Drawing lessons from international experience for health care reform in the United States requires striking a difficult balance between historical determinism and free will, between cynical pessimism and naïve optimism. The key to this puzzle may lie in a paradox: the United States is the most successful exporter of public health policy ideas and instruments yet has failed to build an effective health care system. General ideas (like notions about the role of competition) and microinstruments (like diagnosis-related groups) travel better than do health care systems. Ideas can be adapted to local circumstances, and instruments may easily fit into preexisting systems. Importing systems from countries with different histories and institutions would require a tectonic shift in the American political landscape.