The long-awaited three-digit crisis hotline known as 988 rolls out nationally Saturday, a win for mental health advocates who see the simplified number as the first step on a path toward building out crisis care.

But how ready states and advocates feel about the next steps to improve mental health is more complicated.

The implementation of 988, which will direct callers to the National Suicide Prevention Lifeline, is the first of the federal government’s three-step process to building better mental health care. The steps include the crisis call center number, which will take calls and dispatch support; mobile crisis response, which will send teams to the crisis; and crisis stabilization services, or facilities to receive and serve those undergoing a crisis on a short-term basis.

Experts said that’s not unusual — the implementation, funding and widespread adoption of 911 in the late 1960s and 1970s took years to achieve, for example. 

Becky Stoll, vice president for crisis and disaster management for Centerstone, a nonprofit health system specializing in mental health and substance use disorder services, said “nothing magical” is tied specifically to Saturday.

Instead, she likened it to a launchpad.

“I almost feel like we’ve been pregnant for a really long time and we’re overdue,” she said. “This is the beginning of what, I think, is going to be transformative for the mental health system. So I really hope there’s not a focus on, ‘We’re not ready.’ … I just think that sends the wrong message.”

The rollout, says Benjamin F. Miller, president of Well Being Trust, a philanthropy dedicated to advancing mental, social and spiritual health, will show the need for larger structural reform within behavioral health.

“We are constantly putting out fires without looking at who is starting them,” he said. “We are never trying to actively prevent these crises from happening in the first place. … That is where I think we need to spend a bit more time.”

Miriam E. Delphin-Rittmon, assistant Health and Human Services secretary for mental health and substance use, said funding from the 2021 COVID-19 relief law allowed the lifeline, still at 1-800-273-TALK, to answer substantially more calls in May compared to February 2022, she said.

The current lifeline answered 27,000 more calls, a 20 percent increase; 27,000 more chats, a 165 percent increase; and 3,000 more texts, a 93 percent increase, Delphin-Rittmon said during a briefing hosted by the nonprofit Education Development Center and National Action Alliance for Suicide Prevention.

Advocates have called for sustained funding, as state approaches to find support for crisis centers have varied widely. Four states — Virginia, Washington, Colorado and Nevada —  have enacted comprehensive legislation that can generate a sliding scale of income depending on the state’s needs. As with 911, the fees would be tacked onto phone bills.

Lauren Conaboy, vice president of national policy at Centerstone, said she would like to see state legislatures enact laws to authorize flexible telecom fees this session, suggesting they could look at data collected so far and adjust if needs increase.

But getting state legislatures to act has been a challenge, said Lauren Finke, a policy adviser at The Kennedy Forum, a mental health organization founded by former Rep. Patrick J. Kennedy. She said at least 18 states have pursued fee legislation that has been watered down, stalled or minimized, largely because of lobbying efforts by telecom and cable companies.

Finke said states have also been reluctant to build out crisis care systems without more guidance from the federal government clarifying whether more federal dollars are available to them.

“It’s clear that states need more guidance in order to be compelled to act, but there’s nothing keeping states from acting right now,” she said. “I very much worry that as we’re waiting for guidance from the federal government to come down, that really we’re just dragging our feet on something that we’ll need to figure out as a state anyway, so I think states should enter into these planning processes.”

Conaboy acknowledged the implementation of 988 comes at a unique time.

“We never imagined that — fast forward to July 2022 — we’d be a couple of years into a global pandemic and the most historic workforce shortages we’ve faced and particularly strong workforce shortages in mental health,” she said. “Then on top of that, probably the most acute mental health needs that our country has ever faced.” 

National Council for Mental Wellbeing CEO Chuck Ingoglia said that while participating in a webinar about 988 readiness last week targeted at providers, he observed differences among the approximately 700 attendees.

“What struck me is the varying levels of knowledge about all of this, so I still think we’ve got people all over the place,” he said. “So it’s gonna take a while.”

Legislative hiccups

The 988 implementation date has served as a benchmark for mental health advocates, who had hoped to pass comprehensive mental health legislation before July 16 that would encompass policies related to 988 and crisis care, substance use disorder prevention and treatment, and a broad plate of mental health policies and resources.

Those efforts started last year with Senate Finance Committee leaders beginning to draft legislation, though only sections of that bill have been released to date. Senate Health, Education, Labor and Pensions, which also has jurisdiction, is less far along. 

The House Energy and Commerce Committee’s mental health grants reauthorization package passed the House, and while it includes some 988 provisions it did not include any new spending — a condition necessary to secure Republican support. 

A Senate Democratic aide described the different committees’ work on the issue as a loose alliance, with lawmakers hoping pieces would move forward as part of ongoing discussions over reconciliation measures.

But reconciliation efforts could complicate the pursuit of a separate bipartisan bill simultaneously, and divvying up the varying committees’ work on the issue would require finding multiple vehicles in an already crowded calendar, another hurdle to passage.

The Democratic aide also said Senate Minority Leader Mitch McConnell‘s threat to block a China competitiveness bill if Democrats move forward with reconciliation could also apply to a bipartisan mental health bill.

Sarah Corcoran, vice president of government relations at Guide Consulting Service, a government relations and public affairs firm, said she still hoped to see a bill done by the end of the year.

“It is difficult to do a bipartisan, bicameral package because obviously, each committee has their own and each member has their own priorities,” she said, adding there are limited days in session through September. “I do think it’s easier to get things done after elections are over.”

Megan S. Herber, director at Faegre Drinker Consulting, said the initial hope was for a larger mental health package to be together before August, which is now unlikely.

Advocates have expressed concerns that the gun safety law, which included several mental health provisions, could reduce lawmakers’ appetite for a separate mental health package, among other competing priorities.

Two lobbyists with knowledge of discussions have acknowledged that markups in Finance and HELP pegged for July were delayed because of gun discussions.

But Herber said that since that law only looked at slices of behavioral health, there is still room for other pieces.

“It did not include Medicare intentionally,” she said. “There’s still, I think, some impetus to do something in the Medicare program, and then secondly, it also did not focus on substance use disorder.”

Ingoglia, too, emphasized the need for more comprehensive legislation. 

“We don’t want a system that can only respond to people when they’re having a crisis,” he said. “We want to be able to prevent crises. We need people to be able to get ongoing care. There’s some significant things that need to happen in order for that to become a reality.”