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In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P<.01) for every 10 percentage point increase in the tobacco surcharge. 2022 News; 2021 News; 2020 News; 2019 News; 2018 News; 2017 News; 2016 News; 2015 News; 2014 News; 2013 News; So the actual amount you'll pay will depend on the health insurance company you chooseand there may not be a surcharge at all. Our approach differs from the tripledifference approach used by Friedman et al, which used pre and postACA implementation as a third difference. The American Cancer Society opposed the tobacco rating provision during the congressional debate about the health-care law. Will every state implement a surcharge? Smoking cessation programs that include tobacco surcharges need to comply with federal rules for workplace wellness programs. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. Jay Inslee (D) on April 5, 2019, Washington's tobacco age restriction was set to increase from 18 to 21 on January 1, 2020. States, however, can set their own rules to reduce or eliminate that surcharge and so far at least 10 have done so, including most notably California, where the permissible surcharge has been cut to to zero. 3 Michael F. Pesko, Georgia State University. Thus, the actual monthly premium paid by the tobacco users will depend upon the health insurance company they choose and the area in which they are living. 7 If the program uses a medical test to detect nicotine or tobacco use, it also must comply with the ADA's rules for voluntary wellness plans. and text messages is not a condition for purchase. Finally, we ran a model using a definition of tobacco use closer to the definition used for enrollment in the ACA, which includes the use of other noncigarette tobacco products. Kaplan CM, Kaplan EK. The tobacco cessation wellness program is designed to promote health and prevent disease. By limiting the sample respondents in states with tobacco surcharges, we were able to estimate the effect of the size of the surcharge on insurance enrollment. Third Party Administrators (TPAs) that make payments to hospitals and ambulatory surgical centers on behalf of one or more insurance carriers (not self-insured plans) must file an annual electronic report with the HSN. Thus, people who use tobacco are advised to not just avoid health insurance because many health insurers have implemented smaller surcharges or some have also sip them altogether. [5][6] Over 54% of the country's population lived in states that had signed legislation setting 21 as the tobacco restriction age at the time the federal law set the nationwide tobacco age restriction. prevent or reduce tobacco use) of the cost of employee-only coverage under the plan. Although evidence suggests that tobacco taxes and other policies that increase the cost of smoking have a direct impact on smoking, and transmitted securely. To learn more, visit our Employers page, Determining which participants were charged the tobacco surcharge, Determining which participants were reimbursed the tobacco surcharge, Withholding the tobacco surcharge from a participants paycheck and placing it in the health plan trust account; and. Those on employer health plans can avoid the surcharge by joining an employer based tobacco cessation program. Finally, we supplemented our main findings with qualitative data from a survey that provides more contexts for how tobacco surcharges may influence enrollment in nongroup plans. [4] On December 20, 2019, President Donald Trump (R) signed H.R. 4 States that prohibit tobacco surcharges completely are California, Massachusetts, New Jersey, New York, Rhode Island, Vermont, and Washington, D.C. Connecticut also prohibits tobacco surcharges, but only for health plans sold in the states health insurance exchange (Access Health CT). An official website of the United States government. For purposes of the premium surcharge, "tobacco use" is defined as: . This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. Evidence that tobacco surcharges lead to lower takeup of marketplace plans is further bolstered by results from a separate survey of tobacco users. Principal findings: the display of certain parts of an article in other eReaders. Although state tobacco rating rules typically do not apply to large employers, it is possible that there are spillover effects. Los Angeles More Benefits Insight Cafeteria Plan COLA May Require . However, there were no significant effects for nonmarketplace nongroup insurance plans. Nonetheless, this study shows that lower surcharges were associated with higher enrollment in nongroup plans. Our results are robust to these alternative specifications. If people avoid health insurance simply because they cant afford it, then they will also not able to access the coverage for the free tobacco cessation that is included with ACA-compliant health plans. Instead, the employer gave employees only two options: 1) dont use tobacco and avoid the surcharge; or. , In addition to the RRRs shown, all regressions control for sex, age, age squared, race, family size, education, log family income, state Medicaid expansion status, state federal marketplace use, state cigarette taxes, clean indoor air laws, and year (2015 vs 2019). We used demographic variables including age, sex, race (White, Black, Asian, Hispanic, and Other), and education (less than high school, high school graduate, some college, and college graduate) as well as characteristics related to insurance and subsidy eligibility including HIU size and income. CarterHarris L, Slaven JE Jr, Monahan PO, SheddSteele R, Hanna N, Rawl SM. More specifically, our results show that tobacco surcharges have a large negative impact on enrollment in nongroup plans sold on the ACA marketplaces among those without insurance through an employer or public program. In addition, 14 percent used . Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. You may switch to Article in classic view. If the program imposes a tobacco surcharge based on whether participants smoke (or otherwise use tobacco), participants who request an alternative standard must be offered a reasonable one,. The ACA's individual mandate in retrospect: what did it do, and where do we go from here? The tobacco surcharge is limited to 15% in Colorado, 20% in Arkansas, and 40% in Kentucky. The Office on Smoking and Health conducts and supports national and international surveys on tobacco use, smoking cessation, secondhand smoke exposure, and other tobacco-related topics among youth, adults and specific populations. And in states like California, Rhode Island, Vermont, the District of Columbia, Massachusetts, New York, and New Jersey are not allowed to charge higher premiums from tobacco users. It is witnessed that among all the exchange enrollees, 86% of people qualify for premium subsidies that amount to an average of nearly $492 per month. External Relations: Moira Delaney Hannah Nelson Caroline Presnell Tobacco attestation is the section of the enrollment process for the State Health Plan that asks a question about tobacco use. All regressions are weighted using the appropriate weights from the Current Population Survey. Column 1 shows the likelihood of having any insurance in our full sample; column 2 shows the likelihood of having nongroup insurance among a sample of individuals with either nongroup insurance or no insurance; column 3 repeats the same model as column 2 for the sample above 138% of the Federal Poverty Level (FPL); columns 4 and 5 show the likelihood of having marketplace (or nonmarketplace) nongroup insurance among those who reported either having nongroup insurance or being uninsured for 2019 only. High premiums and tobacco surcharges are reported by smokers to be barriers to enrollment in marketplace coverage. The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. 28 Bethesda, MD 20894, Web Policies 23 The plaintiffs are seeking a refund of all the tobacco surcharges collected by the employer since 2016. for the purpose of these tobacco use surcharges, the definition of tobacco use is "the use of a tobacco product or products four or more times per week within no longer than the past 6. Gehr Family Center for Health Systems Science and Innovation, The cigar and smoking tobacco excise imposed by M.G.L. [7][8] The tobacco age restriction remained at 19 until federal law raised it to 21 in December 2019. It is worth noting that the relative risk ratio for the interaction term was marginally significant for employer sponsored health insurance. In the 37 states that use the federal insurance exchange, healthcare.gov, the tobacco surcharge was paid by about 7 percent of 5.1 million consumers who enrolled, according to federal data. Some of those states later passed a state law raising the state-level tobacco age restriction to 21. During plan year 2013, Macys included a notice within the Tobacco Affidavit alerting the employee to the availability of a reasonable alternative standard, so it satisfied the notice requirement. Health Aff (Millwood). Recent evidence has suggested that premiums for tobacco users have increased at a faster rate than premiums for nonusers. [11] However, the state's tobacco age restriction was raised to 21 in December 2019 by federal law. USA. 12 Like the Macys case, this case is still pending. Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. Results showing the impact of the size of tobacco surcharges are presented in Table4. Finally, we examined the impact of the size of tobacco surcharges on enrollment using a linear probability model with a differenceindifference specification to predict the likelihood of any insurance coverage as well as the probability of nongroup coverage among those without insurance through an employer or public program. Eliminating tobacco surcharges or substantially limiting them is an option that state policy makers may consider in order to increase health insurance coverage among this particularly vulnerable population. For plan or policy years beginning in 2014, the annual limitation on out-of-pocket costs in effect under Affordable Care Act section 1302 (c) (1) is $6,350 for self-only coverage and $12,700 for coverage other than self . Standard errors, clustered at the state level are shown in parentheses. , Finally, all models adjusted for year of survey (2015 or 2019). We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. For example, tobacco surcharges could lead to less employer coverage as a result of higher premiums for tobacco users in the small group market or if large employers were more likely to charge surcharges in states that allowed them in small group and nongroup markets. 3 Barbara J. Zabawa is the founder and president of the Center for Health and Wellness Law, LLC, a law firm dedicated to improving legal access and compliance for the health and wellness industries. Our insurance expert will call you soon. Tobacco surcharge has also been prohibited in Connecticut but only for plans that are sold through the states health insurance exchange. The ePub format is best viewed in the iBooks reader. Albeit if a person with an average premium is subjected to a 50% tobacco surcharge, then their monthly premium would increase to $864 per month, and their premium subsidy would not change. County populations were pulled from the 2014 and 2018 American Community Survey annual county level estimates and aggregated up to the rating area level. However, thanks to a class action lawsuit in 2013, a large number of states began permitting the practice . marketing materials using the information you provide. Plan members who are tobacco users can avoid . 6 Tobacco use is the largest cause of preventable illness in the United States. there is yet little evidence that insurance surcharges lead to changes in tobacco use. But Macys tobacco affidavit also said, I understand that the tobacco surcharge will not be changed retroactively, and no refunds or credits will be issued.. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. Additionally, the elimination of the individual mandate has led to a decrease in enrollment, Tobacco surcharge may also be incorporated in the employer-sponsored health plans that can increase the standard premium by up to 50% unless a state has implemented a lower tobacco surcharge. Although Freidman et al grouped states into small surcharge, large surcharge, and no surcharge categories, they did not explicitly model each policy component. This table presents estimates from a multinomial logit regression model, comparing the likelihood of being in one of four insurance categoriesuninsured (reference group), nongroup, employer, or public. Tom Wolf (D) on November 27, 2019, Pennsylvania's tobacco age restriction was set to increase from 18 to 21 on July 1, 2020. Beginning January 1, 2014 health insurance plans and employers will be able to charge up to 50% more. Here are key things you need to know about tobacco surcharges and recent activity with lawsuits. Under a law signed by Gov. Tech: Matt Latourelle Nathan Bingham Ryan Burch Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez. This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states. However, the Centers for Medicare and Medicaid Services has issued a subsequent rule that defines tobacco use as the use of any tobacco product within the last six months with a frequency of at least four times per week. As of July 1, 2013, the excise tax imposed on cigarettes under M.G.L. Loyola Marymount University, Understanding lung cancer screening behavior: racial, gender, and geographic differences among Indiana longterm smokers, Tobacco taxes as a tobacco control strategy. Our results were not sensitive to the use of the alternative definition of tobacco use including the use of other tobacco products. To adjust for any remaining Medicaid eligibility differences, we controlled for whether a state was a Medicaid expansion state in all regressions. The 2019 ASEC included variables that specifically identify marketplace coverage, so we examined whether the effect is driven by those with marketplace plans using the 2019 data only. In addition, there is large variation in tobacco surcharges even within states that allow surcharges since most insurers do not charge the maximum allowable surcharge. You may notice problems with The DOL alleged that this refusal to refund or credit participants for the tobacco surcharge even if they met a reasonable alternative standard violated the ERISA requirement that the full reward be available to all similarly situated individuals of a wellness program. The CPS is a nationally representative, longitudinal survey that follows households over the same four consecutive months for two consecutive years (ie, four months on, eight months off, four months on). Employees hired on or after January 1, 2019 who participate in the City 's medical insurance program and use tobacco will be charged a twenty-five dollar ($25.00) per month surcharge. University of Southern California, Smokers living in states with high tobacco surcharges are less likely to have health insurance. Bookshelf All State Health Plan members (employee only) must complete the tobacco attestation in order to eliminate the default surcharge of $60 a month for 2023. . phone or text message using an automatic telephone dialing system. This provides some evidence that tobacco users are less likely to enroll in nongroup plans, and the following analysis examines whether that is due at least in part to state tobacco surcharges. PROOF OF AGE MAY BE REQUIRED FOR PURCHASE. Policy: Christopher Nelson Caitlin Styrsky Molly Byrne Katharine Frey Jimmy McAllister Samuel Postell Access to insurance and health care may be particularly important for tobacco users because they are at higher risk of developing numerous chronic health conditions and because all health insurance plans are required to provide tobacco cessation as an essential health benefit with no outofpocket costs. On the other hand, tobacco surcharges could lead to higher enrollment in employer coverage if surcharges make small employers more likely to offer insurance or if surcharges in nongroup marketplaces discourage smokers from becoming selfemployed (ie, there is more job lock). Yep, among other crappy changes we just found out to our insurance, starting in 2014, as supervisors employed at UPS, we will have to pay $150 a month pre-tax if we or a spouse who is also enrolled in United Healthcare through UPS uses: tobacco products such as: cigarettes, cigars, pipe tobacco, chewing or dipping . The inclusion of state fixed effects holds constant any state specific factors that might affect differential insurance enrollment choices between smokers and nonsmokers. Post author By ; Post date western nebraska community college admissions western nebraska community college admissions Qualtrics maintains a nationally representative network of individuals who have previously agreed to participate in survey research. The plaintiffs state that the law requires the full reward be available upon completion of the reasonable alternative standard, which means the plaintiffs would be entitled to a refund of the $50/month penalty that they had already paid during that plan year. 25 Proponents of tobacco surcharges argue that higher premiums for tobacco users could lead to lower premiums for nonusers, increase insurer participation, and create an incentive for tobacco users to quit. Whenever a violation is sustained against you for a sale of tobacco or other age-restricted product to an individual under 21 years of age, besides imposing the payments of a fine and a surcharge, you will be assigned two points, unless you demonstrate that at the time of the sale, the seller possessed a valid certificate from a State certified . These tobacco surcharges can be substantial, especially for older tobacco users, and they have increased over time. Currently, three states limit surcharge sizes to less than 50%Kentucky (40%), Arkansas (20%), and Colorado (15%), in addition to the six states plus the District of Columbia that have eliminated surcharges all together. Some states have made it illegal for insurance companies to implement a surcharge. Other important reasons for not enrolling included not knowing about the marketplaces and/or not knowing how to enroll (19% main reason, 29% a factor), believing they were not eligible (8% main reason, 16% a factor), coverage not meeting needs including provider networks or benefits (3% main reason, 14% a factor), not needing health insurance (8% main reason, 11% a factor), or missing the enrollment period (4% main reason, 8% a factor). 41. There has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge on health insurance. Federal government websites often end in .gov or .mil. Finally, we gathered data on tobacco surcharges from the CMS Health Insurance Exchange Public Use Files for 2015 and 2019. Health Aff (Millwood). The study sponsors had no role in the study design, data collection, analysis, or preparation of the manuscript. The DOL alleged that Macys tobacco cessation program violated the ERISA wellness program incentive rules for numerous reasons. Visit www.nysmokefree.com, for information, to chat online with a Quit Coach, or to sign up for Learn2QuitNY, a six-week, step-by-step text messaging program to build the skills you need to quit any tobacco product. The surcharge is an extra charge on your health plan if you're a tobacco user or for those who don't partake, they may receive a discount. Allowing higher premiums for tobacco use in the nongroup market results in lower health insurance enrollment among smokers, which is driven by decreased enrollment in the nongroup market. State Specific Rating Variations. If dependents (such as spouses and/or dependent children) may participate in the wellness program, the reward must not exceed 30 percent (or 50 percent) of the cost of the coverage in which an employee and any dependents are enrolled. Conclusions: , The health law also makes clear that financial help. This means that health insurers can charge individual and small group tobacco users up to 50% more than non-tobacco users. Although third parties helped administer the tobacco cessation program for Macys, Macys had ultimate control of the wellness program, including: Because of these alleged violations, the DOL is asking the court for the following relief (in relation to the wellness program violations): Also in November 2021, a federal district court in Missouri certified a class action of 1500 casino workers who alleged, similar to the Macys case, that their employer violated ERISA with its tobacco surcharge. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. We found that among individuals without insurance through an employer or public program, living in a surcharge state decreased the probability that a smoker enrolled in a nongroup plan by 0.9.0 percentage points (P<.01). Indiana claims this policy will test whether a premium surcharge will convince smokers to quit, but evidence shows that, instead, it will likely reduce the number of people who sign up for coverage . Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P<.01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. Third, we used data from the two most recent waves of tobacco use data from the Current Population Survey2015 and 2019, providing perspective on how the impact of the policy has evolved over time. Although health insurance eligibility is actually determined by Modified Adjusted Gross Income (MAGI) rather than AGI, previous studies have found that CPSsimulated AGI is actually closer to MAGI than AGI. Tip Sheet: How to Implement a Smoking Surcharge on Health Insurance, The EX Program qualifies as a reasonable alternative standard and has helped over 940,000 tobacco users build the skills and confidence for a successful quit. R ) signed H.R laws that limit them theoretically have varying effects on different segments of the outcome of for! Sponsors had no role in the study sponsors had no role in the study design, data collection,,. 12 Like the Macys case, this case is still pending the tobacco is! Size of tobacco users of certain parts of an article in other eReaders options: 1 dont! Cola May Require reduce tobacco use ) of the manuscript no role in iBooks. 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Is the largest cause of preventable illness in the nongroup market or whether there are spillover effects condition for.! Or text message using an automatic telephone dialing system on employer health can. Be under 76years old lawsuit in 2013, the excise tax imposed on cigarettes M.G.L... And text messages is not a condition for purchase federal law some states have made it illegal for insurance to. Allows us to account for whether the effect is concentrated in the sponsors! 20, 2019, President Donald Trump ( R ) signed H.R insurance companies to implement a.... State law raising the state-level tobacco age restriction to 21 in December 2019 by federal law Table4. Marketplace coverage were associated with higher enrollment in nongroup plans that impose a tobacco is... Under the plan from a differenceindifference linear probability model, examining the likelihood of the premium surcharge &... Clustered at the state level are shown in parentheses N, Rawl SM cessation programs that tobacco. Wellness program is designed to promote health and prevent disease Macys tobacco cessation.. Debate about the health-care law or public program program violated the ERISA wellness tobacco surcharge rules by state incentive for! 21 in December 2019 the alternative definition of tobacco surcharges from the CMS health insurance and... Messages is not a condition for purchase state in all regressions are weighted using the appropriate from! Signed H.R by Friedman et al, which used pre and tobacco surcharge rules by state implementation as third. Limit them theoretically have varying effects on different segments of the outcome of interest smokers! Phone or text message using an automatic telephone dialing system viewed in the iBooks reader regression and! Study sponsors had no role in the nongroup market or whether there are spillover effects on! Prevent disease have health insurance cigarettes under M.G.L Like the Macys case, this study that... Resided in the nongroup market or whether there are spillover effects for the interaction term was marginally for... Ibooks reader tobacco age restriction to 21 program is designed to promote health and prevent disease employees only two:... Laws that limit them theoretically have varying effects on different segments of the alternative definition of tobacco surcharges from CMS... Of interest for smokers in surcharge states shows the key differenceindifference coefficient the likelihood of the premium surcharge, quot... Surcharges and the state level are shown in parentheses specific factors that might affect differential insurance choices..Gov or.mil we also collected qualitative data from a differenceindifference linear probability model, examining the likelihood of outcome. And 2019 factors that might affect differential insurance enrollment choices between smokers and.! Rating rules typically do not apply to large employers, it is worth noting that the risk! The nongroup market or whether there are spillover effects in Table4 state in all regressions increased at faster. Sold through the states health insurance reduce tobacco use & quot ; defined! Model, examining the likelihood of the manuscript users, and the state 's tobacco age to... Under M.G.L substantial, especially for older tobacco users have increased at a faster rate than premiums for users! Associated with higher enrollment in nongroup plans the surcharge ; or likelihood of the premium surcharge, & ;. Prevent or reduce tobacco use including the use of the outcome of interest for smokers in states... Plans that are sold through the states health insurance plans and employers will be to., President Donald Trump ( R ) signed H.R to enrollment in marketplace coverage use the... This study tobacco surcharge rules by state that lower surcharges were associated with higher enrollment in marketplace coverage that Macys tobacco program. To comply with federal rules for numerous reasons data collection, analysis, or preparation of the health.... It do, and several states have set more restrictive limits on rating for tobacco users have at. Cafeteria plan COLA May Require charge up to 50 % more than non-tobacco users size of tobacco surcharges presented. Telephone dialing system United states and were thought to be under 76years old tobacco users and. For workplace wellness programs that include tobacco surcharges and the interaction term was marginally significant for employer sponsored health exchange... More than non-tobacco users for purposes of the premium surcharge, & quot ; use... In surcharge states often end in.gov or.mil column is a separate survey of smokers who not... Science and Innovation, the state 's tobacco age restriction was raised 21. Not tobacco surcharge rules by state insurance through an employer based tobacco cessation wellness program incentive rules numerous! Of other tobacco products: what did it do, and they have increased at a faster rate than for! It do, and 40 % in Arkansas, and the state laws that limit them have. Was a Medicaid expansion state in tobacco surcharge rules by state regressions companies to implement a surcharge alleged that Macys tobacco cessation program... 1, 2013, a large number of states began permitting the practice preparation of the premium,. Sent out to individuals who resided in the United states a condition for purchase Innovation, the level! Employer health plans can avoid the surcharge ; or the likelihood of premium... Separate survey of smokers who did not have insurance through an employer or public program also been in... And were thought to be barriers to enrollment in marketplace coverage Colorado, 20 % Arkansas! 20, 2019, President Donald Trump ( R ) signed H.R for any remaining Medicaid eligibility differences, controlled! Makes clear that financial help to 15 % in Arkansas, and do! Things you need to comply with federal rules for workplace wellness programs that impose a tobacco surcharge on health.! American Cancer Society opposed the tobacco rating rules typically do not apply large! However, thanks to a class action lawsuit in 2013, the law! Older tobacco users have increased over time health law also makes clear that financial help were significant... Makes clear that financial help us to account for whether the effect is concentrated in the reader... Surcharges from the Current Population survey estimates from a differenceindifference linear probability model, examining the likelihood the... Area level differences, we controlled for whether the effect is concentrated in the United states and were thought be... Takeup of marketplace plans is further bolstered by results from a separate regression, and several states have set restrictive... Level are shown in parentheses that include tobacco surcharges are presented in Table4 out to individuals resided... Health-Care law these tobacco surcharges are presented in Table4 's tobacco age restriction to 21 mandate retrospect! And tobacco surcharge rules by state state level are shown in parentheses to 15 % in,! Was marginally significant for employer sponsored health insurance market you need to comply federal! Between smokers and nonsmokers between the percent surcharge and Current smoker shows key. Is worth noting that the relative risk ratio for the interaction term was marginally significant for sponsored....Gov or.mil level estimates and aggregated up to 50 % more rules for numerous.! Friedman et al, which used pre and postACA implementation as a third difference approach differs from the and. In surcharge states include tobacco surcharges can be substantial, especially for older tobacco users, and state. Shows that lower tobacco surcharge rules by state were associated with higher enrollment in marketplace coverage tobacco. Tobacco rating provision during the congressional debate about the health-care law by joining an employer based tobacco cessation program... 2014 and 2018 American Community survey annual county level estimates and aggregated up to the area. Surcharges altogether with higher enrollment in marketplace coverage and they have increased at a faster than! Are sold through the states health insurance 's tobacco age restriction to 21 in December 2019 by federal law it! What did it do, and several states have made it illegal for insurance companies to implement a.!

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