“People waltz in when they want to,” she said, explaining that, in her opinion, there was too little asked of patients. There was nothing that said “‘You’re getting a great benefit here, why not put in a little bit yourself.’ ” At least when she got her tuition help, she said, she had to keep up her grades. “When you’re getting assistance, there should be hoops to jump through so that you’re paying a price for your behavior,” she said. “What’s wrong with that?”

Yes, citizens like Ms. Dougherty are at one level voting against their own economic self-interest, to the extent that the Republican approach on taxes is slanted more to the wealthy than that of the Democrats. This was the thesis of Thomas Frank’s 2004 best seller, “What’s the Matter With Kansas,” which argued that these voters had been distracted by social issues like guns and abortion. But on another level, these voters are consciously opting against a Democratic economic agenda that they see as bad for them and good for other people — specifically, those undeserving benefit-recipients who live nearby.

I’ve heard variations on this theme all over the country: people railing against the guy across the street who is collecting disability payments but is well enough to go fishing, the families using their food assistance to indulge in steaks. In Pineville, W.Va., in the state’s deeply depressed southern end, I watched in 2013 as a discussion with Senator Joe Manchin, a Democrat, quickly turned from gun control to the area’s reliance on government benefits, its high rate of opiate addiction, and whether people on assistance should be tested for drugs. Playing to the room, Senator Manchin declared, “If you’re on a public check, you should be subjected to a random check.”

IT’S much the same across the border in eastern Kentucky, which, like southern West Virginia, has been devastated by the collapse of the area’s coal industry. Eastern Kentucky now shows up on maps as the most benefit-dependent region in the country. The welfare reforms of the 1990s have made cash assistance hard to come by, but food-stamp use in the state rose to more than 18 percent of households in 2012 from under 10 percent in 2001.

With reliance on government benefits so prevalent, it creates constant moments of friction, on very intimate terms, said Jim Cauley, a Democratic political consultant from Pike County, a former Democratic bastion in eastern Kentucky that has flipped Republican in the past decade. “There are a lot of people on the draw,” he said. Where opposition to the social safety net has long been fed by the specter of undeserving inner-city African-Americans — think of Ronald Reagan’s notorious “welfare queen” — in places like Pike County it’s fueled, more and more, by people’s resentment over rising dependency they see among their own neighbors, even their own families. “It’s Cousin Bobby — ‘he’s on Oxy and he’s on the draw and we’re paying for him,’ ” Mr. Cauley said. “If you need help, no one begrudges you taking the program — they’re good-hearted people. It’s when you’re able-bodied and making choices not to be able-bodied.” The political upshot is plain, Mr. Cauley added. “It’s not the people on the draw that’s voting against” the Democrats, he said. “It’s everyone else.”

This month, Pike County went 55 percent for the Republican candidate for governor, Matt Bevin. That’s the opposite of how the county voted a dozen years ago. In that election, Kentucky still sent a Republican to the governor’s mansion — but Pike County went for the Democratic candidate. And 30 percent fewer people voted in the county this month than did in 2003 — 11,223 voters in a county of 63,000, far below the county’s tally of food-stamp recipients, which was more than 17,000 in 2012.