At a Billings hearing in May, Sen. Jon Tester expressed frustration about the management of the Indian Health Service.

The Montana Democrat said: “We need to live up to our trust responsibility and offer tribes the health care they deserve. Ongoing issues around service delivery, transportation for critical care, billing and reimbursement issues abound. We need to prioritize these issues and solve them.”

Tester, of course, is chairman of the Senate Indian Affairs Committee. So his call for improving the agency is worth considering.

Then again, when former Sen. Byron Dorgan (D-ND) was chairman of the same committee, he also held hearings and published a report about the poor management record at IHS. “The investigation identified mismanagement, lack of employee accountability and financial integrity, as well as insufficient oversight of IHS' Aberdeen Area facilities.

These issues impact overall access and quality of health care services provided to Native American patients in the Aberdeen Area. Many of these issues may stem from a greater lack of oversight by the area office and IHS headquarters fostering an environment where employees and management are not held accountable for poor performance.” The year was 2010.

So what kind of progress has the Indian Health Service made during those four years? Unfortunately that’s the wrong question.

In the blink of an eye, the very structure of health care has changed and is continuing to change dramatically in the United States. Yet the structure of the Indian Health Service is the same.

Take the name: Indian Health Service. On the agency’s web page it adds the descriptive line, “The Federal Health Program for American Indians and Alaska Natives.”

Yet some 40 percent of the agency funds go directly to tribes, independent medical nonprofits or urban health programs. The federal health program is a mechanism for funding, not a federal health program. And that percentage is likely to grow because the system is no longer equal. The IHS has less access to a variety of funding pots that are available to tribal and urban health clinics.

A second problem with the IHS structure is that the United States for many policy reasons picked an insurance framework under the Affordable Care Act. And much of that insurance is built on an expansion of “entitlement” programs.

But the IHS is a health care delivery system, not an insurance regime. And, unlike the entitlement programs of Medicare, Medicaid, and Children’s Health Insurance, the IHS is funded through congressional appropriations. So the agency’s primary source of funding is subject to the whims of a Congress that is deeply divided about priorities and the role of government.

This funding mechanism was made worse by the Affordable Care Act when the Supreme Court said states could choose to expand Medicaid (an insurance partnership for people on low incomes) or not. State-based “optional” insurance is creating a divide within the Indian health system. Under current law, IHS rewards facilities for bringing in third-party payers from either private insurance or Medicaid dollars. It’s money that’s added to a local clinic or hospital budget. But most of that money is from Medicaid and if a state rejects the expansion, that becomes, in effect, a structural deficit. Almost half of the states, many with large American Indian or Alaska Native populations, have not expanded Medicaid.

So what should the Indian Health Service look like in the age of Obamacare? That is the conversation that should be occurring, but is not. It’s so much easier to blame underfunding or management instead of rethinking the entire IHS organization.

What would IHS look like if it’s primary role was to act as a funding agent with the goal of sending maximum resources — you know, money — directly to tribally-run and other health care delivery agencies? Or what if Medicaid was administered directly for tribes, leaving states out of the equation?

One thing I would change is The Story. As I have written before, it’s important that Congress know that past efforts worked. The creation of the Indian Health Service in 1955 and the Indian Health Care Improvement Act of 1976 both improved the health of American Indians and Alaska Natives. Yes, there remain health care disparities when compared to the general population but the gap is far less than it was. And IHS did this by spending less money than just about any other health care delivery system in the United States.

Sure, there are management challenges at the Indian Health Service as noted by Senators Tester and before that Dorgan. But as we near the 50th anniversary of the Indian Health Care Improvement Act, it’s time to rethink the agency’s structure and demand reform. It’s time to imagine what success looks like.

Mark Trahant holds the Atwood Chair at the University of Alaska Anchorage. He is an independent journalist and a member of The Shoshone-Bannock Tribes. For up-to-the-minute posts, download the free Trahant Reports app for your smart phone or tablet.