Long-term Care Insurance Research Articles

Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China

BackgroundChina has piloted Long-Term Care Insurance (LTCI) to address increasing care demand. However, many cities neglected adjusting LTCI premiums since the pilot, risking the long-term sustainability of LTCI. Therefore, using Zhejiang Province as a case, this study simulated mortality-adjusted long-term care demand and the balance of LTCI funds through dynamic financing mechanism under diverse life expectancy and disability scenarios.MethodsThree-parameter log-quadratic model was used to estimate the mortality from 1990 to 2020. Mortality with predicted interval from 2020 to 2080 was projected by Lee-Carter method extended with rotation. Cohort-component projection model was used to simulate the number of older population with different degrees of disability. Disability data of the older people is sourced from China Health and Retirement Longitudinal Study 2018. The balance of LTCI fund was simulated by dynamic financing actuarial model.ResultsLife expectancy of Zhejiang for male (female) is from 80.46 (84.66) years in 2020 to 89.39 [86.61, 91.74] (91.24 [88.90, 93.25]) years in 2080. The number of long-term care demand with severe disability in Zhejiang demonstrates an increasing trend from 285 [276, 295] thousand in 2023 to 1027 [634, 1657] thousand in 2080 under predicted mean of life expectancy. LTCI fund in Zhejiang will become accumulated surplus from 2024 to 2080 when annual premium growth rate is 5.25% [4.20%, 6.25%] under various disability scenarios, which is much higher than the annual growth of unit cost of long-term care services (2.25%). The accumulated balance of LTCI fund is sensitive with life expectancy.ConclusionsDynamic growth of LTCI premium is essential in dealing with current deficit around 2050 and realizing Zhejiang’s LTCI sustainability in the long-run. The importance of dynamic monitoring disability and mortality information is emphasized to respond immediately to the increase of premiums. LTCI should strike a balance between expanding coverage and controlling financing scale. This study provides implications for developing countries to establish or pilot LTCI schemes.

Changes in long-term care insurance revenue among service providers during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has impacted peoples’ health-related behaviors, especially those of older adults, who have restricted their activities in order to avoid contact with others. Moreover, the pandemic has caused concerns in long-term care insurance (LTCI) providers regarding management and financial issues. This study aimed to examine the changes in revenues among LTCI service providers in Japan during the pandemic and analyze its impact on different types of services.MethodsIn this study, we used anonymized data from “Kaipoke,” a management support platform for older adult care operators provided by SMS Co., Ltd. Kaipoke provides management support services to more than 27,400 care service offices nationwide and has been introduced in many home-care support offices. The data used in this study were extracted from care plans created by care managers on the Kaipoke platform. To examine the impact of the pandemic, an interrupted time-series analysis was conducted in which the date of the beginning of the pandemic was set as the prior independent variable.ResultsThe participating providers were care management providers (n = 5,767), home-visit care providers (n = 3,506), home-visit nursing providers (n = 971), and adult day care providers (n = 4,650). The results revealed that LTCI revenues decreased significantly for care management providers, home-visit nursing providers, and adult day care providers after the COVID-19 pandemic began. The largest decrease was an average base of USD − 1668.8 in adult day care.ConclusionThe decrease in revenue among adult day care providers was particularly concerning in terms of the sustainability of their business. This decrease in revenue may have made it difficult to retain personnel, and staff may have needed to be laid off as a result. Although this study has limitations, it may provide useful suggestions for countermeasures in such scenarios, in addition to support conducted measures.

Who can see it coming? Demand‐side selection in long‐term care insurance related to decision‐making abilities

AbstractDespite the growing demand for long‐term care (LTC), the uptake of private LTC insurance (LTCI) is low and even declining in the United States. One reason is the complexity of LTCI decisions. Researchers have therefore suggested to support decision‐making abilities. This paper shows, however, that such support would not unambiguously enhance functioning of the LTCI market. We analyze whether selection arises from two correlated but different decision‐making abilities at old age, education and numeracy, and interactions thereof with private information. Using historical data from the Health and Retirement Survey we find that education generates adverse selection, which is only partially offset by advantageous selection due to numeracy. In addition, individuals with greater decision‐making abilities make better LTCI choices, amplifying selection by education and numeracy. This points at a trade‐off between decision simplicity and selection in insurance markets and suggests other steps are needed to enhance the performance of private LTCI markets.

Fruit and Vegetable Intake and Risk of Disabling Dementia: Japan Public Health Center Disabling Dementia Study

BackgroundFruits and vegetables contain abundant amounts of antioxidant vitamins such as vitamin C, α-carotene, and β-carotene. Few prospective observational studies have investigated the effects of fruit and vegetable intake on the risk of dementia, and the results are inconsistent. ObjectivesOur aim was to examine associations between fruit and vegetable intake and the risk of disabling dementia. MethodsWe conducted a follow-up survey within the Japan Public Health Center-based Prospective Study involving 42,643 individuals aged 50–79 y at baseline (2000–2003). Dietary fruit and vegetable intakes and related antioxidant vitamin intakes (i.e., α-carotene, β-carotene, and vitamin C) were determined using a food frequency questionnaire. The diagnosis of disabling dementia was made based on the daily living disability status related to dementia under the Japanese long-term care insurance program from 2006 to 2016. Hazard ratios and 95% confidence intervals for disabling dementia were estimated using area-stratified Cox proportional hazard models adjusted for potential confounding factors. ResultsA total of 4994 cases of disabling dementia were recorded. We observed an inverse association between total fruit and vegetable intake and the risk of dementia among males and females: the multivariate hazard ratios (95% confidence intervals) for the highest compared with lowest quartiles of intake were 0.87 (0.76, 0.99) (P- trend = 0.05) among males and 0.85 (0.76, 0.94) (P- trend = 0.006) among females. Among antioxidant vitamins, vitamin C intake was inversely associated with the risk of dementia among males and females: the multivariate hazard ratios (95% confidence intervals) for the highest compared with lowest quartiles of intake were 0.71 (0.61, 0.84) (P- trend < 0.0001) among males, and 0.76 (0.67, 0.86) (P- trend < 0.0001) among females. ConclusionsFruit and vegetable intake and dietary intake of vitamin C may contribute to reducing the risk of disabling dementia among males and females.

Factors Contributing to Health Deterioration in the Japanese Long-Term Care Insurance System in Terms of Instrumental Activities of Daily Living

This study aimed to determine which instrumental activities of daily living (IADL) are associated with health deterioration from the “support level” to the “care level” among users of the long-term care insurance system in Japan. From April 2017 to March 2020, we conducted a retrospective follow-up survey on 178 Japanese community-dwelling older adults (64 men, 114 women) newly certified as support level. Independent variable was 8 IADL items and the outcome defined as the “support level maintenance time.” Cox models were used to assess the risk of health deterioration, with adjustments for age group, family composition, dementia status, and frailty status by gender. Dependence on 5 items, “laundry” (hazard ratio [HR] =2.5; 95% confidence interval [CI]: 1.1-5.8), “cooking” (HR = 3.7; 95% CI: 1.1-12.2), “telephone use” (HR = 2.4; 95% CI: 1.2-4.7), “financial management” (HR = 2.5; 95% CI: 1.2-5.0), and “medication management” (HR = 2.4; 95% CI: 1.2-4.8), was independently associated with a worse outcome among men, whereas dependence on “financial management” (HR = 2.6; 95% CI: 1.5-4.7) and “medication management” (HR = 2.0; 95% CI: 1.1-3.5) was independently associated with a worse outcome among women. These findings suggest that difficulties in “financial management” and “medication management” are common factors associated with health deterioration from the support to the care level among both genders. An association with household tasks was also seen among men, indicating that a paradigm shift is needed to increase the participation of men in household tasks.

Effect of long-term care insurance policy on depression in non-disabled people: evidence from China

BackgroundPolicy effect might be multidimensional and spill over to non-recipients. It is unclear how the implementation of Long-Term Care Insurance (LTCI) policy affects depression in non-disabled people and how this effect differs in different non-disabled groups.MethodsUsing time-varying differences-in-differences method and nationally representative health survey data in wave 2011, wave 2013, wave 2015 and wave 2018 from the China Health and Retirement Longitudinal Study, we assessed the effect of LTCI policy on depression in non-disabled people aged 45 years and older, and discussed the heterogeneity of effect across different population characteristics: retirement, financial support and social participation status.ResultsWe found LTCI policy statistically significant reduced depression by 0.76 units in non-disabled people compared to non-pilot cities. Depression in non-disabled people who unretired, with financial support and without social participation was reduced by 0.8267, 0.7079 and 1.2161 units, respectively.ConclusionsDepression in non-disabled people was statistically significant reduced because of LTCI policy in China, and non-disabled people who unretired, with financial support and without social participation benefited more from LTCI policy. Our findings highlight the depression-reducing effect of LTCI policy in non-recipients and suggest that non-disabled people who unretired, with financial support and without social participation should be concerned during LTCI policy progress.

Long-term care needs and hospitalization costs with long-term care insurance: a mixed-sectional study.

With the rapid aging of the population, the health needs of the older adult have increased significantly, resulting in the frequent occurrence of the "social hospitalization" problem, which has led to a rapid increase in hospitalization costs. This study investigates whether the "social hospitalization problem" arising from the long-term care needs can be solved through the implementation of long-term care insurance, thereby improving the overall health of the older adults and controlling the unreasonable increase in hospitalization costs. The entropy theory was used as a conceptual model, based on data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015 and 2018. The least-squares method was used to examine the relationship between long-term care needs and hospitalization costs, and the role that long-term care insurance implementation plays in its path of influence. The results of this study indicated that long-term care needs would increase hospitalization cost, which remained stable after a series of tests, such as replacing the core explanatory variables and introducing fixed effects. Through the intermediary effect test and mediated adjustment effect test, we found the action path of long-term care needs on hospitalization costs. Long-term care needs increases hospitalization costs through more hospitalizations. Long-term care insurance reduces hospitalization costs. Its specific action path makes long-term care insurance reduce hospitalization costs through a negative adjustment of the number of hospitalizations. To achieve fair and sustainable development of long-term care insurance, the following points should be achieved: First, long-term care insurance should consider the prevention in advance and expand the scope of participation and coverage; Second, long-term care insurance should consider the control in the event and set moderate levels of treatment payments; Third, long-term care insurance should consider post-supervision and explore appropriate payment methods.

RETRACTED ARTICLE: The impact of long-term care insurance on household consumption and sustainability among aged people in China

RETRACTED ARTICLE: The impact of long-term care insurance on household consumption and sustainability among aged people in China

A Study on Awareness of Long-term Care Insurance and Willingness to Use Long-term Care Services for the Elderly

A Study on Awareness of Long-term Care Insurance and Willingness to Use Long-term Care Services for the Elderly

고령자 지원주택 수요․공급 분석 및 인식조사 연구

According to a survey on the elderly, the majority of elderly people prefer to spend their golden years receiving care at their place of residence rather than entering a nursing facility. However, if their health is frail or semi-dependent and they need care but do not have family members to take care of them, there is no other option other than a nursing facility. Since the introduction of long-term care insurance for the elderly, the increase in nursing facility protection is causing negative results by lowering the quality of life of the elderly and increasing social costs. As a solution to this situation, supportive housing for the elderly rather than nursing facilities is emerging as an alternative. The purpose of this study is to identify awareness of supportive housing for the elderly and priority supply areas in order to preemptively respond to a super-aged society and provide stable community housing for the elderly, and use it as important basic data when promoting future projects. To this end, we analyzed the awareness of public and private experts on the general indicators needed when establishing the elderly supportive housing project plan. In addition, we analyzed the demand for care by identifying the elderly population who are consumers of supportive housing, and analyzed the supply of care by analyzing the status of elderly welfare facilities with similar functions to supportive housing. By analyzing the discrepancy between care demand and care supply, we analyzed priority supply areas that urgently need supportive housing for the elderly. In a reality where we are expected to enter a super-aged society and face a rapid population aging, we are identifying the discrepancy between supply and demand for elderly care in order to improve the quality of life of the elderly and reduce social costs. Efforts to preemptively respond to a super-aged society through research and analysis of priority supply areas for supportive housing for the elderly are no longer an option but a necessity.

Evaluation of China's long-term care insurance policies.

In response to the increasing demand for long-term care services for older people, the Chinese government has launched a pilot program for long-term care insurance (LTCI) since 2016. The objective of this study is to evaluate the performance and effectiveness of this program in China and provide recommendations for the future development and expansion of the LTCI system. We developed a comprehensive evaluation framework to assess these LTCI policies implemented in all 49 pilot cities in China. Based on our evaluation, the average assessment score for the LTCI program across all pilot cities was 71.8 points, with scores ranging from 57.5 to 92.5 points in these cities. Furthermore, most of the pilot cities achieved higher scores in the fact-based assessment compared to the value-based assessment. The results suggested that the overall pilot effect regarding LTCI was favorable, but there were significant regional disparities. Moreover, in most of pilot cities, current LTCI policies were designed to alleviate both the financial burden and the burden of caring for people with disabilities that families faced. However, some challenges still remained, such as the lack of community and home-based care services, the need to expand the coverage of insurance, and the importance of diversifying funding sources.

Factors related to a sense of economic insecurity among older adults who participate in social activities.

Japan has the highest life expectancy worldwide. Older adults who experience economic insecurity may refrain from seeking medical consultation or using long-term care insurance, and these behaviors may increase the incidence and progression of frailty. This study conducted a cross-sectional survey to identify factors related to a sense of economic insecurity among older adults who participate in social activities, and identified support measures. In total, 1,351 older adults aged ≥65 years who had participated in social activities voluntarily completed an anonymous self-administered questionnaire. The questionnaire encompassed their physical, cognitive, social, and psychological conditions, and economic insecurity. We performed univariate analysis considering a sense of economic insecurity as the dependent variable, and conducted multiple logistic regression analysis (forced entry method) considering the independent variables with p<0.1 as the covariates. Among the 872 filled questionnaires, 717 were analyzed as they had no missing data with respect to the responses to survey questions (valid response rate was 53.1%). Analysis results showed that 43.6% of the older adults had a sense of economic insecurity, which was most common among those aged 75-84 years, accounting for 47.3%, followed by those aged 65-74 years accounting for 44.1%, and those aged ≥85 years accounting for 31.5% (p<0.05). The sense of economic insecurity was not associated with physical conditions, subjective symptoms of dementia, or social conditions; however, it grew with increased loneliness (OR: 1.71, 1.002-2.92, p = 0.049) and decreased with an increased subjective sense of well-being (OR: 0.86, 0.81-0.92, <0.001). Economic insecurity among older adults was not associated with physical, cognitive, or social aspects, as reported in previous studies. The survey respondents constituted older adults who participate in social activities. Maintaining interactions within the community, even in old age, may prevent loneliness and improve subjective health.

Statin Use and All-Cause Mortality in Nursing Home Residents With and Without Dementia: A Retrospective Cohort Study Using Claims Data.

Little is known about the benefits of statin therapy in older adults with dementia. We aimed to evaluate the role of statin use for all-cause mortality in nursing home residents with and without dementia. This retrospective cohort study used claims data collected between January 2015 and December 2019 from a German health and long-term care insurance provider. Propensity score-based Cox proportional hazards models were used to evaluate the association of statin use with all-cause mortality and adjusted for potential confounders in nursing home residents. Subgroup analyses were performed based on the presence or absence of atherosclerotic cardiovascular disease (ASCVD), statin intensity (low, moderate, high), dementia type, age, sex, and level of care required. A total of 282,693 participants were included in the study, of which 96,162 were matched. In total, 68.9% were women, and the mean age was 82.91 years (SD ±7.97). The average observation period was 2.25 years (SD ±1.35), and 54,269 deaths were recorded. Statin use in individuals with dementia resulted in lower all-cause mortality (hazard ratio [HR] 0.80, 95% CI 0.78-0.82, p < 0.001) compared with statin nonusers. Similarly, in individuals without dementia, statin use was associated with lower all-cause mortality (HR 0.73, 95% CI 0.71-0.76, p < 0.001) compared with statin nonusers. Similar findings were observed in subanalyses excluding participants with a history of ASCVD and across subgroups stratified by age, sex, care level required, and dementia type. Statin benefits were consistent among individuals with and without dementia. Statin benefits were consistent among individuals with and without dementia. Statin therapy may be continued in nursing home residents with dementia to mitigate the risk of all-cause mortality. This study provides Class III evidence that nursing home patients receiving statins have a lower mortality rate, whether they have a dementia diagnosis or not.

The medical treatment needs and in-home care service utilization of the elderly: a population-based data analysis of long-term care insurance payments in Tokyo, Japan

How can we improve in-home care for the elderly with medical treatment needs? The purpose of this study is to investigate medical treatment and examine the use of home care services. We analyzed the long-term care insurance service payments data in City A (n=18,882) as of January 2019 and checked 12 medical treatment care needs items. The results showed that 10.1% (1913 of a total of 18,882) of people required medical treatment. The analysis was carried out by using a filter, “living in home” (n=15,320). We focused on urinary catheter and tube feeding. The study subjects are categorized into three groups: group 1 [both tubes (n=61)], group 2 [either tube (n=564)], and group 3 [no tube (n=14,698)]. The home help utilization rate was 27.9% in group 1, 29.9% in group 2, and 20.5% in group 3 (p&lt;0.01). The home visit nursing utilization rate was 11.5% in group 1, 23.7% in group 2, and 8.1% in group 3 (p&lt;0.01).

Enhancing Older Household Consumption: The Impact of Long-Term Care Insurance in China.

Household consumption significantly affects the quality of life and successful aging of older adults. However, prior research has often overlooked the connection between household consumption and long-term care insurance (LTCI). This study aims to investigate the influence of LTCI on consumption patterns within older Chinese households. We used harmonized data from the China Health and Retirement Longitudinal Study and merged it with data from cities that implemented LTCI in China. We analyzed a total of 6,494 households consisting of individuals who were 60 years of age or older. To ensure accurate and stable research findings, we employed a series of difference-in-differences models. We found that LTCI has a significant impact on consumption levels, including total and per capita consumption within older households. Furthermore, our research demonstrates that LTCI significantly enhances enjoyable consumption across the consumption types. Through a heterogeneous analysis, it is shown that LTCI has a unique effect on both the total and enjoyable consumption of urban older households and also promotes comprehensive consumption improvements in older rural and disabled households. These findings highlight the crucial role of LTCI in improving the financial security and well-being of older households. They also have considerable policy implications for dealing with the challenges of an aging population.

Chronic pain in older adults with disabilities is associated with fall-related injuries: a prospective cohort study.

Previous studies have shown an association between chronic pain and the occurrence of falls in community-dwelling older adults; however, the association between chronic pain and fall-related injuries in older adults with disabilities is unclear. This study aimed to determine the association between chronic pain and fall-related injuries in older adults with disabilities. This 24-month prospective cohort study included older adults aged 65years or older using Japanese long-term care insurance services. Chronic pain, defined as "pain that has persisted for more than three months to date," was assessed using a face-to-face questionnaire. Fall-related injuries, defined as "injuries requiring hospitalization or outpatient treatment due to a fall," were assessed using a fall calendar. Data were analyzed using a Cox proportional hazards model, with fall-related injury as the dependent variable, chronic pain as the independent variable, and confounders as covariates. Among 133 included participants, 15 experienced fall-related injuries. After adjusting for age and sex as covariates, chronic pain was significantly associated with fall-related injuries (hazard ratio: 5.487, 95% confidence interval: 1.211-24.853, p = 0.027). Chronic pain was associated with fall-related injuries in older adults with disabilities. In this population, a greater focus should be placed on treating chronic pain to reduce the occurrence of falls.

Association of pneumonia admission with polypharmacy and drug use in community-dwelling older people.

The purpose of the present study was to clarify the association of pneumonia admission with polypharmacy and specific drug use in community-dwelling older people. Using health insurance and long-term care insurance data from Kure city in Japan, we retrospectively collected data for older community-dwelling people (aged ≥65 years) from April 2017 to March 2019. The outcome was pneumonia admission. We carried out multivariate logistic regression analysis to identify the association of pneumonia admission with polypharmacy (≥5 drugs), the use of psychotropic drugs or anticholinergics with adjustment for patient backgrounds, such as comorbidity, and the daily life independence level for the older people with disability. Of 59 040 older people, 4017 (6.8%) participants were admitted for pneumonia in 2 years. The ratio of polypharmacy, and the use of psychotropic drugs and anticholinergics in the admission group were significantly higher than the non-admission group. Multivariate logistic regression analysis showed that polypharmacy (odds ratio 1.29, 95% confidence interval 1.18-1.41), and the use of conventional antipsychotic drugs (odds ratio 1.39, 95% confidence interval 1.02-1.90), atypical antipsychotic drugs (odds ratio 1.67, 95% confidence interval 1.37-2.05) and anticholinergics (odds ratio 1.22, 95% confidence interval 1.13-1.33) were significantly associated with pneumonia admission. The present results suggest that polypharmacy, and the use of psychotropic drugs and anticholinergics are risk factors for pneumonia admission. Geriatr Gerontol Int 2024; 24: 404-409.

ELEVATING LONG-TERM ELDERLY CARE IN MALAYSIA: A CLUSTER ANALYSIS APPROACH BASED ON BENCHMARKING WITH SELECTED COUNTRIES

Malaysia is expected to become an aged society with a 14.1% ageing ratio in 2039, boosting demand for Long-Term Care (LTC). Nonetheless, a thorough review of current LTC systems is crucial due to their complexity, encompassing numerous ministries and departments. In analysing LTC systems in various countries based on components of effective LTC systems, this research suggests a new LTC framework for Malaysian systems. Cluster analysis is used across benchmarked nations: Australia, Germany, Japan, Singapore, Thailand, the United Kingdom, and the United States of America. There are two typologies used, with a total of ten variables employed: a) organisational depth with seven variables: legal framework, policy objectives, policy approach, means-tested assessment, entitlements, cash benefits, and choice of care provider; b) financial generosity and sustainability with three variables: financing mechanism, cost-sharing, and LTC expenses. Four key takeaways from the benchmarked countries: a) LTC insurance scheme, as adopted in Germany and Japan, proves effective with universal coverage, greater disclosure, and a structured approach; b) community-based model, widely adopted across all countries, fosters active stakeholders engagement in meeting elderly’s needs; c) Centralised Administration (CA) provides a structured avenue to manage LTC services and expenses; and d) cost-sharing via private-public arrangements ensures the sustainability of the LTC expenses. The study suggests five improvements for effective LTC systems: a) broaden the recipients’ pool to include the bottom 40% of the population to accommodate their financial constraints; b) implement a robust means-tested evaluation for equity, transparency, and inclusivity; c) incorporate a community-based model for comprehensive coverage; d) create a CA to handle complexity; and e) use public-private partnerships for sustainable financing model. In summary, this study aids policymakers in tackling the intricacies of Malaysia’s LTC systems in line with the intended policy goals of guaranteeing a healthy ageing population, advocating comprehensive protection, and stimulating community-based care.

Claims-based Frailty Index in Japanese Older Adults: A Cohort Study Using LIFE Study Data.

We aimed to assess whether the United States-developed Claims-based Frailty Index (CFI) can be implemented in Japanese older adults using claims data. We used the monthly claims data and certification of long-term care (LTC) insurance data of residents from 12 municipalities from April 2014 to March 2019. The 12 months from first recording was defined as the "baseline period," and the time thereafter as the "follow-up period". Participants aged ≥65 years were included, and those with no certified LTC insurance or who died at baseline were excluded. New certification of LTC insurance and all-cause mortality during the follow-up period were defined as outcome events. CFI categorization consisted of three steps including: 1) using 12 months deficit-accumulation approach that assigned different weights to each of the 52 items; 2) the accumulated score to derive the CFI; and 3) categorizing the CFI as "robust" (<0.15), "prefrail" (0.15-0.24), and "frail" (≥0.25). Kaplan-Meier survival curves and Cox proportional hazard models were used to determine the association between CFI and outcomes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. There were 519,941 participants in total. After adjusting for covariates, the severe CFI category had a high risk of certification of LTC insurance (prefrail: HR 1.33; 95% CI, 1.27-1.39 and frail: HR 1.60; 95% CI, 1.53-1.68) and all-cause mortality (prefrail: HR 1.44; 95% CI, 1.29-1.60 and frail: HR 1.84; 95% CI, 1.66-2.05). This study suggests that CFI can be implemented in Japanese claims data to predict the certification of LTC insurance and mortality.

Pooling functional disability and mortality in long-term care insurance and care annuities: A matrix approach for multi-state pools

Mortality risk sharing pools including group self-annuitisation, pooled annuity funds and tontines have been developed as an effective solution for managing longevity risk. Although they have been widely studied in the literature, these mortality risk sharing pools do not consider individual health or functional disability status nor the need for long-term care (LTC) insurance at older ages. We extend these pools to include functional disability and chronic illness and present a matrix-based methodology for pooling mortality risk across heterogeneous individuals classified by functional disability states and chronic illness statuses. We demonstrate how individuals with different health risks can more equitably share mortality risk in a pooled annuity design. A multi-state pool is formed by pooling annuitants considering both longevity and LTC risks and determining the actuarially fair benefits based on individuals' health states. Our methodology provides a general structure for a pooled annuity product that can be applied for general multi-state models. We present an extensive analysis with numerical examples using the US Health and Retirement Study (HRS) data. Our results compare expected annuity benefits for individuals in poor health to those in good health, show the effects of incorporating systematic trends and uncertainty, assess how the valuation of the expected annuity payments interacts with the assumptions used for the multi-state model and assess the impact of pool size.