The move to adult use sales attracts the most industry attention, but for Americans For Safe Access, a national cannabis patient advocacy group, how well medical programs are running sits front and center. And according to AFSA, most of the programs are mediocre, and painfully few are exemplar.

Nationwide, states’ medical cannabis programs were weak in 2021, according to AFSA’s  2021 State of the States report. After all states and territory grades were averaged, access to medical cannabis received a 44% or a D on the grading scale. States with medical programs did not meet the gold standard in 2021. Overall, 13 states received an F, 19 received a D, 21 received a C, and two received a B. 

Integrating AFSA’s report with what we know about patient numbers, state laws, and operating facilities, Grown In took a closer look at AFSA’s state-by-state report. For instance, in the Midwest, access to cannabis is the lowest scoring category in those states. However, access to cannabis does not seem to be that much of a problem in New England, as none of the states obtained a low score in this category. Instead, most states in New England have issues with either their laboratory, cultivation, or dispensary operations, according to the report.

Midwest States

Illinois: B-

Illinois, which kicked off it’s medical program in 2014, scored highest in both patient rights and civil protections, and program functionality, receiving a 90 out of 100 in both categories. Its lowest scoring category was manufacturing operations, where it received 27 out of 50 points. Despite strict Required Vendor Training requirements, it did not receive any points for staff training and environmental impact regulations, and received partial points for standard operating procedures, required testing, and packaging and product labeling. 

Michigan: C

The Mitten, one of the first states to legalize cannabis in 2008, scored highest in program functionality, earning all available points for legal protections within a reasonable time frame; reasonable purchase limits; telemedicine for physician certification; patient and physician representation in program decision making; reasonable caregiver standards; reasonable physician standards; and access to administration methods. Although prices are dropping in the state and it has 241,216 registered patients, the state received a low score for affordability, 50 out of 100 possible points.

Minnesota: D+

This small medical market state, with 51,999 patients in 2021 and 13 active retail locations in 2021, scored the lowest scoring category for dispensary operations, where it received 0 out of 50 points. The Land of 10,000 Lakes did not receive any points for subcategories such as staff training, standard operating procedure, product testing, and complaints, adverse event reporting and recall protocol. 

Missouri: C+

The Show-me State’s highest scoring category was laboratory operations, receiving 45 out of 50 points. It received full points in this category for independent third party testing, lab sampling, quality management systems, standard operating procedures, and result reporting, though it only received a 10 out of 20 for staff training. Missouri only requires security training for employees. Its lowest score was for affordability, as the state does not allow multi-year registrations for it’s 68,222 registered patients, nor does it have a donation program or financial hardship waivers or discounts.

North Dakota: D-

This state, with a very small medical operation of just 6,895 patients eight active retail locations in 2021, earned its highest score with program functionality, which received a 60 out of 100 points. Even in that category, it only received full points for reasonable possession limits. All other subcategories received partial or no points – legal protections within a reasonable timeframe; telemedicine for physician certification; and patient and physician representation in program decision making.

Ohio: C+

With just 56 operating dispensaries in 2021 and 125,398 patients (1.07% of the population), Ohio scored lowest in access to medicine, 30 out of 100 possible points. It received no points for delivery, personal cultivation, collective gardening, and reciprocity. Its highest scoring category is lab operations, scoring 45 out of 50 points. It received full points in each subcategory except independent third party testing, an interesting complaint since the state conducted a recall last December impacting two-thirds of the state’s dispensaries.

South Dakota: C-

South Dakota’s highest scoring category is patient rights and civil protections, receiving 90 out of 100 points and scoring all possible points for arrest protection, affirmative defense, parental rights protections, employment protections, and explicit privacy standards. It received no points for DUI protections. Yet South Dakota did not have any registered patients or active retailers in 2021, according to the report. 

“There is one retailer currently open in South Dakota: The Flandreau Santee Sioux Tribe operate a dispensary on tribal land and have their own patient registry,” researchers wrote, explaining the low score for access. 

Mid Atlantic States

Delaware: C+

“Patients surveyed in Delaware had a low opinion of the existing program, but did feel as though it improved in 2020 thanks to more product consistency and diversity,” reported the AFSA. “Some surveyed patients believe that too few retailers across the state and the high cost of medicine make the program prohibitive.”

Patient comments make sense because although Delaware had 16,497 registered patients in 2021, that made up 1.69% of the total population. Meanwhile it only had six retail locations during that time, according to the report. 

District of Columbia: C

The District of Columbia’s lowest scoring is affordability, receiving 35 out of 100 points. It does not offer sales tax breaks for patients and caregivers, nor is medical marijuana covered by state insurance or health aid. D.C. also does not have a donation program. 

Medical cannabis was first approved in 1998 but blocked by Congress until 2009. Before 2018, the District’s 11,716 patients in 2021 were limited to one dispensary, but now patient access is better and patients can visit any retailer in the District – now at seven. 

Maryland: C+

A state with a relatively high number of registered medical patients,147,070 as of last December, Maryland’s highest scoring category is both cultivation operations and manufacturing operations, receiving 43 out of 50 points. 

Its lowest scoring category is health and social equity, scoring 45 out of 100 points. In this section, it received no points for housing protections, access in underserved areas, and allowing patients to medicate where they choose.

New Jersey: C+

With it’s Alternative Treatment Centers’ 22 retail locations, New Jersey’s highest scoring categories were both cultivation operations and manufacturing operations, receiving 41 out of 50 points. For cultivation operations, it received perfect scores in most subcategories except required testing for terpenes, aflatoxins, and moisture. For manufacturing operations, it received partial points for packaging and product labeling, and required testing. 

On the flip side, with so few ATCs, the state’s lowest scoring category is access to cannabis, where it received 55 out of 100 possible points. Though it received perfect scores for certain subcategories, it received zeros for personal cultivation, collective gardening, and only a five out of 30 for sufficient number of licensed retailers for its 117,734 patients, who made up 1.33% of the state’s total population.

Pennsylvania: C+

The Quaker State’s highest scoring category is program functionality, where it received 91 out of 100 points, scoring perfectly in most categories but receiving partial scores for legal protections within reasonable time frame; reasonable caregiver standards; and reasonable physician standards.

At the time of the report, Pennsylvania had 143 retailers and 384,254 registered patients, making up 2.68% of the total population.

New York: D

ASFA ripped into New York’s legal dispensary operations, awarding three out of 50 points. In this category, the state did not receive any points for staff training, standard operating procedures, and product testing. The only subcategory where it received partial points was for protocols for complaints and adverse event reporting. 

Its highest categories are both program functionality and patient rights and civil protections, receiving a score of 70 out of 100 points. 

New York had 38 active retailers in 2021 serving 151,111 registered patients – 0.78% of the total state population. 

New England

Connecticut: C

It scored highest in the health and social equity category, earning full points for state program protections, housing protections, list of all inclusive qualifying conditions, ownership and employment restrictions, and other categories. It received partial points for access for minors and access in underserved areas, despite the state’s 18 retail locations serving 54,00 registered patients.

Maine: B

Perhaps because it has had more time than most states to build a medical program, first approved by voters in 1999, Maine was the highest scoring state in the nation.

The state had 96,047 registered patients in 2021 – that’s 7.15% of the state’s population – and 430 retail locations. The ratio of patients to retailers is a staggerly low 223:1.

“Surveyed patients in Maine reported some of the lowest costs in the country at between $20-30 per 1/8th,” researchers said in the report. “With over 30,000 new patients, Maine’s per capita participation rate has increased to over 7% of the population. This is likely due to the high cost of cannabis at adult use stores compared to what are some of the most affordable products in the country at one of the states’ many mom-and-pop run caregiver storefronts.”

Massachusetts: C

The state scored highest in cultivation operations, earning 41 out of 50 points. It scored full points in the subcategories of quality management systems, staff training, and pesticide usage limitations and others. It received partial points for packaging and labeling, protocols for complaints and adverse event reporting, and required testing. 

Massachusetts had 86.197 registered patients at the time of the report and 136 retailers. The ratio of patients to retailers in 2021 was 634:1. 

Its lowest scoring category is dispensary operations, where it received 26 out of 50 points. In this category, it received full points for staff training and partial points for standard operating procedures. It did not receive any points for product testing or for protocols for complaints and adverse event reporting.

New Hampshire: D

With medical sales beginning in New Hampshire in 2016, the state scored highest in the patient rights and civil protections category, earning 75 out of 100 points. It received full points for arrest protections, affirmative defense, parental rights protections, and explicit privacy standards. It received partial points for DUI protections and did not receive any points for employment protections. 

In 2021, New Hampshire had 10,688 registered patients and just four retail locations, and the patient-to-retail ratio was 1:2,672. 

Rhode Island: C+

Tiny Rhode Island has a relatively large patient population: 1.87% of the state’s population are registered patients in 2021, 19,803 people. But to serve them there were only three active retail locations in 2021. That’s a ratio of 6,601:1.

Perhaps that’s why lts lowest scoring category is affordability – few places to buy and little market competition. It received full points for financial hardship waivers or discounts, but did not receive any points for state insurance or health aid coverage, donation programs, or allowing multi-year registrations. 

Vermont: D

The Green Mountain State’s highest scoring category is program functionality, where it earned 67 out of 100 points for a program that services 5,209 registered patients and five active retailers. It received full points for access to administrative methods, and received partial points for legal protections within a reasonable time frame, reasonable possession limits, reasonable purchase limits, telemedicine for physician certifications, and other subcategories.

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Cynthia Fernandez is a data reporter for Grown In. Previously, she was a politics reporter for Spotlight PA, a nonpartisan newsroom based in Harrisburg and reported at the Boston Globe. In 2019 she graduated...