COLUMBUS, Ohio — Kimberly Thompson, 43, says she was lying in a hospital bed when she found out that she would no longer receive government assistance. The letter from the county shocked her: “They basically cut me off of benefits for not reporting I was in a coma,” she says.

For a decade, Thompson worked packing boxes in Columbus warehouses for $10 or $12 an hour. She was raising a 15-year-old daughter and managed to pay rent for a trailer she shared with a relative. Then last May Thompson underwent a hysterectomy. Unable to return to strenuous warehouse work, she applied for Medicaid, welfare and food stamps, and enrolled in a computer repair job-training program. But a month later, an untreated infection she’d contracted after surgery worsened, and her organs began to shut down. She spent the next month in a medically-induced coma.

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When Thompson woke up, she learned that her cash assistance through the Ohio Works First program as well as her food stamp benefits had been terminated—more than $700 per month in total. Administrators said the county imposed a sanction because she had failed to complete the mandatory work and training requirement for receipt of government assistance. Thompson called the Franklin County, Ohio Department of Jobs and Family Services to tell them she was in the hospital. A worker there told her she had two days to verify her hospitalization. Frail and unable to move—she’d had seven toes amputated and says she lost some cognitive capacity—she was unable to get to the county office.

“They told me I’d lost the benefits because I didn’t go to class,” said Thompson, who since her illness speaks in a trembling voice and gets tired in minutes if she moves around. “How are you supposed to go to class when you’re in a coma?”

Advocates for the poor in Ohio say that situations like Thompson’s are not uncommon as a several-year-old effort to impose strict work requirements on state welfare and food stamp recipients has led to thousands of families losing aid. Anti-poverty advocates note that even as the state is moving to bolster the medical safety net through Medicaid expansion, it has dramatically slashed its welfare rolls since 2011, shrinking the program from 90,000 cases to 60,000 in the last four years. Most of the remaining people relying on cash assistance are children who often live with grandparents.

With no money coming in for three months as she recovered, and too ill to work, Thompson has bounced from one couch to another, living with an ex husband and another relative. Her daughter now lives temporarily with her father.

Under federal welfare reform laws, at least 50 percent of single-parents enrolled in the Temporary Aid to Needy Families program must have a job or be engaged in education or job training. States that fail to meet these numbers face federal fines.

In 2011, Ohio was in that very position. Since the start of the recession, the state had failed to meet the federal work rates, and by 2011, only a third of welfare recipients were engaged in required work activities. Washington threatened to impose a $1.3 million fine. Under pressure, state officials instructed counties to find ways to increase the percentage of welfare recipients working or in training.

“We were under immense federal pressure,” says Joel Potts, who heads the County Directors of Job and Family Services association. “Counties were threatened with losing millions of dollars if they did not act to bring up the work participation rate.”

Four years later, 56 percent of parents receiving cash assistance are working in Ohio. By that measure, the state policy has been a dramatic success. But according to a 2013 review of the welfare program performed by a research group contracted by the state, many county agencies have reached these numbers not so much by helping poor parents find jobs or enroll in training, but “through a reduction in caseload.”

“The way most counties meet the work requirement is to throw people off,” said John Frech, the director of the Athens County Department of Job and Family Services. Frech has been critical of the state trends. His county is unusual in that its welfare program has maintained similar caseload levels since 2011 even as it has connected more of those on the program with jobs and training. “Ohio made this a success from the state’s perspective by throwing families off of a program that they need. Rather than working to help poor families, we’ve left families in a terrible situation.”

The state report called the trend “an unfortunate side effect of a process focused performance measure.”

“How are you supposed to go to class when you’re in a coma?”

Joel Potts agrees that the outcome of the threat of federal penalty has been a decline in overall caseload. But he says, “Many people have found work. Many people choose to go get a job now rather than apply for welfare.”

Many advocates disagree.

“Performing well in the work participation rate is not the same thing as connecting families to the work activity,” says Liz Schott of the Center on Budget and Policy Priorities, a liberal Washington, D.C. policy group. “This is just one of the latest states to use work requirements as a way to reduce caseloads without actually helping families.”

Nationally, welfare caseloads have fallen by 7 percent since before the recession, even though the economic landscape for poor Americans is bleaker. More people are in poverty and without work. Even as food stamp and Medicaid enrollment increased at rapid paces through the recession and the slow recover, welfare rolls barely budged in many states. States have shrunk their caseloads in a number of ways.

“Imposing strict and unmoving work requirements has been one of the more popular methods for reducing caseloads,” Schott says.

In Ohio, the TANF caseload has fallen by more than 20 percent from its pre-recession levels and by more than 30 percent since 2011, following a slight caseload increase during the worst points in the recession.

In Columbus’ Franklin County, the total number of people on the program has fallen by 40 percent since 2011. The declines have allowed the county to make significant gains in its work participation rate. In January 2011, Franklin County had a 21 percent work participation rate. In September of this year, that had grown to 60 percent.

“Counties feel they have no other choice but to cut the number of people on the program,” said Tara Britton of Ohio’s Center for Community Solutions, a nonpartisan think tank. Britton says that in general counties were left with little choice, pressured to increase the ratio of welfare recipients who are working, but facing significant state budget cuts for supportive programs like transportation subsidies and child care that make it possible for poor parents to work.

“The problem is that many counties felt they did not have the resources to actually support people to find work,” Britton said. “So to meet the work participation levels, they’ve stopped people from getting onto the program in the first place, or removed people from the program who are already on.”

Potts agrees with the concern. During the recession, he says, because of state funding cuts, “We lost options to do some really good meaningful things to connect people with work and training.” He noted that counties have lost dollars for childcare and transportation subsidies, both of which make-work possible for parents.

Ohio, like a number of other states, is also imposing work requirements on a larger number of adult recipients of food stamps. As the economy has recovered, many states lost eligibility for a recession-era waiver that allowed states to stop imposing work requirements on adults receiving food assistance when joblessness remains high. Parts of Ohio are still eligible for that waiver, however lawmakers chose to lift it, and childless adults across the state can receive just three months of assistance before they are required to find work.

“Counties feel they have no other choice but to cut the number of people on the program.”

Kimberly Thompson’s food stamp benefit, like her cash assistance, was terminated when she entered the hospital.

She says she does not understand why her Medicaid caseworker would not have communicated her condition to her welfare caseworker. “Aren’t they all the same?” she asked.

A spokesperson for Franklin County acknowledged that county workers have struggled to streamline casework across different parts of the safety. That problem has been exacerbated, the spokesperson said, since the Medicaid management was moved to a different state database from welfare and food stamps. “The person who would be dealing with the [welfare] case is using a computer systems that is not linked anymore to the Medicaid system,” Lance Porter, the spokesperson, said.

Thompson feels stuck. She uses a colostomy bag following her surgery, and says that for three months she’s eaten just one meal a day because she did not have any money at all. She is sleeping on her ex-husband’s couch in a subsidized housing complex on the outskirts of Columbus. Without money for gas, she rarely sees her daughter, though they speak on the phone most days.

Thompson says she has applied for Social Security Disability Insurance, but the application is still being processed.

In August, after leaving the hospital, Thomson brought her case to The Legal Aid Society of Columbus. An attorney appealed her sanction before a state hearing officer.

"We see not a few clients who lose benefits for bureaucratic reasons," says Kathleen C. McGarvey, a managing attorney with the Legal Aid Society. "For individuals trying to navigate Ohio Works First, the administrative hurdles are huge."

The hearing officer issued a decision days later ordering the county to reinstate her benefits.

Thompson, the officer wrote, “was unable to do anything about verifying or reporting good cause, due to a situation beyond her control, as she was in a coma, and gravely ill.”

Thompson has since been paid several months of welfare and food stamp benefits that were due to her. And as of late last month, she began receiving food stamps again. The county is still deciding whether to reinstate welfare payments in the future, since her daughter does not currently live with her.

“It seems crazy,” Thompson says. “If I’d had that money after the coma, if I’d had it all along, I could have had a place for me and my daughter, but now because she doesn’t live with me it’s impossible to get us back together until I can get work again. I don’t know when that will be.”