I'm sure plenty of people have thought long and hard about this, and I haven't and won't, but it seems likely that the American pharm companies have found ways to exploit the uniquely complicated and opaque American health care system, such that they can charge more here rather than elsewhere. The framing of "Americans pay for R&D while the rest of the world pays for production" is probably just an accident of how the numbers fall out. Software might be a useful analogy where the cost to the company for unit 1 is nearly the entire cost, while the cost for units 2 through infinity is negligible. But Microsoft doesn't charge Americans huge amounts for software while charging Europeans a small fraction. Because that market is more recognizable as supply vs demand, while health care is anything but.
