Suicide was the 10th-leading cause of death in the United States in 2018, accounting for more than 48,000 deaths, according to the most recent data from the Centers for Disease Control and Prevention. In the 18 years beginning in 2000, suicide rates rose 30% nationally and increased in nearly every state.
For every suicide death, there are more than 200 people who consider suicide—over 10 million Americans in 2018. More than 3 million of the 10 million would go on to make a suicide plan, and nearly 1.5 million attempted suicide.
Moreover, in the year beginning April 2020, about 100,000 people died by overdose, a nearly 29% increase from the previous year and the nation’s highest-ever rate of death due to overdose.
While state lawmakers have taken many steps to prevent deaths by suicide, overdose and other behavioral health crises, bipartisan federal legislation enacted in 2020 created new options for preventing suicides and overdoses by establishing a nationwide, three-digit behavioral health crisis call number. The Substance Abuse and Mental Health Services Administration describes the new 988 Suicide and Crisis Lifeline as a “first step” toward transforming the crisis care system, acknowledging the role the number can play in connecting individuals to community-based providers who can deliver a full range of behavioral health services.
Overview of Federal Legislation
Congress enacted the National Suicide Designation Act in 2020, establishing the 988 lifeline to take advantage of the infrastructure of the current National Suicide Prevention Lifeline (1-800-273-8255). The new number, which goes into effect on July 16, will respond not only to people considering suicide but also to those in crisis due to extreme mental illness or drug overdose.
The legislation provided for a two-year transition from the existing line to the new one to allow for widespread network changes and for states and call centers to prepare for the expected increase in the volume of calls. The shorter number is intended to be easier to remember and more accessible to people considering suicide or experiencing a mental health crisis or overdose. In November 2021, the Federal Communications Commission announced that the lifeline would also accept text messages.
Calls from all 50 states to 988 and the existing 800 number will be routed to the National Suicide Prevention Lifeline without additional action needed from state legislatures. The federal legislation, however, gives states the flexibility to invest in different programs to support call centers and the professionals who respond to mental health crisis calls.
Calls to the lifeline will be answered by the nearest available call center in a network of over 200 accredited centers across the country. If a local call center is not available, the call will be redirected to the nearest center or eventually to the national response center in New York City.
People calling or texting 988 will be connected to trained counselors who are part of the existing lifeline network. The counselors will provide callers with support and connect them to resources whenever necessary and possible.
Expanding the Lifeline Capacity
States have the option, but are not required by the federal legislation, to create a surcharge fee for telecommunications service users. The legislation stipulates that this fee must be similar to those already implemented in states to provide emergency services through 911 and that the fee can only be used to support 988 lifeline services. Most states currently assess 911 fees, which, in 2018, generated $2.6 billion to support the service. Similarly, the 988 surcharges can be used to support and expand local crisis response services and enhance communities’ access to behavioral health care.
Options lawmakers may consider to support the lifeline include:
- Expanding call center capacity: Call centers can provide immediate support for a people in crisis, connecting them to care or providing crisis stabilization services. A 2018 evaluation found that nearly 80% of callers interviewed six to 12 weeks after calling said their calls kept them from attempting suicide, provided them with hope and helped them connect with mental health resources. Local call centers can do this more efficiently than distant ones by connecting people to community resources.
- Empowering mobile crisis outreach teams: Behavioral health professionals and EMTs working in teams help stabilize individuals during law enforcement encounters and during crisis situations. These units are trained to respond to behavioral health crises, improve outcomes for individuals in crisis and allow law enforcement to focus on other priorities.
- Expanding local access to behavioral health: Expanding access to care at crisis stabilization centers and other receiving facilities, including Certified Community Behavioral Health Clinics, creates an alternative to treating people in crisis in emergency departments, which tend to be more expensive and sometimes provide inappropriate treatment.
A number of states have enacted legislation enabling some of these options. Colorado created the 988 crisis hotline enterprise in the department of human services to fund the call number and provide outreach, stabilization and acute care to individuals calling the service. On Jan. 1, 2022, the enterprise imposed a 988 surcharge of 18 cents on telecommunications service users. Nevada required its health department to establish at least one support center to answer hotline calls and coordinate the response to them. The measure also allows the department to implement a service fee and encouraged the department to establish mobile crisis teams.
Washington enacted a service fee to develop triage hubs and a new interface to connect callers with care. Virginia directed its health department to develop crisis call centers, community care teams and mobile crisis teams. The state also created a 12-cent fee on postpaid wireless charges to support these programs.
State Actions: Funding and Implementation Models
Some states have supported 988 services without charging a service fee to telecommunications users. Utah, for example, created a statewide account charged with distributing money from the state’s general fund to crisis response programs associated with the 988 service. The programs include the lifeline call center and mobile crisis receiving centers; stabilization services; and other behavioral health crisis services. Spending from the account is tiered, prioritizing the statewide call center before it funds other 988 services.
Both Utah and Indiana took an additional step, directing their state Medicaid agencies to apply for waivers from the Centers for Medicare and Medicaid Services to allow for reimbursement of 988 services for people enrolled in Medicaid. Indiana’s proposed waiver would allow provider reimbursement for Medicaid-eligible individuals who are undertaking an initial assessment, intake or counseling in a community mental health center. It would also allow reimbursement for Medicaid rehabilitation option services concurrently with reimbursement under a residential addiction treatment program.
Still other states are review the best ways to administer 988 in their communities. Alabama, Nebraska, New York and Texas created study commissions or task forces to evaluate the behavioral health care landscape and make recommendations to lawmakers on improving services using 988.
Federal Funding and Support
The Department of Health and Human Services has provided $282 million to states to help transition the National Suicide Prevention Lifeline from the current 10-digit number to the new three-digit code. This investment includes:
- $177 million to strengthen and expand the existing lifeline network operations and telephone infrastructure, including centralized chat/text response, backup center capacity, and special services (e.g., a line for Spanish speakers).
- $105 million to increase staffing across states’ local crisis call centers.
As part of this federal spending package, the Substance Abuse and Mental Health Services Administration will provide a notice of funding opportunity to states to begin building capacity for the lifeline. The funding can be used to recruit, hire and train behavioral health workforces to staff local 988 centers; engage lifeline crisis centers to unify 988 responses across states and territories; and expand the crisis center staffing and response structures needed for the successful implementation of 988.
Charlie Severance-Medaris is a senior policy specialist in NCSL’s Health Program.
This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $200,000 with 100% funded by the CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, the CDC/HHS or the U.S. government.