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Sometimes the keyword is just boned...every person is bidding crazy, so you're screwed.
But normally it is the quality score, which can still be high, but the balance can be off... landing domain/page, keyword, ads relationship is off, bounce rate/return rate is showing the keyword isn't a good match, or the site is to commercial (ie not local)...
The game is very different today, that's for sure..more factors can screw you than I could remember to list.
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