But the true fire bell in the night for Trump and his party comes from a different direction, from the slump in Republican voting in southeastern Kentucky, formerly coal country.

What happened there?

No state saw a more dramatic improvement in its health-care insurance enrollment under the Affordable Care Act than Kentucky. And no part of Kentucky benefited more than the southeast from the ACA…

As the benefits flowed, Kentuckians—once staunchly opposed to Obamacare—came rather to appreciate the Affordable Care Act. By 2018, a plurality of Kentuckians—44 percent—approved of the ACA. Matt Bevin made it his top priority as governor to shred the ACA in Kentucky. He shifted 31,000 people off Medicaid and S-Chip, the state children’s health insurance plan. He added work requirements for Medicaid, and other practical barriers to coverage.