PROJECT SUMMARY
On July 16, 2022 “988” will become the national toll-free dialing code for the National Suicide Prevention Lifeline
(Pub. Law 116-172). The Lifeline receives 3.5 million calls annually and has demonstrated effectiveness at
decreasing suicidality, hopelessness, psychological distress, and suicide death. The transition from the current
10-digit Lifeline dialing code to 988—a three-digit code like 911—is projected to potentially triple call volume.
The impact of 988, however, will likely be determined by state policy responses to financing its implementation.
The federal law that creates 988 encourages states to pass user fee legislation (e.g., a flat fee monthly per every
cellphone plan holder in the state, identical to how 911 is financed). The current state policy landscape is
extremely varied. As of January 2022, four states had passed user fee legislation and many others were
considering such legislation. The proposed policy implementation project focuses on the characteristics,
determinants, and impacts of 988 user fee legislation and other policy strategies used by states to finance 988
implementation. The project’s Specific Aims are to: 1) Characterize states’ 988 implementation financing
strategies and identify determinants of implementation strategy adoption; 2) Explore perceptions of the financing
determinants of 988 policy implementation success and acceptability and feasibility of legislative financing
strategies to improve implementation; and 3) Determine the effects of 988 user fee legislation on the policy
implementation outcomes of fidelity (Lifeline in-state answer rates) and reach (Lifeline state call volume rates),
the effectiveness outcomes of suicide death and emergency department use for mental health crises and self-
harm, and assess effect heterogeneity across demographic groups. These aims will be achieved by a legal
mapping study, national surveys of 250 suicide prevention stakeholders (e.g., Lifeline call center leaders), 60
semi-structured interviews, and a difference-in-differences analysis comparing trends in implementation and
effectiveness outcomes pre (2015-2021) and post (2022-2025) 988 implementation between states that did and
did not pass 988 user fee legislation. The project team has expertise in policy implementation science (Purtle,
Raghavan), suicide (Lindsey), law (Pomeranz), and quantitative policy analysis (Stuart). Practice partners
include Vibrant Emotional Health, which administers the Lifeline, and the American Foundation for Suicide
Prevention. The project is innovative because it advances the understudied area of policy-focused
implementation science. The project is significant and will have impact because it focuses on a major federal
policy in the early stage of implementation and because it will generate knowledge to inform implementation
financing decisions related to 988—which is likely to be a primary gateway to mental health crisis and suicide
prevention services for the foreseeable future. The project is aligned with NIMH’s Strategic Plan, which prioritizes
suicide prevention, and the NIMH pledge to reduce the suicide rate by 20% by 2025.
