[lmm]

Some of the extra money does go to R&D (though that's somewhat misleading: a lot of "R&D" spending is unnecessary duplication of safety trials because the FDA doesn't recognise any foreign medical safety standards, not even e.g. the EU). But a substantial chunk of it is wasteful inefficiencies due to multiple layers of middlemen (there are typically 5 layers between the insurance company that's paying and the company that makes the drug/device) with opaque pricing structures (there are hidden rebates in both directions at every one of those layers). National healthcare systems still have bureaucratic inefficiencies but they do avoid having intermediaries with a direct incentive to bamboozle each other.

[themaninthedark]

"unnecessary duplication of safety trials because the FDA doesn't recognise any foreign medical safety standards, not even e.g. the EU)"

I would say in some cases that is a good thing. https://en.wikipedia.org/wiki/Thalidomide

[lmm]

It's very hard to argue against a safety trial - of course if you duplicate safety trials then there will be occasional cases where you catch something that the original trial missed. But ultimately far more people have died or suffered because a medicine wasn't available yet than been killed or hurt by medicine being approved too early.