Cost Reduction Measures for Low Income Cannabis Patients

Cost-Reduction Measures for Medical Cannabis
Among Low-income Arthritis Patients in New
York State: An Exploratory Study
State University of New York at Oswego
Crystal Hewitt-Gill
Dr. Michele Thornton

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Certification page
Crystal Hewitt-Gill
“Cost-Reduction Measures for Medical Cannabis Among Low-income Arthritis
Patients in New York State: An Exploratory Study”
Advisor Signature: __________________________________
This project is not considered confidential and restricted.

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Table of Contents
Chapter 1……………………… Page 3
Chapter 4………………………Page 30
Chapter 7…………………….... Page 45
Appendix A……………………. Page 53
Appendix B……………………. Page 56

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CHAPTER 1
Purpose of the Project
Medical cannabis is increasingly recognized as a safe and effective form of medication
that can treat the symptoms of a host of medical conditions (Hill, 2015). Research studies on the
efficacy of cannabis as an analgesic medication have been extremely promising. However,
marijuana is not regulated, prescribed, or dispensed like other prescribed medications (Valencia
et. al., 2017). Medical marijuana is not currently approved for use by the Food and Drug
Administration (FDA), and only one cannabis-based medicine (CBM) is currently approved for
use in the United States (FDA.gov, 2018). Because of this federal prohibition, medical cannabis
itself is not covered under any private or governmental health insurance plans, regardless of the
condition or type of insurance (including Medicare and Medicaid). As a result, medicinal use of
cannabis can be prohibitively expensive for consumers, particularly low-income and financially
disadvantaged consumers (a further breakdown of expenses can be found under the next
subsection). Because of this, marijuana’s viability and availability as a medicine for chronic pain
sufferers is currently limited in the state of New York.
The purpose of this project is to identify potential funding sources (both public and
private) that could help offset the cost of medical cannabis for low-income New York State
residents diagnosed with an arthritic condition. Arthritis was selected as a primary area of
concern due to its high prevalence rates in the United States, its potential impact on the body,
and its incurability.
To best determine future steps, we will survey several stakeholders representing different
sides of the medical cannabis industry. The stakeholders reside in different areas of the United

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States, to help provide alternate perspectives from regions whose medical cannabis programs
predate the inception of the New York State Medical Marijuana programs. From there, we will
analyze the results and recommend specific pathways to funding. The funding is intended to
help increase access for low-income and financially disadvantaged individuals who may
otherwise struggle to afford medical cannabis as a primary or ancillary treatment for arthritis
pain.
Setting of the Problem
Marijuana’s effectiveness in managing medical conditions, and its accessibility to the
public, is a complex and widely-debated subject. Cannabis is a Schedule 1 drug on the Drug
Enforcement Agency (DEA) classification schedule. The federal Schedule 1 classification
denotes that marijuana is illegal because it is deemed to have high abuse potential, no established
medical use, and significant safety concerns associated with its use (DEA.gov, 2017). Largely
due to this federal designation, the research surrounding the effectiveness, safety, and associated
public health risks with cannabis is somewhat limited, typically smaller in scope, and conducted
independently of federal funding. However, the research thus far has strongly suggested that
medical cannabis appears to be a highly efficacious in the management of chronic pain and
inflammatory conditions, largely owing to its unique analgesic properties and its response to
endocannabinoid receptors located throughout the brain and body. Medical cannabis is often

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used as an ancillary treatment for chronic nausea, pain, inflammatory conditions, and muscle
spasms or seizures (CDC, 2017).
Figure 1: Marijuana Laws by State
The table above shows current marijuana laws in the United States by late 2018. (Source:
NORML, 2018) As of June 2018, medical cannabis is approved for selective use in 31 states, as
well as the territories of Washington D.C. and Guam (NCSL, 2018). In 2014, New York State
approved a statewide medical marijuana program, through the passing of the Compassionate
Care Act (Public Health Law 3369). The Medical Marijuana program officially began on January
6, 2017. The program was intended to provide “...a comprehensive, safe and effective medical
marijuana program that meets the needs of New Yorkers” (DOH.gov, 2017). However, there
have been documented problems in patient access to the medication since the inception of the
program.
As of June 2018, there were 1,700 medical professionals registered in New York's
Medical Marijuana program, which represented a small percentage of the over 90,000 estimated

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doctors and thousands of nurse practitioners in the state (DOH.gov, 2017). Additionally, there
were 59,000 certified medical marijuana patients registered with the programs, from a pool of
hundreds of thousands of individuals with chronic illnesses who would otherwise be eligible for
the Medical Marijuana program (DOH, 2017).
Medical marijuana costs can vary widely from area to area, so the following prices will
be used only for illustrative purposes. As of 2018, the medical cannabis company Columbia
Care operated four dispensaries in the state of New York. Their prices are listed on their website
as the following: the average cost for a week’s worth of medical cannabis in the form of a
tincture or capsule amounts to $54; in its oil form (used for vaping), the price is $110. (In New
York, medical cannabis consumers are not allowed to consume smokable marijuana products.)
Going by these figures, a month’s supply could run from $216 to $440 monthly (Col-
CareNY.com, 2018). Similarly, the company Vireo Health offers medical cannabis supplies to
consumers in New York State. The company’s website recommends that new patient bring
between $100-$350 to their first appointment. An average cost typically ranges between $80-
$100 for the first visit, although some products cost up to $350. The company offers discounts
to people with financial hardships, either through verbalized or written documentation
(Vireohealth.com, 2018).
History of the Problem (2 subsections)
Arthritis conditions in the United States
Currently, arthritic conditions constitute the most prevalent chronic pain condition among
older adults in the United States (CDC, 2017). Between the years 2013-2015, the Centers for
Disease Control (CDC) reported that approximately 54.4 million American adults (22.7%) had a
medically diagnosed form of arthritis. By the year 2040, an estimated 78.4 million older

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Americans will be diagnosed with some form of arthritis. As the U.S. population grows older
and life expectancy increases, arthritic conditions are likely to increase at a commensurate rate.
Generally defined, arthritis is not a single condition but refers to a host of conditions that can
cause significant joint pain, stiffness, and swelling. In its more extreme or advanced forms, the
condition can result in joint deformity and even death. Arthritis can affect patients of any age
but is seen most commonly in an older (55+) and geriatric population. Arthritis is characterized
by an underlying inflammatory condition of the joints. Arthritis is influenced by both genetic
and lifestyle factors and can also develop after a viral infection or fever (rheumatoid arthritis).
Conditions like obesity, hypermobility, and genetic factors can all increase the likelihood of an
individual developing the condition. Arthritic conditions are a specific area of concern because,
while they are treatable, they are chronic, usually lifelong conditions that require ongoing
medical interventions. There is no recognized cure for the condition, although improving overall
health (including exercise and proper nutrition) can help mitigate some of the symptoms. Over
time, arthritis symptoms can become so severe that they qualify as a disabling condition under
the Americans with Disabilities Act (ADA).
Access to Medical Marijuana (cost barriers)
While the New York State Medical Marijuana program sets forth regulations and
guidelines on dispensaries, it does not regulate or set prices on cannabis products (DOH, 2017).
There is nothing on the federal or state level currently governing or monitoring costs. As a
result, providers, and medical cannabis dispensaries can, to some extent, determine their own
rates. There are numerous reasons for the high cost of medical cannabis: high demand and
relative scarcity of the product; a complex supply chain with numerous intermediaries; lack of
governmental regulations; the lack of insurance participation; and strong financial incentives for

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providers to charge high prices for products to offset the costs of operations (DOH, 2017; Pacula
et.al., 2014). Since dispensaries will not receive insurance reimbursements for their products,
consumers bear the full cost of the medication.
To obtain medical marijuana, a patient must first be diagnosed with one of ten serious
medical conditions and recommended for the program. S/he must then obtain a certification from
a physician, who must have undergone a New York State Health Department approved training
course and registered with the Department of Health (DOH) as a recommending physician. Upon
being certified, the patient can then register online and complete an application to become an
approved patient. Once the patient’s application is approved, s/he will receive a patient registry
card in the mail, which is needed to purchase medicine at a state licensed dispensary.
Scope of the Project
There are a few important guidelines to address. To begin, we must define the term
“low-income”. Federal guidelines are defined annually through the Department of Health and
Human Services (HHS). The 2018 guidelines are defined below (source: www.HHS.gov)
Figure 2 DHHS 2018 Federal Poverty Guidelines

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For purposes of this paper, we will refer to the federal guidelines in our definition of
“low-income” residents of New York State. To note: pathways to reducing cost and increasing
access are not necessarily limited to individuals belonging in the poverty limit income guidelines
provided. The funding sources may be appropriate for a considerably larger population of
consumers who may also struggle to afford cannabis. The income guideline limits are intended
to clarify our use of the term “low-income” and provide a better frame of reference. Efforts to
reduce cost and expand access should be initiated with a basic framework of how the cost of
cannabis can outpace an individual’s wages and earnings.
Next, we must be clear about what I intend to identify. As discussed above, marijuana
occupies a unique and unprecedented position in the context of state and federal law and
regulation. There is significant confusion and ambiguity regarding the laws and regulations of
medical cannabis. The most obvious answer to reducing marijuana costs and increasing access
could be simply stated as, “change regulatory status”. To comprehensively lower costs and
increase access for the consumer across the United States, the FDA would need to approve the
medicinal use of cannabis and cannabis-derived medicines for consumers with various
deteriorative and progressive medical conditions, including illnesses that result in chronic pain. If
the FDA approved medicinal cannabis, insurance companies, including governmental insurances
like Medicare and Medicaid, could cover the cost of the medication. However, FDA approval is
a long and complicated process, and there are numerous considerations before the FDA is likely
to approve or disapprove a medication. While this may be a longer-term goal for advocates and
providers of medical cannabis, I intend to focus on remedies that would be more easily
operationalized through independent funding. In other words, what sort of funding resources

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could be utilized soon to help alleviate costs? Who or what is willing to help now? Are there
agencies or investors to help make marijuana less expensive?
Importance of the Project
From the numbers of arthritic patients outlined under the history, we can state that
arthritis conditions represent a significant concern for patients and providers in the United States.
There are currently several approved medication interventions for arthritic conditions by the
American Medical Association (AMA), including over the counter medications like ibuprofen
and prescription medications like hydrocodone. Prescription medications have long been utilized
as part of a pain management protocol for arthritis sufferers. However, pain medications
(including the above-mentioned NSAIDs and opioid-derived analgesics) can carry a host of
negative side effects (CDC, 2017). Opioid medications can effectively manage arthritic
conditions, but their high addictive potential and significant side effects often precludes their
long-term use for chronic pain (CDC, 2018).
In the last decade, the analgesic and anti-inflammatory properties of medical cannabis
have been a topic of increased interest for providers, patients, and researchers. Medical cannabis
has shown some significant promise in the management of chronic pain disorders, without many
of the associated risks of other medication protocols (e.g., habituation or liver toxicity) (Safe
Access Now, 2017). To put the relative safety of cannabis into perspective, the presumed lethal
dose of marijuana is approximately 1,500 pounds consumed in 15 minutes. There are no current
documented cases of fatal marijuana overdose (Safe Access Now, 2017). The research suggests
that cannabis produces comparatively mild negative side effects and minimal impact to public
health. If cannabis can be shown to be safe, effective, and accessible for chronic pain sufferers,

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then it warrants serious consideration as a viable alternative medicine for a sizable adult
population in the United States.
Definition of Terms
Cannabidiol (CBD) – another compound in cannabis, CBD is non-psychoactive (does not
provide a “high” to the consumer). CBD was federally legalized in 2014 and is available over
the counter as a supplement. CBD has demonstrated anti-seizure activity but has not been shown
to have primary efficacy in the treatment of pain conditions. To date, the Food and Drug
Administration has approved only one CBD medication, the anti-epileptic Epidiolex, for use by
consumers.
Cannabinoids – the chemical compounds unique to cannabis that act upon the cannabinoid
receptor sites in the human body, which produce the effects of marijuana.
Cannabis-based medications (CBM) – an umbrella term for any strain of marijuana that is used
for medicinal purposes. CBMs do not include illicit or recreational usage. For this project, the
terms “cannabis” and “marijuana” will be used interchangeably.
Dispensary – medical cannabis provided at a location licensed (typically by the state’s
Department of Health) and authorized to provide cannabis products to patients. Medical
cannabis is not provided at pharmacies. Dispensaries are also known as “access points”.
Endocannabinoids – chemicals that occur naturally in the human body (e.g., the CB1 and CB2
receptor sites), which respond to cannabinoids. Endocannabinoids are found throughout the
brain and the body, including in immune cells and reproductive organs.
Federal Poverty Limit (FPL) - this is defined as the federally established income limit to
determine the poverty rate in the United States; the FPL is also used to establish eligibility rates
for federal assistance programs (e.g., Medicaid).

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Marijuana – the general terms for female cannabis plants or their dried flowers. Can be used
interchangeably with the term cannabis.
Medicaid - the federal insurance program for people who meet income requirements, have high
medical bills, or currently receive Supplemental Security Income (SSI).
Medicare - the federal insurance program for people over the age of 65, or who receive SSI or
Supplemental Security Disability Insurance (SSDI).
Phytocannabinoids – comprised of the three best known varieties of the cannabis plant, which
include Cannabis sativa, Cannabis Indica, and Cannabis ruderalis. Cannabis sativa is the most
common variety, as it has the highest levels of the Tetrahydrocannabinol compound.
Tetrahydrocannabinol (THC) – while cannabis has numerous active compounds, THC is the
primary psychoactive compound. THC provides the “high” that users experience when
consuming cannabis products. THC is lipid-soluble, so it resides in the tissue of the body for a
significant amount of time.

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CHAPTER 2
LITERATURE REVIEW
Article: Anderson, D. M., Hansen, B., & Rees, D. (2014). Medical Marijuana Laws and
Teen Marijuana Use. doi:10.3386/w20332
Summary: This study looked at the relationship between medical cannabis legislation and teen
marijuana use. The study noted that federal officials had sought to close medical cannabis clinics
located within 1,000 feet of schools, parks, and playgrounds, under the hypothesis that the
presence of clinics will have the unintended effect of increasing access to young people.
However, the study did not find a consistent relationship between the presence of medical
cannabis clinics and youth marijuana rates, possibly owing to the highly regulated nature of
medical marijuana.
Relevance: One common argument against medical cannabis programs is the idea that
accessibility to a substance will also increase illicit, non-medical use, particularly among young
people. The relationship between medical cannabis programs and recreational, illicit use of
marijuana by teens may be a bit more unclear, at least at present. One important distinction lies
between the use of marijuana for medical purposes, and the outright legalization of marijuana for
recreational purposes. The former does not appear to increase usage in other populations. The
relationship between legalization and access is currently unclear.

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Article: Bachhuber, M. A., Saloner, B., Cunningham, C. O., & Barry, C. L. (2014). Medical
Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010.
JAMA InternalMedicine, 174(10), 1668. doi:10.1001/jamainternmed.2014.4005
Summary: This review looked at states with medical cannabis programs in their states, as
compared to states without medical marijuana laws, and contrasted the rates of opioid overdose
between the two groups. Three states (California, Oregon, and Washington) had medical
cannabis laws effective prior to 1999. States with medical cannabis laws had a 24.8% lower
mean annual opioid overdose mortality rate compared with states without medical cannabis laws.
Examination of the association between medical cannabis laws and opioid analgesic overdose
mortality in each year after implementation of the law showed that such laws were associated
with a lower rate of overdose mortality that generally strengthened over time.
Relevance: One of the major driving forces behind the efforts to implement medicinal cannabis
is the need to manage chronic physical conditions for patients eligible for opioid prescriptions.
Contrary to the longstanding perception of marijuana as a “gateway drug” to harder drugs, it
appears from this study that states with implemented medical cannabis laws experience lower
rates of opioid overdose (and, it can be inferred, lower rates of opioid abuse in the first place).

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Article: Bostwick, J. M. (2012). Blurred Boundaries: The Therapeutics and Politics of
Medical Marijuana. SciVee. doi:10.4016/39225.01
Summary: This is an article series that looks at the history of cannabis, its psychopharmacology,
past and present barriers to cannabis research, and promising pharmaceutical applications of
cannabis to a range of medical and psychiatric conditions. This is not a research study per se but
rather provides an overview of cannabis’ potential uses. The series draws from numerous
resources to outline the primary issues surrounding the medical use of cannabis. Bostwick dates
that use of cannabis for analgesic and antiemetic purposes back centuries and differentiates
between medical and recreational usage. Additionally, he details the complex and sometimes
controversial nature of cannabis research, largely due to federal restrictions.
Relevance: This article provides a necessary contextualization and comprehensive history of
cannabis, including its medical applications and the problems with conducting federal research
on the applicability and therapeutic uses of cannabis. One of the most challenging and persistent
barriers to fully understanding the medical usefulness of cannabis lies in the relative scarcity of
research. Many of the studies proclaiming the therapeutic efficacy of medical cannabis rely on
methods of patient self-report. While these reports are promising, there is still a deficiency in
substantive reports verifying the use of cannabis for chronic pain conditions.

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Article: Bradford, A. C., & Bradford, W. D. (2016). Factors driving the diffusion of
medical marijuana legalisation in the United States. Drugs: Education, Prevention and
Policy, 24(1), 75-84. doi:10.3109/09687637.2016.1158239
Summary: This article tracks the path to legalization of medical marijuana in the United States.
According to the article, measures of policy diffusion and political culture are important. Policy
diffusion is defined as the idea that policy choices made in a specific place and time are
influenced by the policy choices made elsewhere; in other words, other states are likely to adopt
certain measures if they have already been adopted elsewhere with minimal negative side effects
or constituent backlash. However, the researchers posited that the ongoing controversial nature
of cannabis, both positive and negative, is significant enough that full policy diffusion is unlikely
– that is, that a national adoption of medical cannabis programs is unlikely, given the current
divided political climate.
Relevance: It is difficult to accurate gauge societal and cultural attitudes towards marijuana.
Additionally, one current criticism of medical cannabis programs is that they are not actually
increasing access for a large enough population, owing to out of pocket cost and a limited
number of dispensaries.

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Article: Cerdá, M., Wall, M., Keyes, K. M., Galea, S., & Hasin, D. (2012). Medical
marijuana laws in 50 states: Investigating the relationship between state legalization of
medical marijuana and marijuana use, abuse and dependence. Drug and Alcohol
Dependence, 120(1-3), 22-27. doi:10.1016/j.drugalcdep.2011.06.011
Summary: The researchers used the second wave of the National Epidemiologic Survey on
Alcohol and Related Conditions (NESARC), a national survey of adults aged 18 and up
(n=34,653). Selected analyses were replicated using the National Survey on Drug Use and
Health (NSDUH), a yearly survey of approximately 68,000 individuals aged 12+. The study
concluded that states with legalized medical marijuana use had higher rates of use, overall. The
researchers stated the need for more studies to determine whether the positive relationship was
due to a causal link.
Relevance: This study again looks at the overall impact of medical cannabis programs and
legislation on the public’s use of marijuana. The relationship here is not completely clear,
although we can tentatively posit that communities that accept the medical use of cannabis are
more likely to have tolerant attitudes towards decriminalization or legalization of a substance.
These attitudes go a long way towards shaping public policy. Does medical cannabis in some
way cause higher rates of non-medicinal use of marijuana in a community?

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Article: D. R. Blake, P. Robson, M. Ho, R. W. Jubb, C. S. McCabe; Preliminary
assessment of the efficacy, tolerability and safety of a cannabis-based medicine (Sativex) in
the treatment of pain caused by rheumatoid arthritis, Rheumatology, Volume 45, Issue 1, 1
January 2006, Pages 50–52, https://doi.org/10.1093/rheumatology/kei183
Summary: This study used a randomized, double-blind group over 5 weeks of treatment. Pain
scales were rates on the Short-Form McGill Pain Questionnaire (SF-MPQ) and the DAS28
measure of activity. The 31 assigned to the cannabis-based medicine reported significant
improvements in pain on movement, pain at rest, and quality of sleep compared to the placebo
group. The majority of adverse effects experienced by participants were mild or moderate, and
there were no adverse effect-related withdrawals or serious adverse effects in the active
treatment group. The researchers acknowledged significant pain-reducing effect, while stating
that the differences were small and variable across the population.
Relevance: This study supports the efficacy of medical cannabis on patients diagnosed with
rheumatoid arthritis. As a double-blind study, it relied on the self-reported perceptions of
patients with no prior knowledge of what they were receiving. As noted above, self-reports may
have issues with reliability, owing to the possibility of the placebo effect. However, the reports
of analgesic effect and increased quality of sleep are important in the treatment of a chronic pain
condition.

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Article: Elikottil, Mbbs Jaseena, et al. “The Analgesic Potential of Cannabinoids.” Journal
of Opioid Management, vol. 5, no. 6, 2018, p. 341., doi:10.5055/jom.2009.0034.
Summary: The study looked at three primary types of pain and the possible mitigating effects of
cannabis. Pain types included neuropathic, inflammatory, and cancer pain. One major cause of
and characteristic of arthritis is inflammation. This study found that cannabis acts on the CB1
and CB2 receptor sites in the brain, a major mediating factor for inflammation pain. According
to this article, cannabinoids found in marijuana may form a useful ancillary medication to current
analgesic drugs for many conditions. They can also be used as rescue drugs when opioid
medications are analgesics are ineffective or inadequate. They also appear to antagonize several
side effects of opioids, and the opioid-cannabinoid combination may become a very useful agent
in the long-term management of severe pain.
Relevance: This study appears to support the efficacy of cannabinoids in marijuana for arthritic
conditions, as there is a direct neurobiological influence for these types of conditions in patients
who consume cannabis. Significantly, the cannabinoid receptor sites in the brain play a role in
antinoception, or the relief of pain. Additionally, the endocannabinoid system is involved in
other physiological processes include appetite, mood, and memory. In other words, there is
some scientific validity to the use of cannabis for pain conditions.

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Article: Fitzcharles, M., Baerwald, C., Ablin, J., & Häuser, W. (2016). Efficacy, tolerability
and safety of cannabinoids in chronic pain associatedwith rheumatic diseases
(fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis). Der Schmerz,
30(1), 47-61. doi:10.1007/s00482-015-0084-3
Summary: This paper used several different search engines to look for randomized controlled
trials (RCTs) that treated at least ten patients per treatment episode with herbal cannabis or
pharmaceutical cannabinoid products for fibromyalgia, osteoarthritis, chronic spinal pain, and
rheumatoid arthritis pain. Outcomes were measured as reduction of pain, sleep problems,
fatigue, and limitations of quality of life for efficacy, dropout rates due to adverse effects for
tolerability, and serious adverse events for safety. The researchers noted that there were no
randomized controlled trials for patients with osteoarthritis.
Relevance: The study concluded that there was insufficient evidence for recommendation for any
cannabinoid medications for symptom management in patients with chronic patient associated
with rheumatic diseases. The findings of cannabinoids over controls (e.g. placebo) were not
consistent. This may speak to the power of placebo effect, or it could be an issue in the different
RCTs that were evaluated.

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Article: O’Keefe K. State medical marijuana implementation and federal policy. J Health
Care Law Policy. 2013; 16 (1): 39 – 58.
Summary: This paper looked at efforts to reschedule marijuana under federal law, and explored
the development of statewide medical cannabis program, and how these federal laws has
impacted state policies over the years. There are three parts: Part 1 looks at how federal policy
affects research and the advancement of medical marijuana; Part II reviews state efforts during
the 1970s and 1980s to allow the medical use of marijuana, and how federal policies led to the
widespread failure of these state policies to provide legal protections for cannabis consumers;
and Part II, which looks at medical marijuana programs passed since 1996, including issues of
access and how statewide programs have been impacted by shifting federal policies.
Relevance: While the interplay between state and federal policies is not the focus of this paper, it
is important to understand that federal policies continue to impact state medical marijuana
programs in myriad ways. It is likely that at least one of the identified stakeholders will discuss
how federal laws are one driving force behind marijuana’s expense. However, there is hope that
future marijuana advocacy will be able to reconcile the disparities between state and federal
legislation and provide a more comprehensive and uniform approach to medical marijuana.

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Article: Klieger, S. B., Gutman, A., Allen, L., Pacula, R. L., Ibrahim, J. K., & Burris, S.
(2017). Mapping medical marijuana: State laws regulating patients, product safety, supply
chains and dispensaries, 2017. Addiction,112(12), 2206-2216. doi:10.1111/add.13910
Summary: The researchers examined different regulations and laws present in the states that
have approved medical cannabis programs. They found considerable variation in specific
provisions such as permitted product supply sources number of dispensaries per state, and
restricting proximity to locations like schools and playgrounds. Qualifying medical conditions,
cost, and the registration process were also highly varied between states. These discrepancies
created a lot of confusion and ambiguity in the public, as well as consumers. The researchers
concluded that the federal ban have resulted in a “patchwork” of regulatory policies inconsistent
with the approach typically taken by the federal government.
Relevance: One of the most complex aspects of medical cannabis in the United States pertains to
the laws surrounding its use. One reason that the cost of medical cannabis fluctuates wildly is a
lack of centralized standards. In the meantime, statewide cannabis programs can take a more
active role in determining prices and monitoring providers to prevent price-gouging and financial
exploitation of consumers.

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Article: Valencia, C. I., Asaolu, I. O., Ehiri, J. E., & Rosales, C. (2017). Structural barriers
in access to medical marijuana in the USA—a systematic review protocol. Systematic
Reviews,6(1). doi:10.1186/s13643-017-0541-4
Summary: Limited evidence is available on the racial, cultural, and socioeconomic demographics
of medical cannabis patients. As a result, there is limited information regarding the social and
structural barriers that inform patients’ success in accessing medical marijuana. This systematic
review is intended to identify the factors that inform disparities in access to medical marijuana in
the United States. The stated goals were to identify how issues like income, ethnic background,
stigma, and physician preference impact access. The researchers posited that these primary
structural barriers most reduced access to medical cannabis.
Relevance: Understanding the socioeconomic demographics of medical marijuana consumers is
critical in planning any path to increase access. We must identify who is using medical cannabis
but more importantly, we must identify underserved populations. Who is eligible for medical
cannabis, and who would most benefit from expanded access? How does poverty impact access?
While it has been established that disparities in socioeconomic status have myriad effects on
healthcare outcomes, there is also a presumed disparity in the types of medications that are
prescribed for patients of lower socioeconomic status. How do factors like race, ethnicity, and
stigma impact utilization of medical marijuana (particularly in contrast to other types of
prescribed pain medication)?

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Article: Reinarman, C., Nunberg, H., Lanthier, F., & Heddleston, T. (2011). Who Are
Medical Marijuana Patients? Population Characteristics from Nine California Assessment
Clinics. Journal of Psychoactive Drugs,43(2), 128-135. doi:10.1080/02791072.2011.587700
Summary: The article used a sample of 1,746 patients from a network of nine medical marijuana
evaluation clinics located in the state of California. The patients completed a medical history
form, as did the physicians. The researchers derived the date from the self-reported patient
characteristics, including the presenting symptoms and medical marijuana use practices. Chronic
pain, insomnia, and anxiety were ranked as the most common conditions for which physicians
recommended medical marijuana.
Relevance: This study provides another example of how understanding the people accessing
medical cannabis is critical to the success of a program. What makes people seek out medical
cannabis? What is likely to cause a physician to prescribe marijuana? There could be one
identified issue wherein low-income patients with chronic arthritis pain are not recommended for
marijuana due to physician bias or stigma. There is not a great deal of information available
about cannabis consumers in New York State’s program. Data collection on consumers will be
necessary to further tailor any financial assistance or financial hardship programs.

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Article: Temple, L. M., Lampert, S. L., & Ewigman, B. (2018). Barriers to Achieving
Optimal Success with Medical Cannabis: Opportunities for Quality Improvement. The
Journal of Alternative and Complementary Medicine. doi:10.1089/acm.2018.0250
Summary: This article identifies several key barriers to medical marijuana’s optimal success,
including: inadequate scientific knowledge regarding effectiveness, dosage, delivery mechanism,
indications, and drug interactions in humans; lack of educational standards for dispensary and
medical staff training; lack of communication and coordination of patient care; the complexity
and consistent availability of dosing options; and barriers to access for patients seeking this
therapy. The article sites, “cultural bias, personal and religious beliefs, stigma, lack of high-
quality evidence on safety and efficacy, limited time during office visits, and paperwork burden”
as all being reasons that physicians were unlikely to recommend cannabis to their patients.
Relevance: Relevance: Stigma is a persistent issue in medical cannabis programs, according to
the literature. Once the data has been collected, it may be worthwhile to see how many
respondents indicate any stigma being an underlying factor in restricting access, and whether the
stigma is likely to impact low-income patients. Further studies can better help determine the
relationship between stigma, and socioeconomic stratification.

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Article: Laporte, J. (n.d.). Topic: Medical marijuana in the U.S. Retrieved from
https://www.statista.com/topics/3064/medical-marijuana-in-the-us/
Summary: This article provides numerous graphs on statistics regarding medical marijuana’s
current availability in the United States. Additionally, the charts looked at projected sales
number for medical cannabis in the U.S. through the year 2021. The industry is expected to
grow substantially in the next several years. Some states have opted to legalize marijuana and
sell the products through dispensaries regulated by state oversight agencies. Massachusetts,
Oregon, Colorado, and Utah all rank among states that have both medical cannabis programs,
and recreational cannabis dispensaries.
Relevance: These statistics help provides an overview on access and utilization rates for medical
cannabis across the country. The medical cannabis industry is regarded as a rapidly expanding
market. With this increase in access, sales, and utilization, it is important to understand the
potential impact of medical cannabis on American consumers. There are also numerous
unanswered questions regarding regulatory oversight of these programs. Additionally, the
interplay between medical and recreational cannabis programs in states that have both will need
to be monitored and compared. Patients who are unable to afford medical cannabis or are
unwilling or unable to undergo the process of patient registration through their state, may
purchase cannabis products legally in these states for less expense. It is difficult to determine
how many “recreational” users are utilizing legal cannabis for medicinal purposes.

27
CHAPTER 3
This project uses the Primary Research pathway. The research pathway presented the
most opportunity for new information. The studies reviewed in Chapter 2 pertaining to structural
barriers to access focused on current deficiencies in the system. Certainly, we can conclude that
the cost of medical marijuana is one significant barrier to consumer access. However, rather
than use pre-existing data that explores systemic deficiencies, this project intends to propose
potential solutions to the burdensome expense of medical cannabis. While there are barriers in
place that should be addressed in federal marijuana laws and policies, this study is trying to
identify new strategies to increase consumer access, ideally within a period of 6-12 months.
Progressive, exploratory research is most likely to yield new insights and ideas to help
consumers.
A grant proposal is a possible option in this case; however, we must consider the
limitations of a grant. Ideally, any funding sources will be both readily available, and sustainable
over a longer term. Grants typically cover a period of 1-2 years and are specific to a business or
project; governmental grants may provide more funding and extend for longer periods but given
the tenuous legality and complicated regulations regarding medical cannabis in the United States,
it may not be feasible to look towards federal or state-sponsored grant money to help cover
expenses for consumers. Again, because of the federal prohibition on cannabis in the United
States, it is unlikely that any sources of federal funding would be approved to increase access to

28
medical marijuana. Additionally, grants typically require an application and approval process,
which could delay the distribution of funds for a significant length of time.
Similarly, an Applied Design Intervention approach may be too specific in scope. Design
Interventions are typically used for a single organization, and the intention is to formulate
something that could be potentially adopted or expanded out to multiple agencies. We may
determine that some agencies in or outside of New York State have effective methods in place
with which they increase access, but that these programs are not viable in New York State, or
generalizable to a broader consumer base. We must consider the heterogeneity of different
cannabis supply companies and dispensaries. There may be significant differences in resources,
investment levels, products, and patient demographics between areas. To be effective, a funding
source would need to be applicable regardless of the demographics of the different agency.
Likely, this could mean that funding would need to come from outside, independent individuals
or agencies.
Finally, the Business Plan pathway is intended to create a new business idea within the
health sector, and includes a format SWOT analysis, primary data collection, and the
construction of a formal business plan. At this point, industry buy-in for the idea of making
cannabis less costly and more available to a socioeconomically diverse population is in no way
guaranteed. Because medical cannabis is a strong emerging market, there may be an internal
incentive to drive up prices and maximize profit. In other words, while the idea of creating a

29
business plan to help lower costs is tempting, we must have a better understanding of the forces
within the medical cannabis community that are driving costs in the first place to propose an
effective industry change.

30
CHAPTER 4
While the complex reasons behind medical marijuana’s cost are an important topic, I will
not look at ways to reduce expenses within the supply chain, nor will I provide an analysis of
marijuana’s cost relative to either illicitly distributed marijuana, or medical marijuana available
for sale in other countries (e.g., Canada). As stated above, I will not propose any change in
marijuana’s classification on the DEA schedule, or recommend that the FDA approve more
CBMs in the future. While these may be longer-term goals of medical cannabis advocates, they
require different strategies and stakeholders than the scope of this project. I will look only at
potential funding sources to reduce the average cost of medical cannabis for low-income
individuals with chronic arthritis conditions.
Statement of Research Objectives
1. Identify potential funding sources (private, public, etc.) that could be used for cost
reduction with the goal of formulating a plan for cost-alleviation services.
2. Identify (if applicable) current programs or financial hardship discounts that could
be expanded on or used as a model for future funding.
3. Identify some pathways to implementation for cost reduction that could follow
(for example, grants, lottery system, etc.) with the goal of developing an
operationalizable cost-reduction plan.

31
4. Determine feasibility of these funding sources, including cost-benefit analysis
(whether there are downsides or limitations to any identified funding source) and
a realistic timeline to implementation, with the goal of parsing out the most
efficient and expedient roadmap to cost reduction.
Description of the Data Collection
This project used a primary data set. The data was qualitative in nature and information
was gathered from interviews conducted with the identified stakeholders. The interview answers
were collected for analysis and aggregation. The data collection process involved the use of
semi-structured phone and/or online interviews with different stakeholders representing different
aspects and perspectives in the field of medical cannabis. There were four key stakeholders in
total (N=4). The template for the interview is located under the Appendix B section. The
interview template was designed to gauge responses about the role that cost plays in limiting
access to medical cannabis consumers. The questions were predominantly in an open-ended
format to invite further discussion and ideas. Additionally, the following criteria was used in
constructing the questions (source: Evalued.com, 2018):
● Can the question be easily understood (reducing likelihood of different interpretations)?
● Is the question biased or leading in any way?
● Is the question necessary to the evaluation? Does it invite future exploration?
● Will interviewees be willing to provide the information? Is anything sensitive,
controversial, or confidential?

32
● Is the question applicable to all interviewees? Is the question reasonable and accessible to
all identified stakeholders?
● Does the question allow interviewees to offer their opinions/expand on basic answers?
● Are follow up questions likely to be required? Can the question(s) be sufficiently
answered in one setting?
● Will the answers be straightforward to analyze? Is there anything confusing or unclear
about what is being asked or what the likely response would be?
Finally, each question was constructed to link back to one of the stated objectives - the
identification of cost as a barrier to access, the identification of any current resources, and the
identification of any potential future resources. The last question looked at longer-term
objectives for reducing cost in the medical cannabis program.
The interviews were expected to last between 15-20 minutes per interview. The stakeholder
organizations were selected because they all play important roles in medical cannabis programs across
the United States, and because they represented a more diverse and heterogeneous sampling of
stakeholders. Additionally, agencies outside of New York State were chosen because of the
comparatively long-standing medical cannabis programs. States like Oregon, who have been at the
forefront of medical cannabis programs, provided some unique insights and suggestions to the question
of accessibility. The names of the individuals representing each stakeholder organization were kept
confidential. No other identifying information was requested or collected during the interview. The
overall intention for the interviews was to further elucidate the role that expense plays in restricting

33
consumer access, and to identify potential short- and long-term ways to alleviate this burden on low-
income patients. The answers were recorded and compared using the Analysis Plan outlined in the next
Chapter. The process was reviewed and approved by the Human Subjects Committee at the State
University of New York at Oswego.
Identified stakeholders include the following organizations:
1. Cannabis Supply Company in NYS - a medical cannabis supply company in New York
State that offers financial hardship discounts to consumers. This company’s program
may provide guidance or parameters for other cost-reduction programs.
2. Cannabis Supply Company in Colorado – a full-service marijuana dispensary that
operates out of Colorado, with sites in both Denver and Boulder. The Health Center
provides both medicinal and recreational cannabis to consumers.
3. Cannabis Supply Company in Oregon - a grassroots organization in Oregon committed to
helping cannabis consumers access medical cannabis. The Guild provides cannabis
products to members and provides advocacy and guidance to growers and community
members. Since the state of Oregon has a long-established medical marijuana program,
there may be some insight to be gained from any cost-reduction or funding measures
already in place.
4. Cannabis Supply Company in Nevada – a full service cannabis dispensary located in Las
Vegas, Nevada. Nevada has both legalized recreational marijuana, as well as a statewide
medical marijuana program.

34
In the interview process, the following steps were completed:
● Confirmation of confidentiality and the data to be collected
● Explanation and/or clarification of the survey scope or any terms, if necessary
● Describe the purpose of the research and the short- and long-term goals
● Transcribe interview responses (no voice recording) or receive written results via e-mail.
● Interviews will be either conducted over phone (when available) or via email. A copy of
the informed consent, questionnaire, and debriefing tool can be found under the
Appendix section.
● Advise interviewees on the intention of the data supplied

35
CHAPTER 5
Population Surveyed
The population surveyed will include representatives from each of the stakeholder organizations
identified in Chapter 4. The interview instrument will be delivered verbally and/or via e-mail to
the interviewee. Informed consent and a post-survey debriefing occurred verbally, or in writing
(see Appendix B). All participants received a copy of the study after its completion.
Inclusion Criteria
The subjects interviewed will all be in an adult population (over the age of 18), employed in some
capacity by the stakeholder agency (preferably in a managerial or leadership position within the
organization). Nobody under the age of 18, volunteers, or unpaid interns was interviewed in lieu
of a paid employee. Additionally, the participants must have some familiarity with medical
cannabis as a subject, and the specific considerations of Medical Marijuana programs (for example,
a pharmacist, provider, or administrator with experience in the medical cannabis program).
Finally, participants should work directly with medical cannabis in some capacity.
Questions and/or Hypothesis
The primary question to be answered is what potential funding sources exist (potential or already
in place) to help offset the cost of medical cannabis for low-income consumers diagnosed with
chronic arthritic conditions. Ideally, I hope to gain knowledge of current, established programs
that could be expanded to reach a wider consumer base of medical cannabis programs. The

36
intended result is to help provide a cohesive framework for future cost-reduction programs in
medical cannabis. I will consider the feasibility and scope of each intervention that is listed.
Programs with greater feasibility and larger scope will be selected in favor of smaller, more
specific measures. In other words, cost-reduction programs that are funded by specific grants or
through smaller non-profit or advocacy groups may be less helpful than programs that can tap into
agencies or communities with more resources available.
Data Analysis
This study uses the model of exploratory research. This research is being conducted to explore
the research questions and does not intend to offer conclusive solutions to the issue of increasing
access to medical cannabis programs. The study does not seek definitive answers and the data
collected may be contradictory. Because the study is exploratory in nature, I am not seeking a
specific response or answer from the interviews. There is no statistical analysis involved and the
answers will not be weighted.
The data will be analyzed using the following criteria:
● Is there any uniformity in response? What themes emerge from the interviews? Is there
consensus regarding the financial barrier to access?
● Is cost consistently identified as a barrier to access?
● What potential funding source(s) are identified? Are they public or private?

37
● Are there specific companies/individuals/investors that may be viable paths to funding? Do
dispensaries have discount or hardship programs that could be expanded statewide or
adopted on a larger scale?
● What role (if any) does the government play?
● Were there any specific programs already in use that could be expanded on or drawn on
for future funding?
Limitations of the Data Collection Plan
The primary limitation of the data collection plan is the reliance on largely personal and
subjective opinions. Additionally, the individual representatives may have specific biases or
perspectives that influence the answers that they provide. (For example, an employee who is
employed through a dispensary may be hesitant to indicate if they believe the products are
expensive, interpreting this statement as a criticism of their employer or even a tacit
acknowledgement of the excessive costs of cannabis in the United States.) The first two questions
of the instrument are intended to gauge responses to the issue of cost specifically as a barrier to
access. However, if a stakeholder indicates that they do not believe that cost is a barrier to access,
then the questions that follow will be impossible to answer. If that happens throughout the course
of the interviews, the results will still be collected and analyzed; however, the survey is unlikely
to provide any assistance meeting the stated objectives of the study.
Finally, while the stakeholders were selected because of their established, first-hand
experience and familiarity with the medical marijuana program, there is no way to completely

38
eliminate the potential for personal bias. Additionally, it should be considered that people may
not be comfortable taking part in a research projects and will not be interested in completing the
surveys. There is no financial or personal incentive for participation. Finally, interviewing can be
a lengthy process, between contacting companies, providing the interview questions, transcribing,
analyzing, and reporting (Evalued, 2018).

39
CHAPTER 6
Chapter 6 summarized the results obtained from implementing the questionnaire
described in Chapter 5. The four identified stakeholder agencies, representing cannabis supply
organizations in New York State, Oregon, Colorado, and Nevada respectively, all provided
responses via e-mail. No telephone interviews were conducted. The results are discussed below.
The responses are categorized by objective and a brief discussion regarding whether the specific
objective was met.
Objective 1:
Identify potential funding sources (private, public, etc.) that could be used for cost reduction
with the goal of formulating a plan for cost-alleviation services. This objective was measured
through Questions 3 and 4 of the survey form, which asked about current and future financial
hardship and cost reduction measures in place at each agency.
Summary: The data collected did not provide independent funding sources; however, the
stakeholders surveyed offered numerous ideas for cost reduction, including donation-based
programs, financial hardship discounts, and membership benefits. In some programs, the regular
consumers can receive discounts through loyalty programs. Other dispensaries offered discounts
to patients with demonstrated financial hardships. Additionally, one stakeholder identified laws
that helped control costs for medical marijuana patients (however, it should be noted that this
state also had full legalization of marijuana as a recreational substance). The implications of this

40
distinction will be discussed further in Chapter 7. No stakeholder agency identified any
governmental cost-alleviation program.
Objective 2:
Identify (if applicable) current programs or financial hardship discounts that could be expanded
on or used as a model for future funding. This objective was again measured through Questions
3 and 4.
Summary: There were no widescale or statewide financial hardship programs identified through
the data; however, Vireo Health and the Oregon SunGrowers Guild identified programs within
their organization that could be used as a template for other programs or potentially adopted to a
broader consumer base. For example, Vireo Health identified a 10% discount on products for
patients with financial hardship, either verbalized or provided through written documentation.
The SunGrowers Guild operated in a more indirect way. The program is one of the largest paid
member cannabis organizations in Oregon. Members can enroll in different “tiers” of
membership, and organization that support the mission are also allowed to enroll. Membership
fees, in turn, help support cannabis cultivators, who can pass along savings to the consumer.
There were some identified benefits and drawbacks to each program. Since there is
nothing to mandate cost-reduction programs in any dispensary, the motivation must come from
internal sources. While cost-reduction programs may be necessary to help increase access (and
broaden the consumer base), it is unclear how they impact the dispensary’s profit margin, and
how sustainable they are overall. While organization like the SunGrowers Guild offer a more

41
comprehensive and sustainable model for cost reduction, their operation is dependent on state
legislation that allows for the open growing and distribution of cannabis. At present, NYS laws
may not allow for operations like the Guild to exist.
Objective 3:
Identify some pathways to implementation for cost reduction that could follow (for example,
grants, lottery system, etc.) with the goal of developing an operationalizable cost-reduction plan.
This objective was measured through Question 3.
Summary: No stakeholders identified specific systems or pathways to implementation. More
general pathways – for example, an application process for financially disadvantaged consumers
– was discussed. The stakeholders did not identify any grants or lottery systems that could be
used to develop a statewide cost-reduction plan. The cost-reduction programs were all internally
funded.
Objective 4:
Determine feasibility of these funding sources, including cost-benefit analysis (whether there are
downsides or limitations to any identified funding source) and a realistic timeline to
implementation, with the goal of parsing out the most efficient and expedient roadmap to cost
reduction. This objective was measured through Question 5 of the survey instrument.
Summary: The cost-reduction measures identified help provide a framework for future plans to
make medical cannabis more accessible to low-income consumers in New York State; however,
it is premature to determine the feasibility of some of these measures, owing to the disparities in

42
state laws, resources, and the relative strengths and scope of advocacy groups. However, it can
be tentatively concluded that internally funded cost-reduction measures typically represent a
quicker path to implementation than externally funded programs or measures.
Data Aggregation
Note: the table with full recorded responses is located under Appendix A.
Question 1: Is the cost of medical cannabis a barrier to patient access?
Summary Response: There was full agreement among stakeholders that cost is a current and
significant barrier to access. The Nevada stakeholder also stated that NYS costs for medical
cannabis far outpaced the cost of cannabis at dispensaries located on the West Coast.
Question 2: How do you think this barrier is impacting low-income or financially disadvantaged
patients?
Summary Response: The stakeholders identified a disproportionately negative response for low-
income consumers. The stakeholders also identified the results of this barrier, including a
continued reliance on pharmaceuticals rather than medicinal cannabis, and an inability to
continuously maintain cannabis treatment. Consumers may have to supplement their pain
medication protocol with other medications.
Question 3: What are some measures (if any) already in place to help consumers in affording the
medication? Are there any financial hardship programs for cannabis consumers?
Summary Response: This question yielded mixed responses. The Nevada stakeholder identified
discounts for medical marijuana on the West Coast, as compared to recreational marijuana.

43
However, other stakeholders did not identify any financial hardship programs for cannabis
consumers.
Question 4: Are there any cost-reduction measures in development at your organization?
Summary Response: This question also yielded mixed responses from the stakeholders.
Membership benefits were mentioned by one stakeholder: essentially, loyalty programs that
provide lower costs to consistent consumers. Additionally, the stakeholder from Oregon
identified Project:Scarecrow, which provides free cannabis products to financially disadvantaged
consumers through donations.
Question 5: What do you see as long-term objectives in making medical marijuana more
accessible to patients?
Summary Response: This question received a great deal of feedback from stakeholders. A few
themes emerged: state subsidies; insurance coverage, and comprehensive increase in cultivators
and dispensaries. The responses were reported in full below.

44
Maintain the quality and
standards of the medical
approach to cannabis while
improving access – mainly by
removing financial barriers –
for patients. The ultimate
answer to this would be
insurance coverage. Until
medical cannabis is on a level-
playing field with opioids and
other pharmaceuticals, it will
be a challenge to offer this
safer option for patients. The
other major challenge to access
are providers that are
knowledgeable about medical
cannabis as a therapeutic option
and willing to explore that
option with their patients.
State subsidies for
donated medication,
elimination of 280E,
interstate commerce, not
taxing any medicine or
food, taking cannabis
out of schedule 1,
raising the THC levels
allowed in 'hemp'
products, open
exchange between
producer/providers and
patients with or without
consideration.
It should be covered
by insurance like
other medications.
Easier access to MMJ Prescriptions
Wider variety of MMJ products
available (Flower, Edibles, Vapes,
Tinctures)
More licensed cultivators
to produce/create a variety of
products
More licensed dispensaries and
licensed delivery services to
distribute products to patients
Federal regulation of MMJ &
Recreational cannabis
MMJ to be covered
as prescribed medication on health
care policies

45
CHAPTER 7
The purpose of this project was to clarify financial barriers to access for medical
marijuana, and to identify any potential funding sources to help offset the costs for low-income
and financially disadvantaged consumers. The objectives of the project were as follows: to
identify potential funding sources that could be used for cost reduction; to identify any current
programs or financial hardship discounts that could be expanded on or used as a model; to
identify some pathways to implementation for costs reduction that could follow, with the
ultimate objective of developing an operationalizable cost-reduction plan; and to determine the
feasibility of these funding sources, including cost-benefit analysis (whether there are downsides
or limitations to any identified funding source) and a realistic timeline to implementation, with
the goal of parsing out the most efficient and expedient roadmap to cost reduction. This chapter
presents an interpretation and discussion of the results and a discussion of recommendations that
can be made from the results.
Conclusions
At present, there are some cost-reduction measures in place across different states to
make medical cannabis more affordable to consumers. The medical cannabis dispensaries and
agencies surveyed in this project uniformly acknowledged that cost remains a significant barrier
to access for low-income patients, largely due to the lack of insurance coverage for medical
cannabis. Additionally, these dispensaries have established cost-reduction incentives and

46
programs in their organizations, as well as more standard methods of cost-savings for consumers,
like promotional offers, loyalty programs, and 2-for-1 sales. Vireo Health, in New York State,
offered a 10% discount to patients with financial hardship, and the threshold was eligibility was
low. The patient could either verbalize or provide documentation demonstrating their inability to
pay the full price. In other words, the feasibility of these types of programs is quite strong in the
medical cannabis industry, since they function internally and do not require external approval,
investment, or funding.
Other dispensaries in New York State have created similar programs. The
Compassionate Care Centers of New York, which provides medical cannabis at sites around the
New York City area, announced in 2015 that they would start a charitable program that could
pay for out-of-pocket expenses for medical marijuana patients with incomes between 139-400%
of the federal poverty limit (FPL) (Metro, 2015). These kinds of programs are all hopeful signs
that there is an industry understanding of current barriers to access, and organizations have
already taken steps to make costs less burdensome to the consumer.
Additionally, there are emerging programs that fully eliminate the cost barrier to
financially disadvantaged consumers. Among the most interesting pieces of information gleaned
from the data was the identification of the program Project: Scarecrow in Oregon, that provides
free cannabis to consumers through supplier donation. A low-resource program like this could
be a viable way to provide free medication for low-income consumers. The feasibility and scope

47
of any donation-based program is difficult to predict; however, there is high stakeholder
investment in providing cannabis to consumers through this program.
The results were partially supportive of the survey questions and provided some
additional insights and potential funding sources for low-income consumers. The objectives
were partially met: the project was successful in its identification of strategies and programs that
could be adopted to help mitigate the expense of medical cannabis in New York State. However,
we should clarify our terminology somewhat: rather than funding sources, most stakeholder
organizations identified internal cost-reduction measures, or independent programs already in
place. No stakeholder identified any governmental or independent programs in place that
currently offer funding for low-income consumers. This is a crucial distinction for future
exploratory efforts, because it suggests that it may be easier and more expedient to work
collaboratively with dispensaries to implement savings and financial hardship programs for low-
income consumers, rather than identifying external or independent funding sources to help
increase access to consumers. In other words, medical cannabis providers should explore cutting
costs for needy consumers through the medical cannabis community in their respective region or
state, rather than seek funding or reimbursement from external sources.
There is some possibility that the state oversight agencies that regulate the medical cannabis
programs in their respective state could provide a more comprehensive approach to cost-
reduction over time; however, these are more complicated and longer-term objectives. For
example, the NYS Department of Health offers a reduction or full waiver on the $50 registration

48
fee for consumers with demonstrated financial hardship. While this is only a small fee in
relation to the overall costs of medical cannabis, it is a promising sign that governmental entities
are aware that registrants may struggle to afford the costs of medicinal cannabis (DOH.gov,
2017). State medical cannabis programs may be able to lever price caps or implement hardship
programs for cannabis products based on income level in the future; however, it does not appear
that the state of New York has any imminent intention or plan to control costs in medical
cannabis dispensaries.
Perhaps most hopeful, there is some suggestion that there may be limited insurance coverage
available for marijuana reimbursements in specific cases: A 2018 report issued by the
Department of Health, titled, “Medical Use of Marijuana Under the Compassionate Care Act
Two-Year Report”, contained the following information:
“…insurance providers under the PHL or New York State Insurance Law are not required to
offer coverage for medical marijuana. However, nothing within the PHL prohibits an insurer
from including medical marijuana as a covered medication. Based upon recent decisions of the
New York State Workers’ Compensation Board (WCB), patients receiving workers’
compensation benefits in New York State may be reimbursed for the cost of medical marijuana if
the following criteria are met:
• The patient is certified to use medical marijuana by a registered practitioner who is WCB
authorized per WCL § 13-b;

49
• The medical marijuana is used to treat a condition authorized under Public Health Law §
3360(7) and DOH regulations (10 NYCRR 1004.2[a][8]);
• The condition for which the patient is certified is related to an established site of injury in a
workers’ compensation claim;
 The treating practitioner has obtained a variance if the condition is addressed in the
applicable WCB medication treatment guidelines (MTGs) OR the treating medical provider has
obtained a C4AUTH approval if the medical marijuana cost exceeds $1,000 and the treatment is
for a body part or condition not covered by the MTGs; and
 The claimant submits a request for medical marijuana reimbursement as a Medical &
Travel (M&T) reimbursement request.” (Source: DOH.gov, 2018)
While Worker’s Compensation case represent a small percentage of cases involving the
medicinal use of marijuana for chronic pain, it is a positive indication that insurance companies
could be amenable to providing reimbursements for consumers under specific circumstances.
The data surrounding medical cannabis programs in the United States is complex, even
convoluted. Federal government agencies with jurisdiction over pharmaceutical supply and
regulations have been largely absent from these discussions, and so the future of medical
cannabis – from laws and regulations, to costs, to public health impact – is largely unknown.
Policy Recommendations
To best inform future policy, it is important to first identify the most pressing deficiencies in
current policies. Certainly, it would be an oversight to discuss any type of policy change without

50
first again acknowledging the discrepancies between current state and federal law. These policy
recommendations, while ostensibly operationalizable in the state of New York, really speak to
the urgency or creating a stronger regulatory framework on a federal level to help inform
statewide programs, promote access, and reduce the potential for financial exploitation among
financially disadvantaged consumers.
There are several identified issues with the current Medical Marijuana program in New York
State. There is a lack of uniformity in laws and regulations governing patient eligibility, patient
registration, provider availability, and overall costs of medical cannabis. Consequently, there is
little in place to govern or cap the cost of medicinal marijuana. Future policies can address the
issue of cost from the following perspectives: is there an element in the cannabis supply chain
that results in greater expense to the provider (and thus, creates more financial responsibility to
the consumer)?
Because the data provided came largely from stakeholder organizations operating outside of
New York State, it must be acknowledged that there may be different considerations for
dispensaries operating inside the state.
Recommendations for Further Research
Marijuana’s efficacy in pain management for chronic conditions is extremely promising.
Additionally, the relatively minimal side effects and risks associated with long-term use could,
potentially, make medical cannabis a serious medicinal alternative to more traditional narcotic-
based pharmacological interventions. However, there must be more widescale research

51
conducted to better understand the potential uses and applications of the cannabis plant. There
are numerous advocacy groups in place, in New York State and throughout the United States.
That are focused on increasing access to medical marijuana for consumers with chronic pain
issues. However, there are still numerous questions about the application and accessibility of
medical cannabis that will require answers.
Future research efforts should include the following topics: More conclusive quantification
of the costs associated with the medical cannabis program for new consumers in New York
State; an average range of costs, from initial registration to all costs of supplies, within the first
12 months of utilization; and the possible option of any insurance companies offering partial
reimbursements or coverage for patients with diagnosed medical conditions.
Promisingly, the NYS Department of Health issued new recommendations and steps forward
to help expedite research studies on the efficacy and applicability of medical cannabis, as well as
providing limited insurance reimbursements. In the same 2-year report, the DOH offered the
following provisions:
“…3. NYSDOH will implement regulatory amendments to support research studies of
approved medical marijuana products, allow registered organizations to use third party
contractors for security, and make other regulatory amendments to continue to enhance the
program.

52
4. NYSDOH recommends allowing researchers in New York State, with proper Institutional
Review Board approval or Institutional Animal Care and Use Committee approval, the ability to
apply for licensure to acquire, possess, store or administer medical marijuana. This would allow
researchers to conduct clinical and basic research involving medical marijuana and lawfully
possess medical marijuana on behalf of patients for the purpose of research without being
designated as a caregiver by the patient.
5. NYSDOH recommends a pilot study with one or more third party payors to demonstrate
the effects on consumption and costs in patients who are taking medical marijuana in New York
State.
6. NYSDOH will continue to work with the New York State Workers’ Compensation Board
to assist patients in obtaining coverage for medical marijuana expenses, and to educate
practitioners and patients on the process for obtaining reimbursement for medical marijuana.”
(DOH, 2018)
While the objectives were not fully met, this study provided some insights and ideas for New
York State dispensaries and providers to help make medical cannabis more affordable to
consumers with chronic pain. While more research is needed, this study helped determine
potential future plans to alleviate the cost burden for New York State residents.

53
APPENDIX A
Data Table (by Stakeholder Organization)
Questions Organization 1 Organization 2 Organization 3 Organization 4
State New York State Oregon Colorado Nevada
Is the cost of
medical cannabis a
barrier to patient
access?
Absolutely. Any out of
pocket cost related to
health care becomes a
barrier when dealing
with chronic illness.
Yes, it is in all
states due to the
fact that no state
health program
subsidizes this
therapy.
Yes. After reviewing the menus
of a few
NY State dispensaries, the
pricing of products was
much higher compared to
west coast
MMJ dispensaries.
To my understanding, it is
quite difficult to obtain an
MMJ card in NY state
which is the first barrier to
entry that patients are
facing. Once a patient is
able to obtain an MMJ card,
the current pricing is very
high (and very limited)
and would be a big barrier
to entry for many who are
trying to
medicate themselves with
MMJ products.

54
How do you think
this barrier is
impacting low-
income or
financially
disadvantaged
patients?
Disproportionately.
Above stated barrier
even more challenging
for low-
income/financially
challenged.
Causing them to
continue to use
state subsidized
pharmaceuticals
instead of their
preferred modality
of medication.
The same ways
access to other
expensive
medicine does-
prevents them
from getting the
quality of care
they deserve and
with the
frequency
required to
maintain.
It makes it complicated for
them to
effectively participate (if at
all) in the states regulated
MMJ program and
interact with the incredible
products that are being
produced today.
What are some
measures (if any)
already in place to
help consumers in
affording the
medication? Are
there any financial
hardship programs
for cannabis
consumers?
Since the start of the
New York Program
(January of 2016), we
have offered a
compassionate discount
of 10% off all cannabis
products to anyone who
expresses financial
hardship (verbal or with
written documentation)
None, and high
license fees and
taxes on
cannabinoid
products only
makes it
worse. The state
does not subsidize
cannabinoid
therapy for either
remediative or
palliative purposes.
Not that I know
of.
On the West Coast where
cannabis is regulated for
both MMJ and recreational
use, MMJ prices are
discounted in comparison to
recreational prices. Many
dispensaries also offer
additional discounts for
army/service vets.
As for structured programs,
I am not sure of any that
exist.
Are there any cost-
reduction measures
in development at
your organization?
On a daily basis. One of
our core company
values IS “value” –
knowing that every
penny spent is, in some
way, passed on to our
patients.
One effort I'm
engaged in in
Oregon, Project:
Scarecrow, uses
donated medication
from producers in
the state license
system to distribute
for free to patients.
Yes,
membership
benefits. Patients
who chose to
allow us to grow
their plants for
them, thus
becoming a
"member,"
receive
additional
discounts on
product.
Not at the moment.

55
What do you see as
long-term
objectives in
making medical
marijuana more
accessible to
patients?
Maintain the quality
and standards of the
medical approach to
cannabis while
improving access –
mainly by removing
financial barriers – for
patients. The ultimate
answer to this would be
insurance coverage.
Until medical cannabis
is on a level-playing
field with opioids and
other pharmaceuticals, it
will be a challenge to
offer this safer option
for patients. The other
major challenge to
access are providers that
are knowledgeable
about medical cannabis
as a therapeutic option
and willing to explore
that option with their
patients.
State subsidies for
donated
medication,
elimination of
280E, interstate
commerce, not
taxing any
medicine or food,
taking cannabis out
of schedule 1,
raising the THC
levels allowed in
'hemp' products,
open exchange
between
producer/providers
and patients with
or without
consideration.
It should be
covered by
insurance like
other
medications.
Easier access to
MMJ Prescriptions
Wider variety of
MMJ products available
(Flower, Edibles, Vapes,
Tinctures)
More licensed cultivators
to produce/create a variety
of products
More licensed dispensaries
and licensed delivery
services to distribute
products to patients
Federal regulation of MMJ
& Recreational cannabis
MMJ to be covered
as prescribed medication on
health care policies

56
APPENDIX A
Personal Reflection
I approached this project out of a genuine interest in the topic of medical cannabis and its
potential uses for chronic pain. There is so much conflicting information about the use of
marijuana to treat illness. My interest in medical cannabis really started because of the opioid
epidemic. I have worked in different aspects of the substance use disorder treatment field for the
last seven years, from clinical counseling to education and administration. In that time,
Oxycontin, heroin, and Fentanyl have really changed the nature of the industry. The lethality,
the scope, and the shameful origins of the crisis (starting in doctor’s offices, with the full
awareness of oversight agencies and pharmaceutical suppliers) have subverted a lot of what
addiction professionals understood about addiction, and recovery. The well-intentioned,
regressive modalities of addiction treatment that permeate the field in the U.S. have been
woefully inadequate in actually saving lives. Like many people who work in behavioral health, I
have been dismayed by the anti-research, pro-ideology tone that still exists in a lot of treatment
arenas. Even through all of this, harm reduction programs still struggle to find a place at the
table. There are long-standing, deeply entrenched belief systems in the American recovery
industry (not elsewhere) that champion an abstinence-based model that is unsupported at best
and highly dangerous at worse, and absolutely contributes to the deaths of opioid addicts.
I had started reading about medical cannabis several years back. I had always regarded
marijuana in the same way: a soft hippie drug with some nebulous therapeutic benefit for its
Oregonian consumers. It was only really when I started reading about in the context of helping
addicts that I began looking into the actual mechanisms of marijuana and how it helped people.
The effect that cannabis has on the CB1 and CB2 receptors is interesting, particularly in how it

57
can manipulate the consumer’s perceptions of and response to pain, even chronic and severe
pain. From there I started reading about the potential of cannabis to help mitigate the effects of
anxiety, OCD, even PTSD. Throughout the course of the project I read a number of case studies
and personal testimonials on the various uses of medical marijuana. The potential uses of
cannabis are genuinely impressive. The concept of a medication that can successfully control
pain, mitigate mental health symptoms, and carries minimal side effects is almost unbelievable.
However, the figure that really stuck with me was the statistic that reported consistently
lower opioid overdose death rates for states that had adopted medical cannabis programs. These
discrepancies appeared to become stronger with every passing year that the state had provided
medical marijuana to consumers. Addiction advocacy groups, in my belief, should be pushing
hard for research into this phenomenon. The overdose prevention response has largely centered
around Narcan and community education. Much less time has been spent with providing safe
alternatives to consumers. How many people are using substances to help alleviate physical and
mental pain? How many people die from a lack of available, safe options to help treat their
conditions? In the haste to crack down on the opioid pill epidemic, lawmakers helped usher in
the heroin epidemic. The full devastation of the heroin epidemic could have been mitigated, had
there been a plan beyond stemming the supply of opioid pills. Additionally, because of state
programs like I-Stop, even patients with chronic pain who have not abused opioid medications,
have struggled to find providers. As unethical as it is to recklessly overprescribe addictive
medications, there are also huge ethical considerations when physicians are undertreating
legitimate pain.
I would argue that the push for legal cannabis for American consumers could not have
succeeded, with the efficiency and reach that it recently had, without the opioid crisis. Certainly,

58
there is an undeniable aspect of harm reduction in the provision of marijuana for medical and
recreational users. Pro-legalization groups have seized on the outrage and disgust the public has
felt in response to the news of the opioid crisis and the healthcare industry’s complicity in
creating it. There is something deeper to it, however. There is a sizable constituency in the US
who, at the very least, recognize the humongous human cost of marijuana prohibition. There is
also a population of people who use marijuana to treat symptoms of psychological or physical
illnesses and want to do so without fear of prosecution. The relentless activism of pro-marijuana
advocacy groups is also to be credited. I can’t think of another example of an issue that has such
strong state-level support, to the point of full implementation, all while being fully illegal on the
federal level.
There were a few points during the project that I struggled with the tone and direction of
the project. Medical cannabis – and cannabis legalization in general - is having a moment in the
sun, and it was important to maintain objectivity and not simply review some of the glowingly
positive studies that have emerged in recent years. Advocates tout it as a panacea, and research
often relies on self-report of improvement in symptoms. This is helpful but will not ultimately
pave the way to legitimizing medical cannabis.
Some of this difficulty in maintaining direction was also due to the rapidly changing
climate around marijuana use. Even as I was gathering data, the laws surrounding cannabis use
in the United States – and beyond – were changing. In October of this year, recreational
marijuana dispensaries were opened across Canada. In November, the first recreational sales of
marijuana in Massachusetts began. At the time I am writing this, New Jersey lawmakers have
included a bill to expunge drug conviction records for people sentenced on nonviolent drug
charges along with the bill proposing legalization of marijuana. In New York State, the

59
governmental tone towards recreational marijuana has shifted dramatically in a few years. All of
this has made it difficult to really capture the laws as they exist now. In a few years, it is within
the realm of possibility that New York State will also have legalized recreational marijuana use.
Will widescale legalization render medical marijuana programs obsolete? Some reports out of
Colorado have indicated that former medical patients are just buying recreational products
because it is less expensive and much easier to obtain. Could the same thing happen in NYS?
Or will there be a bigger push by advocacy groups to obtain insurance coverage for medical
marijuana?
I learned a lot from this project, particularly about the cannabis industry itself and how it
is governed and regulated. I struggled to keep the scope “small”, since something like this could
have easily been book length, and still not covered everything on the topic. I would have liked to
continue with it and gather more data, since there was so much insight from the stakeholders,
particularly the one from Oregon. He was involved in medical cannabis for 30+ years, long
before there was any type of cache to working in the cannabis industry and believed
wholeheartedly in the use of marijuana for pain (having also been a patient for years). My data
was originally intended to only come from NYS stakeholders, but there was a lack of interest
from these state entities. As a result, I had to expand the stakeholder pool to sources from
around the country, but I honestly think I got better data results from it. Overall, I was happy
with how the project turned out and I will continue to follow the state of legalized cannabis in
New York State, as well as the United States.

60
APPENDIX B
Interview form (interviews conducted via e-mail)
M. Thornton, C. Hewitt-Gill
Informed Consent, Instrument, and Debriefing
INFORMED CONSENT
Dear colleagues:
I am a student at SUNY Oswego in the final semester of the Master of Business Administration,
Health Services Administration specialization program. To better understand financial barriers to
accessing medical cannabis in New York State, I am hoping to get your insight. I have included
a short questionnaire and ask for you to complete it and return to me either in writing or together
over a brief phone call. The purpose of the questionnaire is to identify potential funding sources
to assist low-income and financially disadvantaged New York State residents who qualify for the
Medical Marijuana Program for the treatment of chronic pain conditions. To gain insight from
the perspectives of people with first-hand knowledge of the program, I have selected several
stakeholder agencies to interview, including your organization.
This interview is being conducted under the supervision of Dr. Michele Thornton. The research
has been approved by the Human Subjects Committee of SUNY Oswego. Your participation in
the questionnaire will be kept strictly confidential. No identifying information will be collected
or published. Participation is voluntary, and your consent can be withdrawn at any time. The
requirement for participation in the questionnaire is that respondents are adults currently
employed, in a full-time paid position, at their respective agency. Familiarity and some degree
of knowledge regarding the Medical Marijuana program in New York State is also a
requirement.
There are no anticipated or identified risks associated with your participation in the
interview. There may be minimal concerns (e.g., that a colleague could learn of your answers);
however, the interview is not structured to elicit personal perceptions of the Medical Marijuana
program. Participants that provide a valid email address will receive a copy of the final report.
For any questions regarding this project, please contact the faculty advisor overseeing the
research:
Michele Thornton, PhD, MBA
Assistant Professor
Department of Marketing and Management

61
SUNY Oswego
Michele.thornton@oswego.edu
(315)312-2184
Your participation in this questionnaire is greatly appreciated. By checking the "I agree" box
below, you provide your consent to allow us to use your responses in our final report.
I agree to participate in the following questionnaire regarding financial barriers and potentially
cost-reduction programs in the Medical Marijuana program in New York State.
____ I agree
____ I disagree
Questionnaire
Question Response
Do you believe that the cost of medical
cannabis a barrier to patient access?
How do you think this barrier is impacting
low-income or financially disadvantaged
patients?
What are some measures (if any) already in
place to help consumers with the cost
medication? Are there any financial
hardship programs for cannabis consumers?

62
Are there any cost-reduction measures in
development at your organization?
What do you think are the systemic issues
behind the expense of medical cannabis?
What do you see as long-term objectives in
making medical marijuana more accessible to
patients?
·
Debriefing
Thank you for completing this interview. Your responses will greatly contribute to the broader
understanding of financial access issues in medical cannabis programs and increasing access
among low-income and financially disadvantaged New York State residents eligible for medical
cannabis. Your contribution is greatly appreciated.
·
· · ·

63
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