OBJECTIVES: To evaluate transitions in health status and risk of death in older adults in relation to baseline health deficits and protective factors. DESIGN: Prospective cohort study with reassessments at 5, 8, and 15 years. SETTING Secondary analysis of data from the Beijing Longitudinal Study on Aging. PARTICIPANTS: Urban and rural community-dwelling people aged 55 and older at baseline (n=3, 275), followed from 1992 t0 2007, during which time 51% died. MEASUREMENTS: Health status was quantified using the deficit accumulation-based frailty index (Fl), constructed from 30 intrinsic health measures. A protection index was constructed using 14 extrinsic items (e. g. , exercise, education). The probabilities of health changes, including death, were evaluated using a multistate transition model. RESULTS: Women had more health deficits (mean base-line FI 0. 13± 0. 11) than did men (mean baseline FI 0. 11± 0. 10). Although health declined on average (mean FIs increased), improvement and stability were common. Baseline health significantly affected health transitions and survival over various follow-up durations (odds ratio CONCLUSION: Deficit accumulation-based transition modeling demonstrates persisting effects of baseline health status on age-related health outcomes. Some mitigation by protective factors can be demonstrated, suggesting that improving physical and social conditions might be beneficial.