It’s been over two years since the United States Congress passed the National Suicide Hotline Designation Act of 2020, allowing states to implement a monthly telecom service fee for 988 crisis system costs. Yet, only five states have enacted one, said Hannah Wesolowski, chief advocacy officer of the National Alliance on Mental Illness. The nonprofit has been mapping 988 crisis response legislation.
Pushback on the service fee from legislators and telecom industry members is often due to an insufficient understanding of just how underfunded and under-established the behavioral healthcare crisis continuum is in most communities.
So far, California, Colorado, Nevada, Virginia, and Washington State have enacted a service fee in their 988 legislation, with some explicitly stating the fee can’t exceed 30 cents per line. It’s a very minimal amount, said Wesolowski, “Virginia’s is 12 cents.” “Over 12 months, that’s less than two dollars a year.”
Despite service fees equaling a couple of dollars per phone line, Wesolowski emphasized that calling them a tax has been a big turn-off for policymakers. “Many people talk about the fees as a tax, and taxes aren’t popular,” she said. Politicians are especially wary of imposing taxes, particularly during an election year. “It has posed a challenge and can derail the conversation.”
Another barrier to service fee inclusion has been a common misunderstanding of the intent of the National Suicide Hotline Designation Act of 2020 on how states and tribes should use the fees. The federal act explicitly allows them to use the telecom customer service fee to cover 988 crisis system costs and not just for call centers. The service fee is to ensure efficient and effective 988 call routing to an appropriate crisis center and costs related to personnel and providing acute mental health, crisis outreach, and stabilization services responding to the 988 hotline. “Congress was clear in the language around this fee that it’s designed to support the entire 988 crisis care system,” highlighted Wesolowski.
Pushback on the service fee from legislators and telecom industry members is often due to an insufficient understanding of just how underfunded and under-established the behavioral healthcare crisis continuum is in most communities. “Many arguments against the fee are that it’s being used for a wider purpose than with a 911 fee,” she said.
That’s what happened in Washington State, with Gerard Keegan, vice president of State Legislative Affairs at the Cellular Telecommunications Industry Association (CTIA). He testified before the Washington House Committee on Health Care and Wellness in January 2021 that 988 service fees “be kept as low as possible.” Jen Stuber, Ph.D., who helped craft the state’s 988 implementation legislation, said telecom industry members wanted the fee allowance in the federal act to be narrowly interpreted and only go toward direct call center costs. In part, this was because the state’s 911 service fee funds were limited to 911 call centers. “It’s a false equivalency,” said Dr. Stuber, emphasizing that a similar approach for 988 service fees would make it impossible to build an equitable crisis care infrastructure. Washington State passed the 988 legislation with a service fee (the fee increased from 24 cents to 40 cents per month for each service or access line on January 1, 2023); proceeds from the fee go into the statewide 988 behavioral health crisis response and suicide prevention line account.
The purpose of the 911 fee, noted Wesolowski, was to have a communication network for existing emergency services. “With mental health crisis care, we are trying to build that system where it doesn’t exist in most places,” she emphasized. Educating policymakers and telecom industry members on 988 has helped to decrease conflating the intent of 911 and 988 fees.
While legislators and telecom members do react to the language used around service fees, the general public doesn’t care much whether the service fee is called a fee, surcharge, or tax. Public support hinges more on awareness, said Wesolowski. Polls on 988 and crisis response public opinion conducted by NAMI and the market research company Ipsos, revealed that many people didn’t even realize they paid a monthly 911 fee on their phone bill. “Most people were entirely unaware.”
The knowledge that they already pay a fee for 911 shifted respondents’ support of a 988 fee, increasing from 73 percent to 78 percent. Nearly 50 percent of respondents supported a comparable fee for 988 as what they already pay for 911, an average of one dollar per month across the U.S. “There’s a fair amount of public support for a 988 fee on phone bills, which we were frankly somewhat, and pleasantly, surprised by at first,” said Wesolowski. “Our initial concern was maybe people wouldn’t support it.”
The NAMI-Ipsos polls illustrate that the general public is becoming more familiar with 988. In October 2021, only 4 percent of respondents were somewhat or very familiar with 988. By September 2022, 14 percent said they were somewhat or very familiar with 988. “There’s still a long way to go,” noted Wesolowski.
The nation has a system to address physical health emergencies—911, ambulance, and the emergency department. The 988 service fees are helping establish an equitable system to address mental health emergencies and parallel services, including 988 call centers, mobile crisis, and crisis receiving and stabilization services. “The 988 service fees are really about equity,” said Wesolowski. However, she pointed out it will take far more than service fees to sustain the 988 system.
Some states are invoking federal and state insurance benefit parity law requirements to help fund their 988 crisis systems. California’s 988 legislation does so and directly ties behavioral health services to medical necessity. Arlene Stephenson, senior advisor at the National Association of State Mental Health Program Directors (NASMHPD) and co-author of A Behavioral Health Parity Playbook: Strengthening State Laws and Partnerships, has said a barrier to sustainable funding for 988 crisis systems is that “insurers aren’t paying their fair share.”
While not all state 988 legislation directly includes language on federal and state parity laws, Wesolowski highlighted that some states are trying to use 988 legislation to address insurance coverage. For example, New Jersey’s 988 legislation directly refers to the federal parity law, Utah requires a commission to report on barriers for future consideration, and West Virginia’s law focuses on billing, requiring the state department of health and human services to determine coding and payment for crisis stabilization services for people who are uninsured or underinsured. Oregon, Virginia, and Wyoming all have pending legislation that addresses behavioral health coverage, including Medicaid reimbursement, strengthening crisis services insurance coverage, and addressing coverage for uninsured or underinsured people.
Perhaps less obvious for ensuring parity is developing data feedback loops in 988 legislation. It also helps garner support from policymakers and insurers, said Wesolowski, by illustrating the effectiveness and cost benefits of the 988 crisis system and identifying system gaps and disparities. Some states are developing robust metrics to track the 988 crisis system, including 988 volume, wait times, and contacts for whom mobile crisis services are dispatched and who go to crisis receiving and stabilization centers.
New York’s 988 legislation includes metrics on the number of 988 contacts, who mobile crisis transports to law enforcement custody, an emergency department, or inpatient mental health services. It will track the number of times mobile crisis services are the first responder and, if mobile crisis requests law enforcement, the reason for doing so and the outcome of the law enforcement response. The state will examine equity and the success of the 988 system and whether there are variations in system response by race and other demographics.
“We need to know if 988 diverts people from the criminal justice system and if that varies by race, socioeconomic factors, or geography,” said Wesolowski. “It’s important that there’s accountability from the onset.”
She hopes other states follow suit with comprehensive 988 data collection and analysis, which can help assure legislators and insurers that the 988 crisis system is far more equitable, beneficial to consumers, and cost-effective than law enforcement and the emergency room as the default responder and provider. However, change will continue to take a collective effort. Developing state advisory boards or other oversight mechanisms is an essential component, said Wesolowski, ensuring the inclusion of diverse voices, such as people who have navigated the crisis system, peer support specialists, family members, the provider community, and law enforcement.
“Our success with 988 has been because so many groups have come together to speak with one voice and push a clear framework and solution. That continued cooperation and collaboration will be critical to see this through and make certain every single community has the full continuum of crisis care available.”