Toxic harmful algal blooms (HABs) pose serious threats to human health and instances of wildlife death have been documented across taxa. However, the extent of toxicological impacts on wildlife species is largely unresolved, raising uncertainty about the repercussions of increasingly severe HABs on the biodiversity and functioning of aquatic ecosystems. Here, we conducted a field study to assess human health risks from consuming fish caught across all stages of a HAB and to determine the pervasiveness of potentially harmful levels of the cosmopolitan toxin microcystin on fish populations. We collected 190 fish in 2015 and 2017 from Lake Erie, a large freshwater ecosystem that is highly productive for fisheries and is an epicenter of HABs and microcystin toxicity events. Fish muscles and livers were analyzed for total microcystins, which was used to conduct a human health risk assessment for comparison against fish consumption advisory benchmarks available for Lake Erie. We found microcystins pose low risks to human health from fillet consumption (mean 1.80 ng g−1 ww) but substantial risks to fish health and recruitment from liver concentrations measured well before and after seasonal bloom events (mean 460.13 ng g−1 ww). Our findings indicate HABs are a previously underappreciated but pervasive threat to fish populations.