[#item_full_content] Since its initial approval in 1992, medical cannabis (MC) in Israel has undergone extensive regulatory and structural transformation. This study aims to present the most comprehensive retrospective analysis to date of the evolving MC policy framework in Israel and its impact on patient access, prescribing patterns, and treatment characteristics from 2011 to 2025. The study included a longitudinal review and secondary analysis of monthly Israeli Medical Cannabis Unit (IMCU) reports, covering key parameters such as the number of active licenses, indications, dosage patterns, product types, healthcare provider involvement, and importation data. Regulatory milestones and reforms were mapped to observed shifts in these parameters, with particular attention to the transition to per-product pricing (2019), the decentralization of prescription authority to trained physicians (2020), and the Health Maintenance Organization (HMO)-led prescribing reform (2024). The number of active MC licenses increased markedly by over 4,400% from 3,097 in 2011 to a peak of 140,483 in January 2024. This growth coincided with expanded indications, broader pharmacy access, and prescribing authority beyond IMCU physicians. The 2024 HMO-led reform, followed by a 7.5% gradual decline to 129,900 active MC licenses and prescriptions on March 2025, alongside incomplete reporting of prescription indications data. This decline is consistent with this study hypothesis of stricter HMO gatekeeping and transition frictions. The most frequently approved indication was chronic non-cancer pain (CNCP) (increasing from 53 to 63%), with substantial, constant growth of ~ 89% (from 9 to 17%) in the second most common indication, post-traumatic stress-disorder. Approved monthly dosages shifted significantly: the share of patients receiving 50gr/month rose by ~ 108% and 60gr/month by ~ 117%, while the 40gr/month category consistently comprised ~ 22–25% of active patient licenses. Product form trends were also notable: flower-based MC products accounted for over 94% of usage by 2025. At its peak, the estimated annual market value of MC products ranged between $252–$684 million. Israel’s MC program reflects a dynamic interplay between policy reforms and patient treatment patterns. While preliminary MC medicalization improved access, recent decentralization efforts have introduced new challenges related to oversight and data transparency, plausibly reflecting stricter HMO gatekeeping, transition frictions, and the post-investigation non-renewal of irregular licenses (hypothesis given current data gaps), that may be associated with a decline in active MC licenses. The findings underscore the importance of maintaining consistent national reporting standards to guide evidence-based MC policy and clinical practice. 
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