Bernie Goldblatt is still struggling after surviving one of Minnesota's first severe cases of COVID-19.

More than a year after recovery, his breathing grew tighter and tighter until he needed surgery in fall 2021 to place a tube in his neck and relieve the pressure. The 70-year-old retired synagogue director is active and shops at Target — but not without a cart to lean on and a couple of rest breaks amid the shelves.

"Every minute is a gift," he said, but not a free gift.

Minnesota has identified 1.7 million COVID-19 cases since March 2020, not including cases that were undiagnosed or found through home tests. COVID-19 also caused nearly 14,000 deaths of Minnesotans, who left behind grieving relatives and friends. But the pandemic's lasting impact after nearly three years also includes thousands of residents like Goldblatt, who are struggling with the physical and mental aftereffects of COVID-19.

The state's challenge in 2023 will be accounting for that damage.

"For some people, it has economic impacts, it has impacts on their livelihood, it has impacts on their quality of life, on their mental health. It exacerbates chronic conditions. It's really problematic," said Dr. Ruth Lynfield, state epidemiologist and medical director of the Minnesota Department of Health (MDH).

Step one is figuring out the toll of post-COVID conditions — generally referred to as long COVID and defined in the U.S. as symptoms in multiple parts of the body that linger four or more weeks after initial illness.

A national study in December identified more than 3,500 U.S. deaths from long COVID through June this year. MuckRock, a collaborative news organization, drilled into the data and found 63 such deaths involving Minnesotans — from a 39-year-old disabled man to a 100-year-old woman.

Most Minnesotans aren't dying from post-COVID conditions, but many have baffling levels of fatigue — much like people with complications from Lyme disease or infections with the Epstein-Barr virus, said Dr. Tanya Melnik, director of M Health Fairview's adult post-COVID clinic.

"These people need help," she said, and face doubters at home and work about whether they are actually sick so long after their initial COVID-19 cases. Long COVID experts will begin meeting in January as a formal state guidance council to advise doctors and patients on how to identify and manage these cases.

The good news is that long COVID risks appear to be declining. A British study found a 10% rate of long COVID in people infected with the delta viral variant last year, but only a 5% rate in people infected with the dominant omicron variant this year. The study used the British definition of long COVID: symptoms lingering at least three months.

"That's an improvement compared to 10%, but still it's an issue," Melnik said.

The symptom pattern has shifted, with fewer long COVID patients reporting the prolonged loss of taste and smell that had been common earlier in the pandemic, she said. Most new patients have extreme fatigue, often in combination with cognitive problems and clouded thinking — often referred to as "brain fog," she said.

A long-planned survey of COVID-19 patients in Minnesota is scheduled to begin this year to determine the prevalence of people with lingering symptoms, Lynfield said. "It will help us really have an understanding of what the ongoing needs may be for people."

Health impacts of the pandemic extend beyond COVID-19 itself, though. Hospital overcrowding this winter has been due in part to a shortage of burned-out nurses and other caregivers, but also because patients have so many overdue or neglected medical needs.

Chronic illnesses such as diabetes were somewhat managed before the pandemic but neglected after the rise of COVID-19. Federal survey data this fall showed an increase in the share of Minnesota adults considered obese — from 30.7% in 2020 to 32.4% in 2021.

Some people struggled to maintain exercise and diet routines, while others stopped going to clinics for fear of exposure to the coronavirus. Emergency rooms are now filled with some of those people, who also may have lost support from family caregivers during the pandemic and financial resources to maintain good health, said Dr. Will Nicholson, vice president of medical affairs for Fairview's east metro hospitals.

"Sadly, all this stuff ganging up on folks leads to illness that could have been prevented and relapses that didn't have to happen," he said.

One consequence has been an increase in so-called excess deaths — the number of deaths above predicted estimates by the Centers for Disease Control and Prevention. There were about 660 more non-COVID deaths than expected in Minnesota in each of the last two years. The total in 2022 will likely be higher — with 595 excess non-COVID deaths reported through October.

COVID-19 deaths have declined in Minnesota — from 5,912 in 2020 to 4,953 to 2021 to a preliminary total through mid-December of 3,067 in 2022, according to state health figures. Almost half of 2022's COVID-19 deaths occurred in January and February during the peak of the omicron wave.

Goldblatt took precautions after his severe April 2020 case of COVID-19, but he suffered a second, milder case as well. Routine checkups are needed to maintain his breathing tube, along with physical therapy to help him restore lost mobility and balance. He walks with trekking poles, but he sometimes needs a wheelchair or scooter for longer distances.

"I'm trying not to let any limitation hold me back," said Goldblatt, who took recent month-long trips to California and Israel.

Mental health counseling after COVID-19 was helpful, because so many lingering symptoms are hard to explain to others, he said. "Often the challenges are not visible."

An increased need for mental health support statewide is likely in 2023. Health problems, economic losses and the fear of COVID-19 itself raised anxiety and depression levels in Minnesota.

The 2022 Minnesota Student Survey showed an acceleration during the pandemic in the rate of mental health problems lasting six months or more. The 29% of middle- and high-school students reporting such long-term problems represented an increase from 23% in 2019 and 18% in 2016.

The survey isn't proof that the pandemic caused the acceleration, but it certainly was an influence, said Sharrilyn Helgertz, a state health researcher and leader of the student survey. "It was such a huge game-changer and so disruptive. It's hard not to conclude that any differences were due to the pandemic."