Gather up all the people legally allowed to smoke cannabis in Florida and they would be the state’s seventh largest city, with more people than Tallahassee, Fort Lauderdale or Cape Coral.

But the 212,000 people on Florida’s medical cannabis patient registry cannot get health insurance to cover the cost of their medicine.

“Our constitution recognizes that cannabis is medicine, and if it is in our constitution then companies that provide health insurance to Florida patients should be covering it,” Agriculture Commissioner Nikki Fried told the Democrat.

Florida lawmakers first authorized the use of low-THC cannabis in 2014. Upset with the limitations the Legislature imposed on the drug, voters two years later overwhelmingly approved a constitutional amendment that broadly legalized the plant to treat a wide range of illnesses from epilepsy to anxiety and chronic pain.

But while Florida as a government may recognize cannabis as a medicine, the state as an employer does not.

The health insurance plan offered to 162,000 state employees provides no cannabis coverage. A Department of Management Services spokesman said the state has no cannabis policy for coverage because none of the state’s medical dispensaries are part of the group insurance network.

Rep. Ramon Alexander, D-Tallahassee, agrees with Fried: That needs to change.

“We need to have a comprehensive review to allow the use of cannabis for medicinal purposes for health insurance coverage,” said Alexander. “The therapeutic value of medical cannabis may be able to treat and alleviate symptoms of a variety of serious medical conditions … that many of our state employees face.”

Sun Life Financial of Canada, which provides health insurance to more than 20 percent of Canadians, offers cannabis coverage. And insurers in Germany covered $83 million in medical cannabis products in 2018.

But private insurers deny coverage in the U.S. by citing IRS regulations, the lack of FDA approval of cannabis as medicine and a federal classification as a Schedule 1 drug, on par with heroin and cocaine.

Sen. Aaron Bean, R-Fernandina Beach, chairs the Health Policy and Health and Human Services committees and has argued since 2012 for a slow, step-by-step lifting of cannabis regulations.

“We are still in the baby steps phase of the process,” said Bean. “You’re talking about an advance running stage. Until we can build a network that makes sure those who truly need the medicine have access to the medicine it is hard to think about anything else.”

Florida is among the 33 states with a medical cannabis program.

The National Association of Insurance Commissioners has formed a working group to explore how to persuade insurers to provide coverage for a substance the federal government considers dangerous and without any medical benefits.

The cost for medical cannabis treatments adds up before the patient purchases the first gummy bear, ointment or bud. There’s about $700 in certification and registration fees a year to the state and physician. Then there’s another $3,000 to $8,000 to pay for the cannabis that the average patient consumes annually, according to a Minnesota survey.

“The reality is so many of these patients who qualify for medical cannabis are actually poor. They are disabled in some way. They can’t work and are on a fixed income,” said Rep. Carlos Guillermo Smith, D-Orlando. “The very least we need to do is what we can to make sure folks at least have access to the medicine available through medical cannabis.

Nearly a quarter, about 50,000, patients on the registry list cite post-traumatic stress disorder to qualify for a cannabis ID card.

New York recently clarified its law to require insurers to cover physician’s visits related to medical cannabis but not the actual cost to obtain the drug from a dispensary. A bill filed in Maine this year would require carriers to directly reimburse a patient for the costs of cannabis. And a New Jersey judge ruled in favor of a workers compensation claim for cannabis treatment.

The 2016 amendment voters overwhelmingly approved stated it did not require “any health insurance provider or any government agency” to reimburse anyone for expenses related to the medical use of cannabis.

But Sen. Jeff Brandes, R-St. Petersburg, said that does not mean that insurers can’t offer coverage, only that the state can’t mandate coverage.

“The state should allow it to be covered by insurance,” said Brandes.

Fried and Smith also support legislative action.

Ron Watson was among the first medical cannabis lobbyists to work the issue at the state Capitol. With cannabis’s Schedule 1 classification preventing university-related research, Watson has listened to countless anecdotal testimonies in seven years of committee meetings from sick people who said cannabis helps them.

Watson argued the first insurance company to offer cannabis coverage in Florida would see a flood of new clients.

“They might want to look at it for no other reason than they can save money. It would have cost savings,” said Watson, President of Watson Strategies. “The amount of money the companies would save on pharma (prescription drugs) would far outstrip whatever they spend on providing medical cannabis.”

Fried said getting insurers to cover medical expenses for cannabis is “essential to the success of the program.”

Florida growers look to create a billion dollar crop as the industry grows.

Fried said that Florida Insurance Commissioner David Altmaier recognizes that cannabis is a top issue for the Agriculture Department and has been very supportive of her efforts to remove the legal hurdles for insurers to provide cannabis coverage.

“Given the recent advancements of legislation surrounding medical cannabis in Florida, I look forward to maintaining a seat at the table as conversations surrounding the future of medical cannabis in Florida continue,” Altmaier told the Democrat.