COVID-19

[Irishize]

Update for us: I ended up with a pretty bad head cold from Thursday through yesterday. Nothing serious, and never had a temp, but annoying nonetheless. Today I feel like you do normally when recovering from a head cold, much better but still not 100%. I did lose some taste/smell. Beer has had no flavor, but food, iced tea, and etc all taste the same.

The fiance has had absolutely no issues at all, and she's really only suffering from boredom.

Just curious...have you ever had the flu?

What about your fiancé?

 

[GowerND11]

Just curious...have you ever had the flu?

What about your fiancé?

Yes we both have had the flu. Why?

 

[NorthDakota]

Update for us: I ended up with a pretty bad head cold from Thursday through yesterday. Nothing serious, and never had a temp, but annoying nonetheless. Today I feel like you do normally when recovering from a head cold, much better but still not 100%. I did lose some taste/smell. Beer has had no flavor, but food, iced tea, and etc all taste the same.

The fiance has had absolutely no issues at all, and she's really only suffering from boredom.

Consider it a warning shot from the Big Man upstairs. REPENT

 

[RDU Irish]

My premiums and deductibles went way up once the ACA was introduced. I know quite a few that have seen the same thing happen to them.

I lost my plan - cancelled by BCBS after raising rates dramatically for a few years. Couldn't change anything before that - increasing deductible would have cancelled it for example. $2000/month is not affordable for an average family of 4 or 5.

Problem has nothing to do with a $15,000 bill to go to the ER for four hours thinking your daughter has appendicitis. Even after insurance drops it down bigly most people are blowing through their deductible for that quick trip. Thankfully our sharing ministry has a $300 copay for ER including common tests/scans. Wow, that is insurance that works but not how traditional plans are EVEN ALLOWED TO BE SET UP. Gubmint likes that shoe on your throat.

 

[SonofOahu]

IIRC, there are still 600K+ deaths due to influenza worldwide despite a vaccine.

People still die of diarrhea, "worldwide." I don't see too many Americans dying because they lack Immodium and Gatorade. Worldwide statistics are often meaningless because it's comparing apples to oranges.

 

[SonofOahu]

My premiums and deductibles went way up once the ACA was introduced. I know quite a few that have seen the same thing happen to them.

Mine became lower and have remained so. My wife works for a government agency and her plan has improved over time since ACA. Weird how it all works.

My wife lost her doctor she had been going to her whole life (regardless of where she worked or her insurance). He was a part of a small consortium of doctors which was no longer covered under the ACA. My guess is companies like Kaiser signed on to the ACA with the knowledge the "little guys" would not be covered.

I work for a Fortune 500 company and because of the increased rates under the ACA our corporation went from Aetna to Anthem. Even with that change, our monthly rates are still higher than pre-ACA.

Lastly, and the worst of all. My Mom's meds for A-Fib went from approx. $100 to over $1000 per month. Unbeknownst to us she stopped taking it which led to her having a massive stroke. I can say the ACA is partly responsible for her not being alive today so I TAKE THIS PERSONAL.

The Afib medication thing is specifically covered in Biden's plan just FYI. And expansion of medicare to 60 will also lead to reduced commercial insurance prices by shifting off a high risk demo.

Same. I take it personally too, my father is certainly not with us due to that bill, my uncle probably so as well tho his situation was one that may have worsened regardless (tho the ACA def helped quicken things). I get some are just programmed to support it because it’s a dem bill but I get very angry when I see some defend it like it’s this huge win win with nothing problematic at all about its passing or consequences. I often have to just step away and not post when it’s brought up.

In my life, I have learned not to trust anything a politician says (or writes for that matter) especially one who was part of an administration who said "if you like your doctor you can keep your doctor" and promised a $2500 savings for the average family under their plan.

Fool me once.....

Healthcare is personal. It’s personal for everyone. My own personal experience and that of my immediate family has been improved. I don’t know why mine is better and yours isn’t. It’s weird and I don’t think wholly the fault of the bill but I know some people hate the bill so much they wont see past that. I know it’s not the same for everyone and I don’t blindly praise it because it’s a Dem Bill.

ACA is a great idea, in theory. Its goal mirrors the "Triple Aim" as put forward by the Insitute for Healthcare Improvement (IHI): Low cost, great patient experience, better health.

Some of you are directly attributing the ACA to your family member's demise. That's not a proper attribution. You should be attributing the rising cost to the actual sources of your issue: the market that you are in and your payor's actuarial team.

ACA made people get coverage, and in doing so, it also forced insurers to cover them. People in poor health often don't do well, even with coverage. So now they are a liability -- they'll take more from the system than they'll provide. As a result, the insurance companies raise everyone's premiums to cover the liabilities. That's why it was important for the younger people to join the markets -- they're lower risk and lower cost.

The ACA did not set rates. Rates are determined by the payor's market. If you are like OMM, you live in a market highly skewed towards older people. They are the worst, from an actuarial perspective -- they utilize the most resources. If you are like Cack, who probably lives in a market dominated by younger professional types, it's a mixed bag. Younger people don't utilize as many resources, until they start to have families. Even then, peds charges are far, far less than geri charges.

Oh, there's actually a third party you should be pissed at. The GOP who has continuously tried to kill the ACA, even though the GOP was its strongest proponent in the 90s. By taking away the structure that forced the younger people to stay in the market, they basically forced all of that cost onto everyone else. Now your risk pools got deeper and more expensive.

"I have seen the enemy, and it is us."

 

[SonofOahu]

Back to COVID: Has any member of this board died from it?

 

[calvegas04]

Back to COVID: Has any member of this board died from it?

lol wut? Chances are no

 

[notredomer23]

https://www.bloomberg.com/news/articles/2020-11-09/pfizer-s-covid-vaccine-prevents-90-of-infections-in-large-study

If actually 90%, that is pretty huge news given that there will be some vaccine hesitancy and also a significant portion of the population fully protected before the roll out is even complete.

 

[Cackalacky2.0]

ACA is a great idea, in theory. Its goal mirrors the "Triple Aim" as put forward by the Insitute for Healthcare Improvement (IHI): Low cost, great patient experience, better health.

Some of you are directly attributing the ACA to your family member's demise. That's not a proper attribution. You should be attributing the rising cost to the actual sources of your issue: the market that you are in and your payor's actuarial team.

ACA made people get coverage, and in doing so, it also forced insurers to cover them. People in poor health often don't do well, even with coverage. So now they are a liability -- they'll take more from the system than they'll provide. As a result, the insurance companies raise everyone's premiums to cover the liabilities. That's why it was important for the younger people to join the markets -- they're lower risk and lower cost.

The ACA did not set rates. Rates are determined by the payor's market. If you are like OMM, you live in a market highly skewed towards older people. They are the worst, from an actuarial perspective -- they utilize the most resources. If you are like Cack, who probably lives in a market dominated by younger professional types, it's a mixed bag. Younger people don't utilize as many resources, until they start to have families. Even then, peds charges are far, far less than geri charges.

Oh, there's actually a third party you should be pissed at. The GOP who has continuously tried to kill the ACA, even though the GOP was its strongest proponent in the 90s. By taking away the structure that forced the younger people to stay in the market, they basically forced all of that cost onto everyone else. Now your risk pools got deeper and more expensive.

"I have seen the enemy, and it is us."

I do live in a rather youthful professional city. Its food and bev, hospitality and travel, with 3 colleges, a huge medical professional community and heavy manufacturing with Boeing, Volvo, and Mercedes plants within 10 miles of each other. Its also located on the coast. Average age of my county is 37 yo. Average age of my city is 41 (me)

 

[NOLAIrish]

My wife lost her doctor she had been going to her whole life (regardless of where she worked or her insurance). He was a part of a small consortium of doctors which was no longer covered under the ACA. My guess is companies like Kaiser signed on to the ACA with the knowledge the "little guys" would not be covered.

I work for a Fortune 500 company and because of the increased rates under the ACA our corporation went from Aetna to Anthem. Even with that change, our monthly rates are still higher than pre-ACA.

Lastly, and the worst of all. My Mom's meds for A-Fib went from approx. $100 to over $1000 per month. Unbeknownst to us she stopped taking it which led to her having a massive stroke. I can say the ACA is partly responsible for her not being alive today so I TAKE THIS PERSONAL.

I’ve got a lot of problems with the ACA. I’ve posted many of them here in the past - I think it largely was designed to avoid addressing the core problems in health care (cost, massive disincentives to price sensitivity in areas not affecting outcomes, waste) while handing out costly wins to the health industry. But there’s a lot of misinformation about what it actually does floating around this thread right now, and I’d like to bring a little clarity - I hope. I quoted you, yankeehater, because I think your post demonstrates a lot of these misconceptions; I really hope it doesn’t come across as picking on you.

Starting with your wife’s doctor. What’s happened here is the doctor’s group is no longer in your wife’s insurer’s provider network. This is a private contract between the physician group and the insurance company. If the physician group left your wife’s insurer’s network, that was due to the two sides not coming to an agreement to renew the network participation contract. It’s not related to the ACA in any real way. Now, if your wife changed insurance as a result of the ACA (e.g., her employer chose to stop offering small group coverage and instead pay the penalty, forcing her into the individual market) - that could be blamed on the ACA. But small doctors groups weren’t pushed out of insurance networks by the ACA. What’s more likely here, actually, is two totally separate phenomena that’ve happened over the past decade as the overall health insurance industry has seen massive price increases (which largely mirror what the market was doing pre-ACA and which ACA failed to stop): network narrowing and provider consolidation. Insurers cut their networks way down over the last decade in an effort to contain costs. This was an industry measure - the ACA neither drove it nor required it. At the same time, physicians groups found they could often leave network as a negotiating/price maximization tactic. Both of these led to fewer providers in networks today than a decade ago,

On to your coverage. If you work for a Fortune 500 company, you are covered by a grandfathered self-funded, large group employee plan. That plan is almost entirely exempted from the ACA and instead is governed by a much older federal law called ERISA. Rate increases in that market are unrelated to the ACA - large self-funded plans have been getting more expensive since the 90s (though at a slower pace than small group and individual plans) and continued to get more expensive at about the same pace after the ACA passed. What’s more, your “insurance company” in a self-funded plan is really just providing back office services for your employer’s insurance plan (your employer designs the benefits and funds all claims; the insurer is just doing admin). Switching carriers may have changed the employer’s admin cost and switched provider networks, but it’s got nothing to do with any ACA-related costs (a lot of large employers have found it convenient to blame the ACA for their own cost growth).

Your mother’s experience is one of the most sickening issues in our system today. I don’t know her insurance history (if the ACA led her to switch coverage and the new coverage had her medicine on a separate formulary tier, that certainly could’ve driven that price increase). That’s both an ACA and non-ACA problem - you see the same issues in the grandfathered market and even in the Medicare market. Insurance companies use a separate company - called a Pharmacy Benefit Manager - to administer their drug benefits. Between PBMs and drug wholesalers, the abuse of prices and of the aging population throughout our prescription drug market is unconscionable. A lot of these abuses were known and addressable at the time of the ACA, and one of its biggest failures was that it didn’t even try,

Another poster mentioned prices going down in their wife’s government plan post-ACA. Just a quick note there as well - that’s also not an ACA effect. ACA (and HIPAA and ERISA) doesn’t apply to government plans.

One final aside - a lot of People Who Want to Sound Smart But Don’t Actually Understand the ACA like to “yeah, but” about the ACA having some magical overall effect on healthcare prices “across the industry” and then try to bootstrap that into affecting costs of health insurance products that it doesn’t directly regulate. There’s absolutely no evidence that it had any such effect. The ACA is far more narrow than its often credited with being - it had massive effects in the individual market, which is by far the smallest market in the country; modest effects in the small group market, which is the next smallest market; and virtually no effect in the large-group market, which covers most Americans. Outside of the ACA markets, cost growth was in line with what we were seeing prior to the ACA and was entirely explainable through non-ACA-related medical cost inflation. The sin of the ACA is that it wasted our “fix the broken health care market” energy on a series of projects that did little to fix the broken health care markets. But on average, it also didn’t really make things any worse for the overwhelming majority of people - this irrational, frustrating, broken, overpriced payment system is largely the same irrational, frustrating, broken, overpriced payment system we’ve been assiduously crafting for the past 80 years.

 

[Cackalacky2.0]

^ Excellent post.

 

[zelezo vlk]

Rates are going up down here in Austin and back in my hometown. Got me a bit worried about driving up to see my fam for Thanksgiving, especially since my dumbass company decided that everyone needs to go back in the office again.

I knew there'd be a spike from the holidays, but I expected it to happen after Thanksgiving, not before.

 

[irishff1014]

Sounds like the Gov. Of Maryland is going to shut everything down again today. I have heard we are going back to stage one. And so it begins.....

 

[notredomer23]

Sounds like the Gov. Of Maryland is going to shut everything down again today. I have heard we are going back to stage one. And so it begins.....

Idk what stage 1 in Maryland is, but my guess is he does what Murphy did here in NJ and close restaurants & bars after 10 PM + ban bar seating.

 

[TorontoGold]

Idk what stage 1 in Maryland is, but my guess is he does what Murphy did here in NJ and close restaurants & bars after 10 PM + ban bar seating.

Same stuff is happening up here too, all indoor dining is getting shutdown and our RT factor is 1.2 or higher.

I read an interesting study on twitter that transmission is getting driven more by relaxed workplace settings rather than schools.

 

[notredomer23]

Same stuff is happening up here too, all indoor dining is getting shutdown and our RT factor is 1.2 or higher.

I read an interesting study on twitter that transmission is getting driven more by relaxed workplace settings rather than schools.

The vast majority of the spread here is taking place in get togethers at private homes. I don't see any warning or restriction really stopping people from already getting together with friends/family reversing that behavior.

 

[Legacy]

Oahu's and NOLA's postings are excellent in explaining aspects of the ACA and different group's coverage rates.

The cost control mechanism built into the ACA for the individual market for those making between 101-138% income were left up to state insurance commissions regulators if rates exceed 7% rate increases as well as a medical loss ratio for excessive profits by health insurance companies.

Kaiser Family Foundation tracks the Insurance Market Performance by quarter and annually. for 2019 (pre-Covid),
Individual Insurance Market Performance in 2019

The early years of the Affordable Care Act (ACA) exchanges and broader ACA-compliant individual market were marked by volatility. Markets in some parts of the country have remained fragile, with little competition, an insufficient number of healthy enrollees to balance those who are sick, and high premiums as a result. By 2017, however, the individual market generally had begun to stabilize, and by 2018 insurers in the ACA-compliant market were highly profitable, despite the elimination of cost-sharing subsidy payments and expansion of short-term plans. However, 2019 was the first year that the repeal of the individual mandate penalty went into effect, raising concerns that healthy enrollees would forgo coverage, leaving sicker and more expensive enrollees behind and requiring insurers to increase premiums. Nonetheless, Marketplace premiums fell slightly on average going into 2019, as it became clear that some insurers had raised 2018 rates more than was necessary (and premiums dropped again heading into 2020). (cont)

Individual Insurance Market Performance in Early 2020

The coronavirus pandemic and the resulting economic downturn are likely to impact the individual insurance market in profound but complex ways. In this brief, we analyze first quarter data from 2011 through 2020 to examine how the individual insurance market performed under the Affordable Care Act (ACA) and during the first few months of the year, when the coronavirus pandemic was first emerging in the United States. (cont)

Figures that I have seen are that with this economic downturn, due to the pandemic many people who lost their jobs will get fall back on their spouses insurance or Medicaid and state unemployment without a significant increase in the ACA population.

NOLA has previously said (in the Healthcare thread) is that the lack of real competition across insurance groups is a major factor in rate increases. In states like California which have competition among multiple HC companies, the state has more leverage. Increases in drug prices without much cost control mechanisms accounts for much of rate increases.

As far as leverage and competition, in one small city in Colorado the physicians will not accept anything other than private payer insurances, not even those in HMOs. Practices will often merge in specialties, sometimes becoming the only practice alternative and may choose a company to represent them in contract negotiations with area hospitals. Sometimes those practices are bought by private national health organizations who operate for-profit. Physicians or private entices that provide care at other levels may limit the amount of Medicaid patients due to federal reimbursements being 60% of private payers and take longer with more paperwork.

With many individuals who lost their jobs and had enrolled in the ACA, we'll have to wait and see if the ACA market sees any rate increases or if that group actually lowers the risks for an insurance company reesulting in a rate decrease. If that is the case and the ACA is upheld, until they get employment the risk that is carried with them is transferred to ther federal and state government through Medicaid. Those with post-Covid illness may or may not increase the burden in those markets.

 

[Irish#1]

Indiana joining the crowd in putting restrictions back in place. Chicago with a "Stay at home" policy for 30 days.

 

[irishff1014]

Idk what stage 1 in Maryland is, but my guess is he does what Murphy did here in NJ and close restaurants & bars after 10 PM + ban bar seating.

He and his team are not making well informed decisions. We can't have a gatherings of 25 people at hall we use for the fire house but we can continue our Friday night bingo at 50% capacity. And i know why her put more restrictions on. The liberal county executives on the wester shore were crying that the Governor needed to shut things down and rode him hard last weekend. They also know he can't run anymore but they can so they don't want it to hurt their political future.

 

[IrishLax]

If I was in charge, I would announce a strict 3 week nationwide lockdown after Thanksgiving with opening back up before Christmas. Short term pain for long term gain. I don’t think the federal government has the authority to do that even if they wanted, but they’ve been conspicuously silent on this as cases continue to spiral out of control.

As is, cases will continue spiking through the winter thereby threatening 2021... as well as the remainder of this football season and winter sports and everything else.

 

[zelezo vlk]

If I was in charge, I would announce a strict 3 week nationwide lockdown after Thanksgiving with opening back up before Christmas. Short term pain for long term gain. I don’t think the federal government has the authority to do that even if they wanted, but they’ve been conspicuously silent on this as cases continue to spiral out of control.

As is, cases will continue spiking through the winter thereby threatening 2021... as well as the remainder of this football season and winter sports and everything else.

We claiming a contested Natty boys!

 

[calvegas04]

<blockquote class="twitter-tweet"><p lang="en" dir="ltr">Something extremely bogus is going on. Was tested for covid four times today. Two tests came back negative, two came back positive. Same machine, same test, same nurse. Rapid antigen test from BD.</p>— Elon Musk (@elonmusk) <a href="https://twitter.com/elonmusk/status/1327125840040169472?ref_src=twsrc%5Etfw">November 13, 2020</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>

 

[RDU Irish]

TWO WEEKS to flatten the curve!

 

[Sea Turtle]

We claiming a contested Natty boys!

That would be 23 nattys. 12 claimed and 11 unclaimed.

I claim them all.

 

[phork]

If I was in charge, I would announce a strict 3 week nationwide lockdown after Thanksgiving with opening back up before Christmas. Short term pain for long term gain. I don’t think the federal government has the authority to do that even if they wanted, but they’ve been conspicuously silent on this as cases continue to spiral out of control.

As is, cases will continue spiking through the winter thereby threatening 2021... as well as the remainder of this football season and winter sports and everything else.

But no damn liberal gonna take my gunz or make me wear a mask as I protest at this anti-abortion rally!

 

[Sea Turtle]

If I was in charge, I would announce a strict 3 week nationwide lockdown after Thanksgiving with opening back up before Christmas. Short term pain for long term gain. I don’t think the federal government has the authority to do that even if they wanted, but they’ve been conspicuously silent on this as cases continue to spiral out of control.

As is, cases will continue spiking through the winter thereby threatening 2021... as well as the remainder of this football season and winter sports and everything else.

Lockdowns only delay the inevitable. Ask Europe.

This is going to be a two year ordeal and we are just going to have to suck it up.

 

[notredomer23]

<blockquote class="twitter-tweet"><p lang="en" dir="ltr">Something extremely bogus is going on. Was tested for covid four times today. Two tests came back negative, two came back positive. Same machine, same test, same nurse. Rapid antigen test from BD.</p>— Elon Musk (@elonmusk) <a href="https://twitter.com/elonmusk/status/1327125840040169472?ref_src=twsrc%5Etfw">November 13, 2020</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>

Hospitalizations are all time high

Cases are irrelevant given the inadequate testing and the fact this virus is mostly asymptomatic or lightly symptomatic. Hospitalizations are through the roof, so not sure what Musk thinks is up.

Even with 1.5MM tests a day, Dr. Scott Gottlieb estimates we're at best detecting 1 in 5 cases.

Extrapolate that based on testing capacities that were significantly lower over time, there have been at least 10 times more cases than reported, more likely closer to 15x. We know that while you may not be fully immune forever, you maintain a degree of immunity for an extended period of time regardless if your antibodies have waned. So if there really has been 100MM to 150MM cases already, when is the peak? Would think it has to be before the end of the year. Time will tell.

 

[dublinirish]

https://www.theguardian.com/world/2...n-sweden-surge-dashing-hopes-of-herd-immunity

New infections and hospital admissions have surged in Sweden as the country battles a second wave of the coronavirus pandemic that officials had hoped its light-touch, anti-lockdown approach would mitigate.

“We consider the situation extremely serious,” the director of health and medical care services for Stockholm, Björn Eriksson, told the state broadcaster SVT this week. “We can expect noticeably more people needing hospital care over the coming weeks.”

Swedish hospitals were treating 1,004 patients for Covid-19, SVT said, an increase of 60% over the previous week’s 627. Data from the European Centre for Disease Prevention and Control suggests the rise in recent weeks may be Europe’s fastest.

New infections are also surging, hitting a seven-day average of more than 4,000 this week against fewer than 500 at the beginning of October. The country recorded 4,635 new infections on Thursday.

Anders Tegnell, the country’s chief epidemiologist, told a press conference that case numbers had shown “a pretty big increase last week” and would “certainly increase” again this week, although perhaps not by quite as much.

The prime minister, Stefan Löfven, however, said on Wednesday that all indicators were “going in the wrong direction. The infection is spreading fast, and in the past week the number of people being treated in intensive care has more than doubled.”


Löfven said Sweden risked “more people getting sick, more people dying, more overworked people in the healthcare sector, more postponed operations … We need everybody to follow the recommendations. Every decision we take matters.”

On Wednesday the government announced it would ban the sale of alcohol in bars, restaurants and nightclubs after 10pm from 20 November to the end of February. Stockholm has banned visits to care homes and Gothenburg is set to follow suit.

On Thursday Sweden added four more regions to the list of those taking stricter local measure, in line with an approach that, since the start of the crisis, has been asking – rather than ordering – people to comply with health agency advice on physical distancing and hygiene.

Unlike other countries that have imposed (and re-imposed) strict lockdowns on shops, bars, restaurants and gyms, Sweden has kept similar facilities open throughout the pandemic, and the wearing of face masks is still not officially recommended outside hospitals.


Tegnell has always denied the aim was rapid herd immunity, but to slow the virus enough for health services to cope. He has also, however, repeatedly said he expected Sweden’s second wave to involve relatively fewer cases than countries that locked down, because of an expected higher level of immunity.

In fact, all studies carried out so far suggest immunity in and around Stockholm is significantly lower than the national health agency predicted. Twenty per cent of Covid-19 tests in the capital last week were positive, compared with 16% and 8.4% in previous weeks, the national news agency TT reported.

However, officials note that countries such as Spain and France, which stemmed their first wave through tough mandatory measures, have also experienced dramatic second waves, which might suggest Sweden’s decision not to lock down has not played a significant role in the recent surge in infections.

Since the start of the pandemic Sweden – which at one stage in June had Europe’s highest per-capita Covid-19 fatality rate – has confirmed 171,365 cases of infections and 6,122 deaths. Its death toll per capita is many times higher than its Nordic neighbours, but lower than countries such as Italy, Spain and the UK.

Lena Einhorn, a former virologist who is one of the fiercest critics of the country’s strategy, said whatever people outside Sweden thought would make little difference. “At first they said: ‘Wow, perhaps they are right,’” Einhorn told Deutsche Welle.

“Then there were more and more deaths in Sweden, and we became a monster; everyone thought Sweden was mad. Then in the summer, when there were fewer deaths, Sweden became a heaven on earth again,” she said.

“And finally when infections increased again in many countries in the autumn and there was opposition to new lockdowns, Sweden became the idol of libertarians. That’s no longer the case, now that cases are going up again in Sweden.”

 

[IrishLax]

Lockdowns only delay the inevitable. Ask Europe.

This is going to be a two year ordeal and we are just going to have to suck it up.

Europeans got 3+ months of living normal life by having a short, strict lockdown in the spring. They got to travel, vacation, and resume other normal activities. Now they're having a spike and going to shut down again... look for them to have cases back under control by the start of the new year.

The only "inevitable" thing is that trying to pretend the problem doesn't exist and/or having an uncoordinated effort leads to being stuck in a morass of failure with normal societal function permanently disrupted.