I live in Lincoln, so about 50 miles south of Omaha. I think a crucial point left out by the author here may be the massive (at least perceived) demographic disparities between Omaha and Council Bluffs.

Council Bluffs is a vastly less financially successful city than Omaha with far more visible opioid problems.

That is to say, as a local, I don’t know if I would associate the term as much with demeaning “hillbillies or hicks” but more for the socioeconomic and drug disparities between the two cities.

I don’t know if the drug disparity is so large between them, but it certainly feels more visible in Council Bluffs. Maybe why we don’t see the -tucky suffix used as much with other twin cities is that St Paul and Fort Worth are still quite successful metropolitan areas in their own right.