The US health system is enduring a shock during the coronavirus pandemic and the aftershocks will continue to be felt long after the virus itself has been contained.

Hospitals nationwide have canceled elective surgeries en masse. Visits to primary care doctors and specialists have dropped off precipitously. Now the US economy is experiencing levels of unemployment not seen since the Great Depression and millions of people have lost their employer-sponsored health insurance.

I posed a simple question to a few different experts who study population health: Have we ever seen disruption to medical care like this before?

I dont recall there ever being a disruption to the health system like were seeing, Cheryl Damberg, the director of the RAND Center of Excellence on Health System Performance, told me. Weve had recessions where people have lost insurance and there is more uncompensated care, but nothing like canceling surgeries and declines in ambulatory visits.

Others concurred. I do not believe there has ever been a similar hiatus, Mark Cullen, director of Stanford Universitys Center for Population Health Science, told me, and the short answer is that yes, it will take some time before we will know the total health impact, or even to effectively estimate some

It is, unfortunately, an unplanned natural experiment. Rifat Atun, a professor studying global health systems at Harvard University, gave me a useful way of understanding the sprawling effects that a major trauma like the coronavirus pandemic will likely have on Americans health. You can put them, for starters, into four broad categories.

1.3 million cases. Nearly 80,000 people dead (at a minimum). Tens of thousands of people hospitalized we arent even sure how many. At least 86,000, according to a tracking project at the University of Minnesota.

It may be easy to become numb to them, but those numbers we have been tracking for weeks are the first and most direct impact of the coronavirus. We should also be bracing ourselves for second, third, fourth waves of the outbreak. The virus itself wont be fully neutralized until there is a vaccine or treatment.

And those acute effects could, somewhat paradoxically, linger with us for a long time. Just because people have recovered from Covid-19 doesnt mean their health has gone back to normal.

As Lois Parshley wrote for Vox recently, the long-term health consequences of this disease are just starting to come into focus:

Because Covid-19 is a new disease, there are no studies about its long-term trajectory for those with more severe symptoms; even the earliest patients to recover in China were only infected a few months ago. But doctors say the novel coronavirus can attach to human cells in many parts of the body and penetrate many major organs, including the heart, kidneys, brain, and even blood vessels.

The difficulty is sorting out long-term consequences, says Joseph Brennan, a cardiologist at the Yale School of Medicine. While some patients may fully recover, he and other experts worry others will suffer long-term damage, including lung scarring, heart damage, and neurological and mental health effects.

Parshley ticks through some of the potential long-term complications: lung scarring, strokes, embolisms, blood clotting, heart damage, mental health, and more. The point is, people will be living with this disease and the damage it did to their body for years and so will our health system.

All those canceled surgeries, delayed doctor appointments, and the rest will also have a lasting effect on peoples health.

One of the key concerns that practitioners in particular are having is related to the backlog that is piling up, Ellen Nolte, professor of health services and systems research at the London School of Hygiene and Tropical Medicine, told me, and the impacts this will have on medium- and long-term outcomes, in particular for people with chronic conditions.

As I reported recently, visits to primary care doctors and other outpatient specialists have fallen off steeply during the Covid-19 pandemic. Here it is, in one chart:

Ateev Mehrotra, a professor at Harvard Medical School who led the study above, told me our real concern is those patients who might have deferred a visit and theyre going to have a flare-up of their chronic illness. In the worst-case scenario, a patient could die because they werent able to have a routine check-up.

Dania Palanker, an assistant research professor for the Center on Health Insurance Reforms at Georgetowns Health Policy Institute, said she worries about people recently diagnosed with diabetes or heart disease who wont be able to get that critical first appointment with a new doctor. You cant delay those appointments for a few months.

And if people do delay care whether because their surgery was canceled, their doctors office was closed, or they chose on their own to skip treatment to avoid potential exposure to Covid-19 their health outcomes are probably going to be worse.

There is also a risk that the decline weve seen in medical utilization will lead rural hospitals to close or primary care practices to consolidate, which in turn restricts access and drives up costs. That is another factor that could lead to less timely medical care for Americans in the future, which would in turn lead to more adverse health outcomes.

And there is one other obvious thing could lead to people postponing medical care: a loss of income and/or health insurance.

More staggering numbers: 33 million people have filed for unemployment benefits since the pandemic took hold and the unemployment rate is nearly 15 percent. Experts project that as many as 7 million people will be left uninsured as a result of the economic crisis precipitated by Covid-19.

Economic downturns can have countervailing effects on peoples health. We know that losses in income and health insurance can have a negative impact. Atun has actually studied this question himself, looking specifically at cancer-related mortality. He and a team of researchers found that in the 2008-2010 recession, there were an estimated 260,000 excess cancer-related deaths in that time, including 40,000 from treatable cancers, in OECD countries.

Those consequences were felt most in countries without universal health coverage of which, of course, the United States is one. And now millions of Americans have lost the health insurance they did have.

On the other hand, there is some research suggesting that overall mortality actually falls during economic downturns. But the reasons are not well understood and, for people who actually experience joblessness or other financial trouble, there still appears to be higher rates of acute heart problems and overall mortality, according to a 2011 summary of the available research.

Excess mortality is a complicated soup of many different variables, some of which hurt health and some of which may help it (if, for example, people smoke less and exercise more during a recession). This is one of the reasons why it will take us so long to understand the full impact of Covid-19.

But I think the negative effects far outweigh what these positive effects might be, Atun told me.

If there is one place where the research on economic turbulence and health outcomes converges, its that behavioral and psychological well-being is harmed during an economic crisis.

This is perhaps the most speculative category, so I will keep it short. But Atun pointed out that the various social distancing measures weve taken to clamp down on Covid-19 will have an effect on our collective mental health, as will the economic crisis and the simple, painful reality of 100,000 or more people dying of the virus in just a few short months. There is a medical toll to all that mental pain, though it will again take a long time to reveal itself.

And that is the point. It will take years for the full impact of the coronavirus to be understood.

The effects will be longer-lasting than the immediate figures that we see, Atun said. Or as Cullen put it: Bottom line is this will be a beast to sort out.

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