In general, new technologies take one to two generations to become widely adopted. This is partly a result of what must be learned but is also infl uenced by the nature of graduate and postgrad­uate education. Surgical residents, who are being trained in programs in which MISS deformity sur- gery is already being practiced, will simply learn these skills as part of their armamentarium. As

Intraoperative “navigation” and intraoperative CT imaging have signifi cantly impacted these challenges. Kim et al. recently reported that “total” exposure to radiation time was decreased from 147 to 57 s using “Fluoro-Navigation” ver­sus standard fl uoroscopy [ 17 ]. Similarly, using CT-based image guidance, Florian et al. reported a decrease from 177 to 75 s of total radiation time [ 18 ].

All of the above discussion focuses on medical, technological, and educational aspects of the delivery of medical care, which can be evaluated, understood, and altered in relatively predictable fashions. Each of these would predict the slow, but progressive, expansion of the use of MISS surgery for most spinal procedures, including deformity procedures. What is less certain, how­ever, is the impact of recent changes national health-care policy will have on the delivery of health care in the United States, particularly as it relates to surgery. Implementation of the massive Patient Protection and Affordable Care Act (PPACA) will undoubtedly change the delivery of spine surgical care to patients, but all claims of improvement or deteriorization are mere specula­tion, devoid of any real information upon which to make a claim. The thousands of new regula­tions being implemented, many of which com­pete with one another, could result in any variety of alterations. For example, the health insurance exchanges and new laws regulating the behavior of insurance companies could be suggested to increase the number of patients who would have access to health care. On the other hand, potential decisions by the Independent Payment Advisory Board (IPAB), early directions of the Comparative Effectiveness Research Committee, and payment “punishments” for the so-called never events would all seem to conspire to restrict advanced medical care to those patients who are sickest and most in need of care. Advanced deformity patients would certainly fall into this category. One potential scenario, for example, could be that rather than insurance companies denying surgery to a potential candidate (where upon the patient has legal recourse), IPAB could pass a national policy determining that that same patient was not eligible for payment for that surgery (whereupon the patient had no recourse). Thus, the question has to be asked, “Exactly what” medical care “will” be available to these patients?