"It seems like the harder you worked in life, the less help you get," Toler said.
Some fall completely through the gaps. Seven years ago, Alexsandria Elliott, now 37, said she developed hereditary periodontal disease. Last year, the infections grew so severe that a doctor told her she may die if she didn't have her remaining eight teeth pulled. The extractions would cost $2,300. First she had to find the money.
Elliott, who used to work as a low-wage hotel housekeeper, didn't have health insurance. She couldn't get on Medicaid, because working-age Indianans without dependent children aren't eligible. She didn't qualify for cash welfare benefits for the same reason - her daughter was over 18.
In February, she had to borrow to have the dental surgery, leaving her with a debt to pay. When she gets a job, she hopes to raise the $800 she said she'll need to buy dentures. Elliott also isn't receiving food stamps.
"I tried the (university hospital), I tried the schools, I tried state assistance.... And nothing," said Elliott. "And I'm suffering to the degree I want to shoot my head right off my shoulders and can't take it anymore. Why can't I get a little help to pull a tooth?"
Shaun Case's problems began long before his difficulties in getting help from the government.
Case, a short and mild man with a boyish face, favors baggy clothes. The son of a drug-addicted mother and alcoholic father, he - and his three brothers - spent much of childhood in foster care. Case's mother said she was abused by his father, and she fled when Shaun was a toddler. Shaun's father repeatedly beat him and his brothers, according to Case, his mother and a sibling. When Case was 14, his grandmother pushed him through a window. He nearly bled to death from the resulting gash in his wrist, relatives say.
"Two major arteries were cut," said Case, who also suffered nerve damage. "I have no feeling in my left hand."
Placed in foster care, Case underwent a psychiatric evaluation. He was found to have a learning disability but not bad enough to have him officially declared mentally disabled.
Case's father couldn't be reached for comment.
When he was a senior in high school, Case got his girlfriend pregnant and dropped out to try providing for her. She later miscarried but the two eventually married. The couple had two daughters together, but divorced.
His primary source of employment has been temp agencies. He has worked as a janitor, airport security guard, construction worker and in other low-paying roles. He has no substance-abuse problems and no scrapes with the law, relatives say.
But Case's meager skills and cognitive problems trap him. He has tried to get a high-school equivalency degree but struggles in the classroom. His temporary work assignments have all ended with companies choosing to not permanently hire him.
THE BIGGEST CHALLENGE
"It didn't work out," Case said, referring to a stint as a supermarket cashier. "I was either giving too much or too less change. The manager was like, 'Are you serious? What is going on here?'"
Emotional problems hinder him as well. "People will tell him he's retarded or stupid and it sets him off," Case's older brother Joe said in an interview.
Today, Case and his siblings remain mired in poverty. Joe makes $400 to $500 a month as a self-employed computer consultant, and Joe's wife makes $1,000 a month at a daycare center, with no health benefits. Raising five children together, Joe said, they usually receive Medicaid and $520 a month in food stamps.
As an able-bodied adult without dependent children, Shaun qualified for no help other than food stamps. He has repeatedly applied for disability but been turned down. He applied for free healthcare at a local hospital but missed appointments and was rejected.
When Case falls ill, he goes to hospital emergency rooms. During his divorce, he experienced severe pain in his abdomen, he said. Emergency-room doctors found that he had untreated stomach ulcers.
Case said his biggest goal - and challenge - is finding steady well-paid work.
"When I was 18, you could leave a job and find another one," Case said, tucking into an omelet at Burt's Peppy Grill, a diner in eastern Indianapolis. "Every year, it just gets worse."
A LONG JOURNEY
As in other parts of the country, the loss of high-paying manufacturing jobs in Indiana has eroded economic opportunities for people with few skills. Seven out of 10 jobs in Indiana now pay less than $45,000 a year, according to the Indiana Institute for Working Families, a think tank. That's just a few thousand dollars above the income the institute says a three-member Indianapolis family needs to be self-sufficient.
Case now lives on the living-room couches of Joe and a second brother, Tom.
In October, Case lost his food stamps after a paperwork glitch: The state sent him a letter requesting more documentation, which he said he never got. After he tried and failed to straighten things out, a notification arrived saying he'd been cut off. As of last week, he was still trying to land an appointment with a caseworker to restore his benefits.
Case said his dream is to be an art teacher, something his foster father said is impossible given Shaun's cognitive and emotional problems. Case said his second choice is to learn a skilled trade such as plumbing or carpentry.