"Though weirdly in modern American politics, there's some degree of inversion there, with the "coastal liberal elites" voting for "socialist" healthcare and the unemployed coal miner with black lung disease voting against it."

This is not the paradox that people think it is.

If you're a coastal, progressive elite, you've already gone "all in" on an urban, socialized, statist (for good or for bad) social arrangement. You've shifted towards a pole and you might as well keep doubling down on those strategies/policies.

But if you're rural (or, as is the case with most of red-state US, sort-of-semi-rural), you're not down that path at all.

There are costs as well as benefits to social benefits and welfare programs. Many of those costs may be intangible, but they are costs nonetheless. Consider: what if a very large portion of your self esteem and "face" was tied to being self-sufficient in certain realms ?

And so therefore, if you're not already at the urban-progressive-socialized pole of attraction, it makes sense that people resist the costs (and the benefits) of going down that road.