Hannah Berkowitz is 20 years old. When she was a senior in high school her life flew off the rails.

She was getting high on whatever drugs she could get her hands on. She was suicidal. Berkowitz moved into a therapeutic boarding school to get sober, but could only stay sober while she was on campus during the week.

“I’d come home and try to stay sober really hard — really, really hard,” says Berkowitz. “Sometimes I’d make it through the weekend, and sometimes I just couldn’t make it. It was white-knuckling it, just holding on.”

The transition back home always triggered a relapse for Berkowitz.

“I thought it was just my fault and there was no hope,” she says.

No hope — but Berkowitz did have luck. She had private health insurance and she lived in Connecticut, where a startup company, Aware Recovery Care, had begun treating clients in the very environment where Hannah was struggling to stay sober: her home.

A chronic disease approach

Treating addiction is a growing business, but a lot of the treatment that’s available is expensive and patients often relapse. Fortunately, there is a way to help some people pay less for better results, says Matt Eacott, vice president of Aware Recovery Care.

“Ninety-nine percent of the industry really treats addiction as an acute problem — like a rash on your arm that you rub lotion on and you’re done,” says Eacott.

Instead, Aware treats addiction as a chronic illness — it doesn’t disappear just because symptoms are temporarily under control. The approach is a cost-effective way of treating addiction, Eacott says, with better results than most competitors achieve.

Aware comes into clients’ homes and connects them with a nurse, a primary care doctor, a therapist, peer support, 12-step meetings and a case manager. Clients hooked on opioids can get medication-assisted treatment. They can also submit to urine screening and GPS tracking, if that helps them stick with the program.

Hannah’s mother, Lois Berkowitz, says the program is intense at first. But as Hannah built coping skills the supports faded into the background.

“It’s not like they’re doing the work for the addict,” says Lois Berkowitz, “they’re just basically taking them by the hand and saying, ‘Here are the places you need to go that will help you. And I’m going to go with you to start, so it doesn’t feel that uncomfortable. And then we’re going to let you fly.’ “

Before they “fly,” Aware clients have a pretty long runway. The treatment lasts for a full year.

Benefits worth the initial cost, insurer says

Aware has now expanded from its base in Connecticut into New Hampshire. The program is expensive. It costs $38,000 a year. As of now, it’s only available to private-pay clients and people insured through Anthem health insurance in New Hampshire and Connecticut.

Anthem became the first insurer to pay Aware, because the treatment is based on hard science that’s yielding solid results for clients, says Dr. Steven Korn, Anthem’s behavioral health medical director. Science and results are rare in addiction treatment, he says.

“There are old, old notions that have hung pretty tough,” says Korn. “When I was young — when I was in training — as soon as substance abuse was mentioned, the response of physicians was, ‘Well, go to AA. That’s not our problem. We don’t treat that.’ “

For a year of treatment, Anthem says it’s paying Aware about the same as the cost of a month or two of inpatient treatment. Anthem also says 72 percent of Aware clients are either sober at the end of one year or still in active treatment.

That’s about twice the sobriety rate of people who check in to a facility for a month and then get no follow-up care, says Dr. Stuart Gitlow, past president of the American Society of Addiction Medicine.

Treating addiction at home makes sense because it’s the exact place where people learned all their bad habits, Gitlow says.

“It’s all based on this concept that addiction is not about the substance use,” he says, “but is about what led to the substance use in the first place. And you can’t really get there without getting to know the patient.”

Aware says it’s in negotiations with four more major insurers. The program hopes to have a couple hundred clients in New Hampshire by the end of the year.

This story is part of NPR’s reporting partnership with New Hampshire Public Radio and Kaiser Health News.

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For most of his life, Carl Goulden had near perfect health. He and his wife, Wanda, say that changed 10 years ago. Carl remembers feeling, “a lot of pain in the back, tired, fatigue, yellow eyes — a lot of jaundice.”

Wanda, chimes in: “Yellow eyes, gray-like skin.” His liver wasn’t working, she explains. “It wasn’t filtering.”

Carl was diagnosed with hepatitis B. Now 65 and on Medicare, he had a flower shop in Littlestown, Pa., back then, so had been buying health insurance for his family on the market for small businesses and the self-employed.

The medications to manage Carl’s hepatitis cost more than $10,000 a year — and if he ever needed a liver transplant, as some people with hepatitis eventually do, the further costs could be formidable. Thank goodness they had health insurance, the couple thought.

But then, Carl says, “the insurance renewals went way up.”

After a few years he could no longer afford to buy the coverage — more than $1,000 a month — and also maintain his business. So he dropped the health insurance.

“I was devastated,” he says, “because I didn’t know when my liver might fail.”

But that steep increase in his insurance rate was completely legal, says Pennsylvania insurance commissioner, Teresa Miller. And back then, before the Affordable Care Act became law, a patient like Carl Goulden might have had a very hard time buying another policy; he likely would have been turned down by other insurers because he now had what’s called a “pre-existing” medical condition.

A family like the Gouldens would “just have been out of luck,” Miller says.

Pennsylvania: The wild, wild West

Before the ACA, states had differing approaches to handling pre-existing conditions.

Pennsylvania was typical. Until the ACA mandated that insurers treat sick and healthy people equally, buying insurance was the wild, wild West.

Insurers couldn’t overtly kick people off a plan if they got sick, but they could find ways to charge them a lot more, even those whose chronic condition wasn’t all that serious — such as acne. For individuals looking to sign up in the first place, “an insurance company could simply decline to offer you insurance at all because of your pre-existing condition,” Miller says.

Insurers who did offer a policy to someone with a pre-existing medical condition might have done so with a catch — the plan could require a waiting period, or might exclude treatment for that condition.

“So, let’s say you had diabetes, for example,” Miller says. “You might have been able to get coverage for an unexpected health care need that arose, but you’d still be on your own for any treatment and management of your diabetes.”

From the perspective of the insurance company, these practices were intended to prevent the sick from signing up for a health plan only when they needed costly care.

Pennsylvania did try to partially solve this problem. It created a more scaled-back health plan, called Adult Basic, for those with lower incomes who didn’t have any coverage. Lots of people signed up, but the plans didn’t include coverage for mental health care, prescription drugs or more than two nights in a hospital. Even so, Miller says, the strategy proved too expensive for the state.

“That program was spending $13 million to $14 million a month when it was shut down,” she says.

High-risk pools

More than 30 other states dealt with pre-existing conditions by setting up what are called “high-risk pools,” a separate insurance plan for individuals who couldn’t get health coverage in the private market.

These plans could be real lifesavers for some people with conditions like cancer — which can cost tens if not hundreds of thousands of dollars to treat.

The experiences with high risk pools varied, but states faced lots of challenges, says John Bertko, an insurance actuary with the state of California. And the main problem was the high cost.

“The one in California, which I was associated with, limited annual services to no more than $75,000, and they had a waiting list. There was not enough money,” Bertko says. “The 20,000 people who got into it were the lucky ones. At one point in time, there were another 10,000 people on a waiting list.”

The pools also had catches; premiums were expensive, as were out-of-pocket costs. And plans often excluded the coverage of pre-existing conditions for six months to a year after the patient bought the policy.

New Jersey: Pre-existing conditions were covered, but with a catch

Around that same time, across the Delaware River, the state of New Jersey was trying something different.

“Insurers could not take health status into account,” says Joel Cantor, director of Rutgers University’s Center for State Health Policy who has been analyzing the New Jersey experience.

Before the ACA, New Jersey was one of just a handful of states that prohibited insurers from denying coverage to people with pre-existing conditions. Insurers also weren’t allowed to charge people a whole lot more for having a health issue, and the plans had to offer robust coverage of services.

There was a one-year waiting period for coverage of a pre-existing condition, but a larger issue became cost. The entire individual market in New Jersey became expensive for everyone, regardless of their health status, Cantor says. Because there was no mandate to have health insurance coverage, those who signed up tended to really need it, and healthy people did not enroll.

And so, “the prices went up and up,” he says. And the premiums and enrollment “went down and down.”

The state tried to address this in the early 2000s by introducing a “skinny” health plan, Cantor says.

“By that I mean very few benefits,” he explains. “It covered very, very limited services.”

The plan was affordable and really popular, especially among young and healthy people and about 100,000 people signed up. But if something did happen, or if a person had a chronic health need, lots of the costs shifted to the individual.

“It left people with huge financial exposure,” he says.

That’s, in part, why the ACA included a rule that insurance plans now have to offer good benefits and be available to everybody. In exchange, insurers have the mandate and subsidies — so that everybody will buy in.

Cantor says these experiences point to an ongoing dilemma in health care: A small portion of people consume a big chunk of health care costs. It’s hard to predict who among us will cost a lot — or when. So, the question becomes, what kind of care should insurance plans cover and who should shoulder that cost?

This story is part of a reporting partnership with NPR, WHYY’s health show The Pulse and Kaiser Health News.

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