988 crisis response: A promise in peril

There’s no shortage of headlines about tragic outcomes for those living with mental health and substance use disorders in this country. Whether addressing rising suicide and overdose rates or fatal interactions with police, at the heart of these headlines is a gross inequity the U.S. has yet to fully acknowledge — the failure to provide a mental health response to mental health crises. This failure is driven by a deeply rooted systemic bias that is evident in the separate and unequal treatment of mental illness. It impacts every facet of society, contributing to tens of thousands of preventable deaths each year and fueling a dangerous undercurrent of stigma.

At its most obvious, bias in our health care system is reflected in disparate access to care and higher costs for people with mental health and substance use disorders. In fact, a recent report from the Government Accountability Office (GAO) casts doubt on whether insurers are complying with the Federal Parity Act, which requires them to cover treatment for mental health and substance use disorders at the same level as treatment for other conditions, such as diabetes and cancer.

Less obvious, but even more insidious, is the fact that the response to people experiencing a mental health or substance use crisis is often law enforcement. Police were never meant — or adequately trained — to deal with psychiatric crises. The results are both traumatizing and, frequently, tragic. According to the Treatment Advocacy Center, people with untreated mental illness are 16 times more likely to be killed by police. In 2017, an average of 10 percent of law enforcement agencies' total budgets and 21 percent of staff time were spent responding to and transporting persons with mental illness. And that’s just the tip of the iceberg. A 2015 analysis found that the 10 largest police departments in the country paid out almost a quarter of a billion dollars the previous year in settlements and judgements (up nearly 50 percent from four years earlier). Many of these settlements were related to wrongful-death lawsuits of people in a mental health crisis.

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Some cities have taken action to change this. For example, Eugene, Oregon’s Crisis Assistance Helping Out On The Streets (CAHOOTS) program sends a mobile team consisting of a medic and a mental health counselor to de-escalate crises and formulate plans. The program cost $800,000 in 2018, less than 2 percent of the annual Eugene police budget.

Thankfully, in fall of 2020, Congress approved a national mental health crisis alternative to 911 through the Suicide Hotline Designation Act: 988. But a number alone isn’t enough. Congress recognized that states would need 24/7 call centers staffed by trained individuals; mobile crisis teams, and crisis stabilization services that transition to follow-up care. Accordingly, they proposed state fees on telecommunications bills to help implement the needed networks.

State policymakers are now responsible for introducing and passing bills that include 988 fees on telecommunications bills to support crisis call centers and non-billable mobile crisis and crisis stabilization program costs. Many are making progress, but they’ve hit a major roadblock.

The telecommunications industry is fighting state 988 bills because of the fees they would have to facilitate — fees that supposed to pay for “efficient and effective routing of calls, personnel, and the provision of acute mental health crisis outreach and stabilization services,” according to Congress. So far, the industry, which made billions in profits during the first quarter of 2021 and has benefitted from recent expansions in tele-mental health, has fought to lower and narrow fees in states ranging from Kansas to California — even though these small fees (typically, less than $.50 per phone line per month) will be paid by consumers.

With Americans reporting increased depression, anxiety, financial strain, social isolation, substance use, and suicidal ideation amid the pandemic — and with increases in completed suicides among certain populations like Black youth — now, more than ever, we must get people help when and where they need it. Everyone must do their part, including an industry that has enjoyed tremendous growth in our smart phone-driven world.

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With 988, we have a historic opportunity to reduce avoidable emergency or hospital admissions; make better use of law enforcement resources; address long-standing inequities; and build healthier, more resilient communities — all for a fraction of what we are spending on our current response to mental health crises.

It’s time to shed antiquated prejudices and make a bold statement that mental health is not a moral failing or a crime. Let’s take action now to right the wrongs of our past through a reimagined crisis system that benefits everyone.

Former U.S. Rep. Patrick J. Kennedy is founder of The Kennedy Forum and co-chair of the National Action Alliance for Suicide Prevention’s Mental Health & Suicide Prevention National Response to COVID-19 (National Response). Daniel H. Gillison Jr. is the Chief Executive Officer of the National Alliance on Mental Illness (NAMI) and National Response Steering Committee member.