful.”
There’s a laundry list of reasons why we might end up with Miller’s 51 versions of bad, including problems with staffing, stigma, training, and technology. But let’s just focus on federal funding. In December, the Department of Health and Human Services committed nearly $300 million to “shore up, scale up, and staff up” the National Suicide Prevention Lifeline and its local call centers.
What about funding for all the services that could come after the call, the mobile crisis teams, the care facilities? States and cities are scrambling, piecing together federal mental health grants, Medicaid dollars, dipping into pots of money wherever they can find them. It leaves advocates like Wesolowski frustrated: “We have funded mental health this way for decades. It is pennies here, pennies there. It is out of the goodness of people’s hearts that organizations are there to support people experiencing mental health conditions. I’m hoping policymakers make the investments that we know we need to make.”
Wesolowski and others believe three different groups should split most of the tab for 988 and all the services that surround it. First, the federal government. There are several bills kicking around to step up funding. Second, the states. When Congress passed the 988 legislation, it gave states the authority to tack fees onto people’s cellphone bills to cover these crisis services—which is how 911 is funded. Most of us pay about a buck a month to support 911, for example. But these new 988 charges have to pass through legislatures, and that’s been tricky so far. Just four states succeeded last year.
The third group is health insurers. And there’s an important bipartisan bill, supported by Sens. Catherine Cortez Masto, a Democrat from Nevada, and John Cornyn, a Republican from Texas, that would require most insurers, including Obamacare plans, employer plans, and Medicare and Medicaid to reimburse this full spectrum of crisis services from mobile teams to urgent care facilities. For the first time it would establish federal standards for what those services need to provide—so insurers know what they’re paying for and what they’re getting in return. The legislation is still in the early stages, so it’s hard to say if it will pass.
Most researchers and advocates expect the 988 rollout to be bumpy. Federal health officials have said to give local providers more time to ramp up operations, they will begin serious promotion of the new line in 2023. But there are reasons to think we’ll start to see some progress, too. Every state in the nation has people like Andrea Harrison, who now works for a crisis call center in West Virginia, excited for the calls to start coming in this July. It’s a job, she says, that brings her almost as much joy as the bond she’s rebuilt with her two sons.
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