More than nine out of every 10 Americans over the age of 45 lack long-term care insurance, according to a study.

In addition, the percentage of older adults who are uninsured for long-term care ranges from a low of 78% to a high of 97% across the country, according to the third annual Index of Long Term Care. Also, 18 states have a market penetration of long-term care insurance that is above the national average.

Three of the states – California, Connecticut and New York – have a “Partnership for Long Term Care” program, a model that combines Medicaid and private long-term care insurance.

The index looks at adults age 45 and older with incomes such that they could theoretically afford such insurance. The Long Term Care Group Inc., which provides long-term care insurance services, created the third annual report.