WASHINGTON — A report from a patient advocacy group found the future of medical cannabis in the states is hazy unless costs are decreased, product safety standards are improved, and civil rights are strengthened for patients and prescribers.

Americans for Safe Access issued its annual State of the States report on Thursday. The organization, a nonprofit, has put out the document to advocates and state policymakers since 2014, as a tool to “assess and improve medical cannabis programs.”

ASA Executive Director Debbie Churgai said that one of the main surprise findings of this report was the lack of progress being made to strengthen and develop the medical cannabis sector.

“This was the first report that we saw the fewest improvements in the states,” Churgai said. “So much so that I felt a little shocked at first.”

The five states with the highest-graded medical cannabis access programs were Illinois, Michigan, Maryland, Connecticut and Rhode Island. Of the five, Maryland had the highest score, receiving a 75.7% on the group’s scale.

ASA issued 13 failing grades to state medical cannabis programs: Texas, Idaho, Wyoming, Nebraska, Kansas, Wisconsin, Indiana, Kentucky, Tennessee, Mississippi, Georgia, South Carolina, and North Carolina. The lowest-scoring states were Idaho and Nebraska, which both received a zero for a lack of medical cannabis programs.

ASA issued letter grades to all state medical cannabis programs in the report, based on a 0 to 100 scale. The programs were evaluated on the metrics of: patient rights and civil protection, accessibility, program functionality, affordability, health and social equity, consumer protection and product safety, and penalties.

The report does not evaluate recreational or adult-use cannabis programs.

ASA found that the number of medical cannabis patients continues to expand across the country, now numbering more than 6 million. That represents an increase of close to 1 million patients from the 2021 State of the States report.

The authors said that two states have added legal medical cannabis access programs in 2022, bringing the total to 48 states plus the District of Columbia, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, and Puerto Rico.

Churgai noted that when the group started issuing the report, only 14 states had medical cannabis legislation.

How grades are computed?

The letter grades distributed to states in the report range from B, meaning a strong medical cannabis program, to F, for a fatally flawed or absent program. Churgai explained that an A represents the “ideal medical cannabis law,” and no state received one.

“We know that we already know that some things do not exist in states, like coverage under health insurance for cannabis products,” Churgai said. “We base everything on a perfect program that we know cannot exist right now without federal oversight.”

As such, ASA graded on a curve in the 2022 report, allowing states that offer a full range of access and protections to the best of their ability a passable grade.

Still, even with the adjusted system, no state earned a grade above a B-, or 76% on ASA’s medical cannabis grading scale.

The report also highlighted individual “gold standard” provisions in each program.

For the civil rights and patient protections category, Arizona received the highest score, at 96%. The national average score in this category was 58%.

Maryland received the highest score for consumer protection and product safety, at 84.5%, compared to the national average of 44.8%.

Illinois and Virginia scored the highest in the affordability category, with a score of 65%. The national average score for affordability was 39.6%.

For access to medicine, Maine received the highest score at 95%. The national average in this metric was 42.13%. In the health and social equity category, Ohio received the top score of 90%, while the national average was 45.82%.

ASA averaged the 56 state and territory grades to find that medical cannabis access in the United States only received 46.16% or a “D+” on ASA’s grading scale. The authors said that the score marked a 2-point improvement from 2021.

“We’ll take that,” Churgai said. “But one of the themes actually in this year’s report was our surprise that more states are not making improvements.”

Affordability, consumer safety

The ASA leaders said issues with affordability and consumer safety remain commonplace nationwide.

For the second year in a row, affordability for state medical cannabis programs recorded the lowest national average score among the categories measured by ASA.

“In our patient feedback section, in almost every state, we have at least a few responses that talk about how affordability is an issue for patients,” Churgai said. “So it’s definitely a huge problem.”

The executive director noted that registration fees are “still too high,” ranging from $50 to $350 for patients, as are costs for targeted medicines.

“It’s a huge, huge burden for patients all across the country,” Churgai said. “This is a medicine that they’re using not only daily, but sometimes every day for the rest of their lives. And the fact that there’s no insurance coverage, this is all out-of-pocket, and expensive.”

Churgai and Steph Sherer, president of Americans for Safe Access, also lamented the lack of collective safety standards and training in the medical cannabis industry.

“If you go through this report and look through everything that we grade, it’s astounding how different the states are in every little aspect of testing and labeling standards,” Churgai said. “We need some national standards. We really need some kind of federal oversight that really guarantees that patients are protected and safe.”

Other challenges ASA noted included lacking employment protections, insufficient retailers and restrictions on patient cultivation programs.

Still, the group did note some progress in improving arrest protections, increased adoption of adult-use cannabis and low-THC strains from more conservative states, and growing reciprocity programs.

Competition with recreational cannabis

More than anything, the ASA team emphasized the growing challenges represented by the recreational market.

“This is a huge trend that we’re seeing as more states are allowing adult use,” Churgai said. “Unfortunately, they’re giving a regulatory preference to it, so much so that they’re ignoring or pushing aside the patient medical program.”

The executive director noted that 14 states were penalized on their report cards this year for giving regulatory preference to adult-use cannabis operations. Churgai added that the ASA analysis also showed states lumping their medical and recreational cannabis programs together, and not comprehending patient needs and protections.

“It’s not the regulators’ fault, or policymakers’ fault,” Churgai said. “I believe that they think that they’re still helping people. But they don’t understand the needs of patients, and why patients actually still want a medical program, and they still need a medical program.”

Sherer added that the consolidation of these cannabis programs is leading to consolidation of product for cost-saving purposes, as companies fire their chief medical officers, and compete with the upstart cannabinoid market. Cannabinoids are cannabis-derived chemicals, like Delta-8 THC and cannabidiol, or CBD. Products containing these substances can be sold in grocery stores and gas stations, and have no federal age requirement.

“I think that what we’re seeing is that without these companies being able to increase their available market size to a federal market, they’re really struggling to stay in business,” Sherer said. “They’re finding that they often have to serve the adult-use population in order to pay for the business altogether.”

This decision ultimately harms medical cannabis patients, as their needed medicine gets sold as a consumer product.

The ASA leaders offered policy ideas, including increasing insurance coverage of cannabis, expanding medical cannabis licensing, standardizing lab testing, and reducing taxes along the supply chain.

“It’s really important to understand that we’re not just telling states what they’re doing wrong, or what they could be doing better,” Churgai said.? “But we actually give them ways to improve the law for patients.”

“The big elephant in the room for these programs is that when we first created access programs to medical cannabis, they were meant to be a type of triage, to get patients off the battlefield of the war on drugs while we changed federal law,” Sherer said.

“And 25 years later, states have done a lot to navigate this very odd situation of regulating an illegal substance. It’s really time for the federal government to move forward with the comprehensive program for medical cannabis.”

The first medical cannabis laws in the United States were implemented 26 years ago.

Consumption and sales of medical cannabis are illegal under federal law.