In 1996, California became the first state in the nation to legalize the medicinal use of cannabis with the approval of a landmark ballot measure. In the ensuing quarter-century, nearly every state has crafted its own legislation to legalize medical cannabis, either at the polls or through action by state lawmakers. While progress continues to be made at the state level, the effectiveness of medical cannabis programs for patients that need them can vary dramatically from state to state.
Debbie Churgai, executive director of the medical marijuana advocacy group Americans for Safe Access (ASA), says that the 25 year years of progress on medical cannabis reform have led to a common misperception that patients who need medical marijuana are able to easily obtain and use it. But the patchwork of state regulations, fashioned over the span of more than two decades without guidance from the federal government, has led to widely different programs from state to state.
“I think the mainstream media gives a very big perception that there is so much access. You see the reports that say 48 states have some form of access and you see all the articles about all the companies that are making money and how the patient population is growing,” Churgai told High There in a telephone interview. “You see all that in the media, but what you don’t see is that the patients that are still unable to access medicine due to dozens of crazy different reasons within each state.”
Churgai cites several types of regulations that serve to impede access to medical cannabis, including restricting use to those with certain specified medical conditions, with the number of ailments allowed ranging from a handful to dozens. Some states impose limits on the amount of medicinal cannabis that can be purchased, while others restrict the forms of medical marijuana available to patients.
Rating the Medical Cannabis States
To help patients make sense of the situation, ASA recently released its
Penalties for harmful policies are also factored into each state’s score. The scoring rubric is divided into more than 100 factors divided into several categories including patient rights and civil protection, accessibility, program functionality and affordability.
“Some states did amazing in certain categories and really bad in certain categories and that made their grades low,” said Churgai. “Some states did pretty good in each category, which made their overall grade pretty good.”
Overall, ASA gives the 55 states and territories assessed for the report a collective grade of D. The best grade, a B, went to Maine, and only one other state, Illinois, scored better than a C+. The majority of states and territories scored in the C and D ranges. States receiving a failing grade on the report include Georgia, Idaho, Indiana, Kansas, Kentucky, Mississippi, Nebraska, North Carolina, South Carolina, Tennessee, Texas, Wisconsin and Wyoming.
Maine Came Out On Top
“This year, Maine came out on top. That doesn’t mean that Maine is doing everything perfectly,” noted Churgai. “That just means that Maine is doing the best in several different categories and its overall score was the best.”
Patients in Maine surveyed for the report generally gave very favorable reviews and unanimously said that access has improved in the past year, citing falling prices and a larger choice of cannabis retailers. Second-best in the report was Illinois with a B-, with a slight majority of patients giving the state’s program favorable reviews.
“The two worst states were Idaho in Nebraska,” Churgai says. “These are the two lone states that offer no access to cannabis and have do not yet have any medical cannabis program. So those both received the zero because they offer no access.”
Idaho and Nebraska, however, were not the only states to receive failing grades. Other states’ programs are so restrictive that ASA does not consider them a viable option for patients.
“There are nine states that only offer CBD and very low levels of THC. To us, and to patients everywhere, that does not equal a medical cannabis program,” explained Churgai. “So for those states, almost all those states received Fs as well because again, they’re not providing a full level of access for patients.”
Can Medical Marijuana and Recreational Cannabis Coexist?
The report reveals that the states with the most progressive cannabis reforms do not necessarily have strong medical cannabis programs that guarantee access for patients. In fact, states that legalize recreational marijuana often see setbacks for medical patients as adult-use customers flood the regulated market. Churgai says that as states further liberalize their cannabis laws, protections for patients must be built into the legislation.
“It is very important to keep these programs separate,” Churgai emphasizes. “Patients should have priority in medicine. A lot of them need a certain type of medicine. They need It every day, and they need it every day for the rest of their lives.”
Churgai noted that one of the keys to maintaining access for medical marijuana patients in states that have legalized recreational marijuana is protecting the supply of cannabis earmarked for medical use. Unfortunately, specialty products such as high-dose edibles and RSO are often snatched up by the recreational market, while others unpopular with adult-use consumers are eliminated to make room for more profitable offerings.
“Unfortunately, what we’re seeing is that when adult-use comes in, a lot of states do not have those product protections, and patients are not getting the medicine that they need,” she said.
Churgai also noted that legislative efforts in some states actually constitute a step backward for patients. In Colorado, for example, lawmakers passed
“But what it really does is create new and unnecessary restrictions and mandates for medical cannabis products and concentrates,” Churgai explained in a follow-up email. “Physicians will have to provide a THC dosage amount with a patient’s medical card, and patients are limited in their purchasing outside of those recommendations.”
Cannabis Patient Purchase Amounts
The measure also lowers the amount of cannabis concentrates patients are allowed to purchase and mandates mental health reviews for prospective patients under the age of 21, further restricting access for patients.
Oliver Summers, a legacy dispensary operator and CEO of Summers International Cannabis Consultants, noted that cannabis companies can also play a role in protecting and improving access to medical marijuana. He shared that many dispensaries used to have compassionate care programs that provided free cannabis to patients in need. But as the industry has become more tightly regulated and dominated by multistate corporations, protecting “access to cannabis has gone by the wayside.” The solution, he says, lies in a mix of industry action and new regulation.
“The industry needs to start looking back to how we started and adapt some of the older best practices. So much cannabis is wasted every day, simply because of arbitrary laws,” Summers explained in an email. “That product should be parlayed into free items for people who meet certain qualifications like SSI. There also needs to be an easing of rules at hospices and convalescent homes, so that they have a safe space for consumption. We also need to revisit the tax structure for medical patients.”
“Overall, taxes are the primary issue hindering patient access,” he adds. “The final costs are just too high for people dealing with medical issues. Compassion programs need to be brought back for qualifying patients.”
The report also notes that small changes to regulations can have large impacts on patient access. The COVID-19 pandemic led to changes including telehealth appointments, curbside pickup and home delivery that made tremendous improvements to patient access. In many cases, these changes were made without legislative approval.
The report also noted that the cost of medical cannabis remains a major burden for many patients. In the patient survey completed for the report, 70 percent of respondents said that the cost of medicine was either very prohibitive or entirely prohibitive. The report also illustrates that while great progress has been made since California first legalized medical cannabis in 1996, no state’s medical cannabis program is perfect.
Federal Legalization is Essential
However, in its fifth key point highlighted by the report, ASA noted that state-level medical cannabis programs will not reach their full potential until federal cannabis legalization is achieved. So, Churgai says, the work of medical cannabis advocates is not yet done.
“I want to highlight that advocacy is very much still needed. Federal legalization is going to help but it’s not going to solve all the problems,” explained Chugai. “Even after federal legalization, we still have so many things that we need to work on to educate the public,” including addressing the ongoing stigma associated with cannabis.
“So I think it’s just important for people to remember that we’re not there yet and even though it feels like we’re so close to full legalization and ending the stigma, we certainly have a far, far away to go.”