Addressing racial differences in US health care is difficult, in part because the origins of these differences are complex and poorly understood and also because only some differences may represent legitimate agendas for reform. For example, racial differences that result from differences in access or from clinician prejudices are symptoms of a problem that must be addressed; in contrast, racial differences that arise from different pREFERENCES for health care might be seen as acceptable consequences of variation in personal or cultural values that are worth respecting and preserving. However, we believe that this distinction is sometimes overstated. We present several fictitious clinical stories to illustrate how what appear to be individual or cultural pREFERENCES are often substantially shaped by modifiable practices of the health care system. True differences in preference that are worthy of respect surely exist between individuals or demographic groups, but some apparent differences in preference may actually reflect problems with the health care system that are worthy of remediation. Uncovering the hidden constraints that we impose on health care choice may help us reduce unwanted disparities in health care.