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Every year the ASA team and I spend a considerable amount of time formally comparing every medical cannabis program in the United States. In 2019 this meant assessing the medical cannabis programs of 47 states, the District of Columbia, and four territories. The nearly 200-page report we created provides a detailed analysis of the state of medical cannabis programs around the country. Access to medical cannabis has come a long way since California passed Proposition 215 in 1996. However this report shows us that while the national trend is towards better medical cannabis laws, many states still need significant improvements in their programs to ensure that all patients have access to the medicine they need.

1. 2019 was the first year that any state received an A grade, but every low-THC or Cannabidiol program still failed

This marks the first time since this reporting began in 2014 that any states have broken into the “A-” category. Illinois and Oregon both received a grade of A- in 2019. Illinois received the highest percentage due to the state’s already strong medical cannabis program being improved by passing a law that allowed individuals with opioid prescriptions to exchange these prescriptions for a medical cannabis card. Additionally, Illinois passed HB1438, which allows individuals 21 years and older to purchase cannabis without a medical card. What is significant about this bill is the great lengths the state’s legislative body went through to protect the existing medical program and offer additional benefits to patients, like the ability to home cultivate, and medicine becoming tax-exempt once adult-use sales go into effect. 

Meanwhile, Oregon achieved an A- grade by improving packaging, labeling, and pesticide regulations, ending housing discrimination against patients, and allowing medical deliveries to municipalities that had banned storefronts. 

While both these states allow for the adult use of cannabis, they have made significant efforts to ensure the patient populations in the state remain a priority.

Meanwhile, of the states that only allow cannabidiol or low-THC products, all received a failing grade. Limiting access to one cannabinoid or dictating what levels of cannabinoids are present can severely limit access for patient populations and needlessly handcuffs physicians. Even Virginia, which allows THCA and CBD to be recommended for any condition, still did not enter into the passing grade category as product has not yet been distributed and there are still limitations on the formulations that patients can obtain. 

2. Affordability of Medical Cannabis Remains the Primary Issue Nationwide

In the states where medical cannabis has been legalized, its affordability has been one of the most consistent critiques and remains the single greatest challenge that patients face. As part of the State of the States Report, ASA conducted a survey in 2018 revealing that 88.5% of medical cannabis patients believe that their medicine is not affordable, with over a quarter of patients surveyed indicating that their medicine is often so cost prohibitive that they must go without treatment. 

While some states have worked to clarify the role of insurance and insurance companies when it comes to medical cannabis, no state has yet adopted a law that permits or requires insurance companies to cover the cost of medical cannabis. New York has indicated that insurance coverage must apply for visits to physicians’ offices relating to medical cannabis as long as obtaining a recommendation is not the sole reason for the visit. Denial of coverage of visits where medical cannabis is discussed is unlawful under New York State law. However, insurers are currently under no obligation to pay for actual medical cannabis or medical cannabis products. Other states have approved workers’ compensation to cover medical cannabis. ASA urges all policymakers to work to make medical cannabis affordable in their state by adopting legislation that reduces the costs of medical cannabis and allows for health insurance to help defray the costs of a medicine that currently must be paid for out of pocket. 

3. Opioid Response is of Critical Importance

This year, for the first time ever, ASA introduced a new category in the report to assess how states used medical cannabis to respond to the opioid crisis. 2018 marked the first year since the early 1990’s where the trend of increasing opioid overdose deaths reversed. In 2017, ASA launched a report called Medical Cannabis as a Tool to Combat Pain and the Opioid Crisis. Since then, states have begun to implement strategies described in that report through their medical cannabis programs, and preliminary data suggests that effective implementation of medical cannabis programs can greatly reduce the number of opioid deaths and opioid prescriptions. 

Every day, more than 130 individuals lose their lives to opioid overdose. Beyond the horrific human toll, this crisis wastes billions of dollars and other resources. In looking to mitigate this tragedy, practitioners and state health departments should have as many treatment options available to them as possible. 

Based on our criteria, California (29/40 points) and New York (27.5/40) had the best response to the opioid epidemic, but there is still much more they can do. Research has shown that medical cannabis is  an effective treatment option for pain. In a 2017 report, the National Academies of Sciences, Engineering and Medicines conclusively found that cannabis and cannabinoids are effective for treating chronic pain in adults. States with medical cannabis programs have demonstrated 5.88 percent lower prescribing rates for opioids, with a nearly 30 percent reduction in Schedule III opioid prescriptions for Medicaid enrollees between 1993 and 2014. We urge states to continue to explore using medical cannabis to help reduce opioid deaths. 

4. Implementing ASA’s Suggestions will Lead to Significant Improvements

During the time frame assessed for the 2019 State of the States Report (January 1, 2018 - June 1, 2019), over 2,000 bills were introduced across the country that dealt with creating or amending existing cannabis programs. While this flood of legislation is welcome progress, not all bills are created equal. In developing our scoring framework, we have assessed which legislative changes make the biggest impact on the patient community. The bottom line is that states that adopt legislation that is in line with our rubric and framework receive higher grades than states who propose and adopt cannabis bills not within our framework. 

Since its founding in 2002, ASA has been instrumental in shaping state medical cannabis policy. We know that lawmakers trust and rely on this report as they are crafting policy, and we are grateful for the states that use this report as a blueprint to address legislative problems. ASA and its affiliates played a direct role in changing laws in Arizona, Colorado, Florida, Georgia, Maine, Maryland, and Utah. 

5. West Virginia is Failing its Residents

West Virginia passed its medical cannabis law to help alleviate the state’s catastrophic level of opioid overdose deaths. However, due to politics and administrative delays, they have become the first state in the history of the report to pass a comprehensive medical cannabis program and receive a failing grade the following year. Many West Virginians are frustrated by the state’s slow rollout of its medical cannabis program, which lawmakers have attributed to a lack of banking access. West Virginia serves as an example that just because a state passes a medical cannabis law does not mean that the work of lawmakers and regulators is finished. More important than passing a law is its actual implementation. Too many states pass a medical cannabis law and then take months or years to start providing medicine to patients. (For example, it took Maryland nearly five years). 

Medical cannabis in West Virginia was supposed to be available in the state by July 2019, but regulators failed to make that a reality by the beginning of the month, and a spokeswoman for the state’s Department of Health & Human Resources says it could be another two to three years after a banking vendor is in place before sales begin, a delay of which would be devastating to patients and likely result in many lives lost unnecessarily.

Download the full report here