1: yes I believe it is possible to better. However I also believe that many of the reasons those other countries do better than the US - as much a 7 times cheaper - are political and thus not something any manager can solve. Going from 4x more expensive than best world prices prices (LA is about 4x, NYX is about 7x) to 3.9x more expensive than world prices are possible - that is a drop in the bucket though compared to the 4x improvement possible by finding the real issues where are political.