The simple answer is that better care costs more.

OK. Does costing more mean quality must be better or do you have some other comparison in mind? Example: does care cost more in California or Ohio? I ask because Ohio did better in the most recent Commonwealth study than California.

Some specific factors include higher per capita income, burdensome overhead from both private and public insurance due to rising legal costs and malpractice costs, fewer health care workers entering the profession and of course governmental regulation and intervention, mainly through mandated employer-provided care.

Care to predict a % additional cost caused by each? For interest, what proportion of the working day do you suppose physicians say they must dedicate to defensive activity/administration?

Contrary to popular opinion, I'd suggest that per capita spending on health care is far too low around the world and I'd cite rationing of care as primary evidence.

Everybody rations care though there are many drivers. It used to be parsimonious physicians ("waste is unethical") but the lawyers soon fixed that. Now it's the insurance companies with their caps and the HMOs with their policies, though I have no doubt that the lawyers will figure out ways to fix them too once they've forced the entire medical workforce to behave defensively at whatever cost.