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April 29, 2025
Quarterly Article
Jonathan Purtle
Amanda I Mauri
David Frederick
Apr 29, 2025
Back to The Milbank Quarterly
Policy Points:
Rising rates of suicide and psychological distress in the United States have prompted a range of policies to strengthen mental health crisis systems and increase access to quality crisis services.1-5 The US Substance Abuse and Mental Health Services Administration (SAMHSA) defines mental health crisis services broadly, as those that are available to “anyone, anywhere and anytime.”6, 7 Further, SAMHSA enumerates three main types of services in a crisis system: 1) crisis call centers (i.e., “someone to talk to”), 2) mobile crisis teams (MCT) (“someone to respond”), and 3) short-term crisis stabilization programs (“a place to go”). Recent federal initiatives that have sought to improve crisis systems include the 988 Suicide and Crisis Lifeline (988), which was created by an Act of Congress8 that went live nationally in July 20229, 10 and the creation and expansion of certified community behavioral health clinics (CCBHCs), which are required to provide or contract for crisis services.11
Evidence suggests that such investments in crisis services hold potential to prevent suicide death and emergency department visits and hospitalizations for mental health crises and self-harm.12-14 However, the magnitude of these investments’ impact will likely be influenced by the extent to which crisis services are sufficiently and sustainably financed. Currently, the sources and adequacy of funding for crisis systems varies significantly across services in the crisis continuum and among states.15-17 As noted in SAMHSA’s 2025 National Guidelines for a Behavioral Health Coordinated System of Crisis Care, “funding for behavioral health crisis services differs significantly across states. Often these funds are pieced together, lack consistent support, and are not aligned with financing best practices.”6
In this article, we provide an overview of emergent models for funding crisis systems in the United States and the policy and service contexts related to these models. Our review assesses the status of crisis system financing recommendations proposed by Hogan and Goldman proposed in 20204 and complements prior reports about financing crisis services.18-21 The article is structured in three parts. First, we provide high-level descriptions of the three main types of crisis services, giving expanded detail about crisis call centers because of policy developments related to 988. Second, we review three emergent and evolving models for funding crisis systems: 1) telecom fees and other earmarked revenue streams, 2) the federal community mental health services block grant (MHBG) program, and 3) Medicaid via CCBHCs and other payment innovations. Third, we conclude by discussing two key priority areas for research related to financing crisis systems: 1) quality metrics and value-based payment models and 2) and the role of non-Medicaid payors.
Curtin SC, Garnett MF, Ahmad FB. Provisional estimates of suicide by demographic characteristics. Centers for Disease Control and Prevention Vital Statistics Rapid Release Report No. 34. 2023. CDC.gov. Accessed April 8, 2025. stacks.cdc.gov/view/cdc/135466
Centers for Disease Control and Prevention. Preventing suicide. CDC.gov. 2024. Accessed April 8, 2025. cdc.gov/suicide/pdf/NCIPC-Suicide-FactSheet-508_FINAL.pdf
Substance Abuse and Mental Health Services Administration. Results from the 2022 National Survey on Drug Use and Health: a companion infographic (SAMHSA publication No. PEP23-07-01-007). SAMHSA.gov. 2023. Accessed April 8, 2025. samhsa.gov/data/report/2022-nsduh-infographic
Hogan MF, Goldman ML. New opportunities to improve mental health crisis systems. Psychiatr Serv. 2021; 72(2): 169–173.
Purtle J, Mauri AI, Lindsey MA, Keyes KM. Evidence for public policies to prevent suicide death in the United States. Annu Rev Public Health. 2025;46: 22.1–22.19.
Substance Abuse and Mental Health Services Administration. 2025 national guidelines for a behavioral health coordinated system of crisis care. SAMHSA.gov. January 15, 2025. Accessed April 8, 2025. library.samhsa.gov/sites/default/files/national-guidelines-crisis-care-pep24-01-037.pdf
Substance Abuse and Mental Health Services Adminstration; US Department of Health and Human Services. National guidelines for behavioral health crisis care: best practice toolkit. 2025. Accessed April 8, 2025. samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf
National Suicide Hotline Designation Act of 2020, Pub L No. 116–172 (2020).
Draper J, McKeon RT. The journey toward 988: a historical perspective on crisis hotlines in the United States. Psychiatr Clin North Am. 2024; 47(3): 473–490.
Purtle J, Lindsey M. 988 Suicide and Crisis Lifeline in the US: status of evidence on implementation. World Psychiatry. 2025; 24(1): 135–136.
Mauri AI, Rouhani S, Purtle J. Characterizing crisis services offered by certified community behavioral health clinics: results from a national survey. Psychiatr Serv. 2025; 76(1): 13–21.
Mark TL, Henretty K, Gibbons BJ, Zarkin GA. Association of Arizona’s implementation of a behavioral health crisis response system with suicide hospitalizations. Psychiatr Serv. 2024; 75(2): 148–154.
Burns A, Vest JR, Menachemi N, et al. Availability of behavioral health crisis care and associated changes in emergency department utilization. Health Serv Res. 2025; 60(2):e14368.
Niederkrotenthaler T, Tran US, Gould M, et al. Association of Logic’s hip hop song “1-800-273-8255” with Lifeline calls and suicides in the United States: interrupted time series analysis. BMJ. 2021; 375:e067726.
Purtle J, Ortego JC, Bandara S, Goldstein A, Pantalone J, Goldman ML. Implementation of the 988 Suicide & Crisis Lifeline: estimating state-level increases in call demand costs and financing. J Ment Health Policy Econ. 2023; 26(2): 85–95.
Purtle J, Mauri AI, Cantor JH, McBain RK. Using 911 financing data as a model for 988. Psychiatr Serv. 2024; 75(7): 613–613.
Savill M, Banks LM, Gemignani R, et al. Barriers to and facilitators of effective behavioral health crisis care services. Psychiatr Serv. 2024:appips20240281.
O’Brien J. Policies and strategies to strengthen the continuum of crisis services. Brookings.edu. May 17, 2023. Accessed April 8, 2025. brookings.edu/articles/policies-and-strategies-to-strengthen-the-continuum-of-crisis-services/
Stephenson, AH. States’ options and choices in financing 988 and crisis services systems. National Association of State Mental Health Program; 2022.
Mathmatica. Financing crisis services through public and commercial insurance: current landscape and future opportunities. ASPE.HHS.gov. January 2025. Accessed April 8, 2025. aspe.hhs.gov/sites/default/files/documents/39f90405c77dd3b192c72a182ed5202e/financing-crisis-services-current-future-opportunities.pdf
RTI International. Federal funding compendium of crisis services: final report. ASPE.HHS.gov. December 2024. Accessed April 8, 2025. aspe.hhs.gov/sites/default/files/documents/2f36a29dabbbaf3e464ba3729ccc404f/federal-crisis-services-funding-compendium.pdf
