The papers by Paul Ginsburg and Jason Lee and colleagues make it clear how far we have come on the issue of cost shifting and how far we still have to go. We have created some new myths, persisted in some old confusion, and largely ignored an enduring reality. That enduring reality is that lack of competition in the health care sector permits cost shifting to occur. Instead of focusing on this causal condition, public discussion has been centered on the symptoms. A number of steps can be taken to deal with causes; this paper discusses several of these steps.