Amid growing concerns about the impact of the pandemic on Americans' mental health, and the rollout of a new three-digit number for the National Suicide Prevention Lifeline this summer, advocates say local call centers across the nation remain underfunded and understaffed for an expected increase in call volume.
Despite the effort to improve the system, they say, people in crisis could face delays -- or might not be able to reach a counselor at all.
On July 16, the Lifeline will transition from its current 10-digit hotline number to the much easier to remember 988, modeled after the 911 emergency number for police and fire.
The 24-hour hotline has been in service since 2005, and in that time has received more than 20 million calls from people looking for help.
"What we're building on is a proven, existing service that's shown to reduce emotional distress and suicidality," Lifeline Executive Director Dr. John Draper told ABC News. "It's essentially scaling up that service to make sure that we're going to be able to reach more people and serve them more effectively."
When possible, calls are received by the nearest crisis center, but if a local center cannot handle them, they get routed to one of several national backup centers that receive federal funding to maintain staffing.
"And the more that happens, the longer people wait. And that's something you don't want for people in crisis," Draper said is the case when there's not enough money.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which allocates federal funding for the program, estimates a 25% increase in callers to the Lifeline for fiscal year 2022. The 988 number will only be operational for the final three months of that period.
During the first full year of 988 implementation, FY2023, SAMHSA estimates calls received will reach 7.6 million, which is more than double the most recently recorded metrics.
This year, the federal government allocated $282 million through SAMHSA for 988 implementation, an amount stakeholders call "unprecedented."
The organization has two major goals for supporting the Lifeline crisis center network, according to John Palmieri, acting lead for the 988 and behavioral health crisis team at SAMHSA.
"One of them is making sure that there is that safety-net infrastructure that exists at the national level, so that when individuals call, if for some reason those calls aren't able to be received at the local level, that there's a national safety net to support those individuals in crisis," Palmieri said.
A total of $177 million dollars is dedicated to fund the backup centers with the other $105 million going to states and territories to support local crisis centers.
"We really feel like from the perspective of the individual in crisis, it really is best for them to be connected at the local level to the degree possible, to be better integrated with the local system of care, to provide wraparound services and so on," Palmieri said.
An internal 2021 survey of local crisis centers in the Lifeline network found that only about 43% were explicitly funded to answer Lifeline calls, according to Draper.
"They were simply volunteering their services because their organization, their agency's mission, aligned with ours," Draper said. "And so they would basically borrow staff from other lines of business, who were dedicated to other lines of business, to help answer calls that were unfunded. So that's the steep hill that we have to climb."
Since its inception, the Lifeline network has been underfunded, according to Draper. With the transition to a three-digit number looming, even more funding is needed to ensure centers are adequately staffed to accommodate the expected increase in callers.
As it stands, Draper says about 20% of calls that should be answered at the local level are currently being picked up through the national backup network. Even with the national backup network, a SAMHSA report shows that at its current capacity, the Lifeline can only address approximately 85 percent of calls.
Because local crisis centers are funded at the state level, resource allocation and sustainability of funding are inconsistent across state lines.
The National Academy for State Health Policy (NASHP) has been tracking state level legislation around the implementation of 988.
"States are all over the map on this," said Kitty Purington, senior program director for NASHP. "And I think there are many states who have not really grappled with what sustainability looks like going forward."
When Congress enacted legislation to designate 988 as the new Lifeline number in 2020, that law included a provision allowing states to place a tax on cell phone bills to support the service. Similar taxes are used to support emergency medical and law enforcement services through 911 call centers.
Few states have enacted legislation to impose these taxes so far. A handful of others have implemented exploratory committees or provided some funding for the rollout of the new number.
"There's going to be some time to build this out," Purington said. "And potentially, it's going to be something that states are going to be doing for years."
She compared the transition to the implementation of emergency services through 911 call centers.
"People say  took like 60 years to really get its footing," Purington said. "It took decades for people to really understand and have 911 be really the go-to number. And so, this is not going to be like flipping a switch."
Stakeholders in the mental health field remain optimistic, despite the underfunding of the program. Laurel Stine, senior vice president of public policy at the American Foundation for Suicide Prevention, said, "ultimately, 988 is more than just a number."
"It is an opportunity to really reimagine the behavioral health crisis response system," Stine said.
Stine says the vision of an ideal 988 system would include well-resourced crisis centers across the country, the ability to provide follow-up care as needed, mobile mental health crisis response teams and crisis stabilization centers.
"We understand fully that a lot has to occur," Stine said. "There are states that are well equipped, and have mobile crisis teams and are well-resourced and there's others that are not. And so the local level of readiness is varied."
The overall need is pressing.
U.S. Surgeon General Vivek Murthy recently sounded the alarm to lawmakers over an increase in suicide attempts among young people during the the pandemic.
And President Joe Biden called mental health a priority in his State of Union address earlier this month, saying, "let's get all Americans the mental health services they need."
If you are struggling with thoughts of suicide or worried about a friend or loved one, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 [TALK] for free, confidential emotional support 24 hours a day, 7 days a week.