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Objective-To quantify the number of children who experience gaps in insurance coverage and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage. Vulnerable subgroups of children included children with chronic conditions, those from ethnic/racial minorities, and those living in poverty. On the basis of cumulative annual monthly insurance coverage status, each child fell into 1 of 3 groups: continuous coverage, uninsured, or gaps in coverage. Using SAS-callable SUDAAN, we conducted multivariate ordinal logistic regression model to quantify the likelihood of having gaps in coverage for vulnerable subgroups of children. Methods-WeResults-From 1999 to 2001, we found that > 9 million American children annually had gaps in coverage and that 5 to 6 million children annually were uninsured for the entire year. Sixty percent of children experienced gaps of at least 4 months, and > 40% of all publicly and privately insured children had coverage gaps. After accounting for relevant covariates, children with chronic conditions were just as likely as other children to have gaps in coverage or be uninsured; Hispanic children were most likely to have insurance gaps or be uninsured; and children from poor and nearpoor families were 4 to 5 times more likely to have lapsed coverage than children from high-income families. Poverty and maternal education were the strongest factors associated with lapsed coverage.Conclusions-Unstable health insurance is an underrecognized problem for children, including those with chronic conditions. Because unstable insurance coverage can lead to inadequate health care utilization and poor child health outcomes, strategies to promote stable insurance coverage merit serious consideration. Creating a stable insurance coverage system for American children has been one of the most persistent and intractable challenges in health policy. Previous studies have documented that uninsured children are less likely to use medical services, less likely to use preventive services, and less likely to have a usual source of care. 1-6 Cross-sectional studies of uninsured children likely capture some children who experience short-term gaps in coverage as well as those who are ineligible for any coverage within the current system. Unlike ineligible children, it is likely that children with short-term gaps in coverage are eligible for insurance but not enrolled, and there may be opportunities to simplify the current system of enrollment and renewal to prevent these lapses in coverage. Because gaps in coverage can disrupt patient-provider relationships and affect appropriate utilization for children during critical periods of growth and development, 7,8 maintaining stable coverage is an important priority. Many childhood and adolescent problems, such as developmental delays, risk-taking behaviors, and nutritional concerns, require regular supervision for early identification and optimal treatment. 9-11 For children with chronic conditions, such as asthma or diab...

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