Faced with enormous political pressure from Gov. Jan Brewer (R-AZ), the Arizona House passed a budget and Obamacare’s Medicaid expansion in a rare 3:40 a.m. vote on Thursday. The bills now go back to the state Senate — where they are expected to pass easily later this morning — for final approval before heading to Brewer’s desk for her signature.

The vote signifies the final skirmish in a five-month long battle to expand Medicaid that pit the combative Brewer against members of her own party and conservative constituents. The window for passing the expansion and a budget would have closed on July 1st. With that deadline looming, Brewer called a surprise, special legislative session on Tuesday without getting permission from — or even informing — lawmakers in her party.

Studies by the Kaiser Family Foundation (KFF) have shown that expanding Medicaid will cut Arizona’s uninsurance rate by nearly third. That means approximately 50,000 low-income Arizonans will be covered for medical benefits such as doctor’s visits, prescription drugs for chronic conditions like diabetes, and mental health care services.

Brewer made expanding Arizona’s Medicaid program under the health law a top priority for this legislative session. After becoming the third GOP governor to endorse expansion in January, she held rallies throughout the state meant to shore up support for the controversial Obamacare measure, and implored Republican moderates to vote for it. Brewer often used personal rhetoric that emphasized the consequences failing to expand Medicaid would have on Arizona’s poor. “The human cost of this tragedy can’t be calculated,” she said during a rally in March.

Thursday’s victory came only after significant tensions threatened to derail the entire process. Brewer played political hardball to push the expansion, even following through on a threat to shut down lawmaking entirely until she had a budget and the Medicaid expansion bill on her desk. She refused to compromise with Republican House Speaker Andy Tobin, who had proposed a far more conservative alternative plan that would have put a time limit on how long poor Arizona residents could qualify for the expanded program.

The tough tactics earned her scathing reviews from conservatives, with the chairman of the Maricopa County Republican Committee calling her a “rogue governor.” Republican lawmakers who opposed the expansion also slammed Brewer for her aggressive methods in speeches on the House floor Thursday.

Arizona will now be the 21st state to expand Medicaid under Obamacare.

Under pressure from Gov. Jan Brewer (R-AZ), who is refusing to sign any laws until her party expands Medicaid under Obamacare, Arizona’s Republican House Speaker Andy Tobin surrendered his fight to block the governor’s expansion proposal on Tuesday. Tobin was pushing for a more conservative plan that would have put a time limit on how long poor Arizonans could qualify for the expanded Medicaid pool.

Now, the governor’s preferred proposal — which passed the state Senate in May — will proceed through the committee process in the House, with a full vote possible as early as next week.

Time is an important factor for passing the expansion. Arizona’s state constitution requires a budget to be finalized by July 1st — an outcome that was in question as tensions flared over the Medicaid issue. Tobin said that he relented after realizing how much daylight there was between his alternative proposals and Brewer’s far more expansive plan.

“The counteroffers that we heard from [Brewer's] staff were so far away from where I was at, that it just became apparent that because you have to have Medicaid with the budget that the time was running out. I didn’t think there was enough room to negotiate a closer deal,” said Tobin in an interview with the Associated Press.

Brewer is far from the only Republican official to endorse expansion. But the combative governor’s tenacious — and often aggressive — pursuit of expanding Medicaid has taken many political observers by surprise.

While promoting Medicaid expansion in March, Brewer warned that the “human cost” of failing to expand the program “can’t be calculated.” At another rally, she sounded defiant in the face of Republican political blowback. “This is a fight worth fighting for. Are we going to win? Darn right, we are going to win,” she told a cheering crowd.

The Kaiser Family Foundation estimates that expanding Medicaid would cut Arizona’s uninsurance by almost a third. That means that about 50,000 poor Arizonans would have access to basic and specialty health care, including diagnostic and clinical services, as well as care for the disabled and the mentally ill.

Brewer has followed up on her tough rhetoric with action. She recently vetoed five bills in quick succession to show her displeasure with the legislature’s inaction, following through on a threat she made to shut down lawmaking until Medicaid and the budget issue was resolved.

The arm-twisting appears to have worked, despite sharp criticism from conservatives in her own party. The chairman of the Maricopa County Republican Committee called Brewer a “rogue governor” in a letter warning Republican state senators not to buck the traditional party line on Medicaid. Tea Party activists have dismissed her actions as “tyranny.”

Although expansion is not quite a done deal yet, Republicans opposed to the measure admit that it’s likely to pass. “I don’t know if we have the numbers to stop it. But we are going to continue to fight,” said state Rep. Bob Thorpe (R).

West Virginia Gov. Earl Ray Tomblin (D) announced in a press conference on Thursday that his state would take part in Obamacare’s optional Medicaid expansion, calling the decision “the best choice for West Virginia.” But many states still remain up in the air with their decisions, either because they haven’t decided yet or because state executives and legislators are at odds with each other on the issue — and time is running out.

Speaking at St. Francis hospital and flanked by nurses, doctors, and hospital administrators, Tomblin laid out the medical and financial case for expanding Medicaid eligibility — a conclusion that he reached after commissioning a study to examine such a move’s effects on West Virginia. “Expansion will allow us to provide insurance coverage to 91,500 West Virginians,” said Tomblin.

Indeed, West Virginia has much to gain and very little to lose by embracing the Obamacare provision. The state has abysmal health demographics, and over half of West Virginia’s uninsured population lives below 138 percent of the Federal Poverty Level (FPL). These poor and vulnerable populations would gain access to health coverage under the Medicaid expansion, leading the Kaiser Family Foundation to conclude that expansion will reduce the number of uninsured West Virginians by a staggering 67 percent.

Those numbers likely led Tomblin to his decision. But the moderate Democrat has an advantage that governors of other conservative — and highly uninsured — states don’t: the almost assured support of his legislature. Democrats hold a supermajority in the state Senate and an eight seat edge in the House of Delegates, and both of West Virginia’s U.S. senators also support expanding Medicaid, making intraparty barriers unlikely.

The same cannot be said of Republican Govs. Jan Brewer (AZ) and Rick Scott (FL), who have been lobbying for Medicaid expansion after intense pressure from hospital associations and advocates for the poor. Their Republican-controlled state legislatures have been bending over backwards to stop it from happening. Although there is no hard deadline for expanding Medicaid under Obamacare, many of these states’ legislative sessions are quickly coming to an end — meaning that if no agreement is reached soon, they won’t receive the additional federal funds and won’t be able to extend coverage to low-income residents for at least the first full year of Obamacare implementation.

Texas and Louisiana face similar issues. Although some GOP lawmakers in those states are contemplating Arkansas Gov. Mike Beebe’s (D) alternative “private option” — which would take federal money and use it to help an expanded Medicaid pool buy private insurance — those efforts also remain in limbo, as former and current Republican presidential aspirants Govs. Rick Perry (TX) and Bobby Jindal (LA) have oscillated between flat-out rejecting expansion and being coy about their intentions.

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Jan Brewer (R), Arizona’s combative GOP governor, stunned political observers and health care reform advocates when she became the third Republican governor to endorse Obamacare’s expansion of the public Medicaid program. That decision is great news for Arizona’s poor and uninsured, as well as for the state’s budget. But it’s been met with fierce resistance from state lawmakers in Brewer’s own party, setting up an unusual showdown between Brewer, hospitals, doctors, and reform advocates on one side, and Republican state lawmakers — who Brewer must still persuade to pass legislation accepting the Medicaid expansion — on the other.

That’s why on Wednesday morning, flanked by Arizona public health officials on the steps of the state Capitol, Brewer begged reticent GOP lawmakers — many of whom showed up in black to protest Brewer’s decision — to look past politics and understand the human and financial toll that failing to pass the expansion would instill on Arizonanas. “The human cost of this tragedy can’t be calculated,” Brewer said. “Remember, there is no Plan B.” Brewer estimated that 50,000 low-income Arizonans would lose health coverage without the expansion.

Study after study has shown that expanding Medicaid is the right move for states’ budget, the poor, and the uninsured, especially considering that the federal government will fully finance states’ Medicaid expansions for the first three years. Republican governors, faced with the reality that Obamacare is here to stay, have finally been inching away from their knee-jerk opposition to the Medicaid expansion after intense lobbying from hospitals and advocacy groups.

But skeptics — particularly GOP lawmakers in Republican-led states open to the expansion — are wary of increasing their Medicaid pools, warning that the federal government may renege on its promise to provide the lion’s share of funding for the expansion. GOP governors will need these lawmakers’ support to actually expand Medicaid, and as Brewer’s example demonstrates, that could make for some intra-party conflict in the eight GOP-led states whose leaders have embraced the expansion.

In a blow to anti-abortion activists looking to use Planned Parenthood as a political pawn in their crusade against women’s reproductive health rights, a federal judge has overturned an Arizona law signed by Gov. Jan Brewer (R) in May 2012 that prohibits using Medicaid funds for services provided by Planned Parenthood facilities in the state.

Judge Neil Wake ruled that Arizona residents “are entitled to get their services from any qualified medical provider,” and the fact that Planned Parenthood provides some abortion-related services does not disqualify the organization from being a “qualified provider,” as the law claimed it did.

State and federal GOP officials have been tripping over each other to strip Planned Parenthood of its federal funding — even though federal dollars can’t be used to cover abortion services, through Planned Parenthood or any other medical provider. Planned Parenthood is actually simply a health care provider for low-income women in the Medicaid program, providing them with preventative screenings and family planning services.

Republican efforts to defund Planned Parenthood have already taken a toll on low-income women in states like Texas, where the war against the provider has sharply curtailed the number of doctors and services available to women, and Oklahoma, where women’s health clinics have been forced to close. But federal courts have consistently ruled that efforts to cut off Medicaid funding to Planned Parenthood is an overreach, stripping low-income women of essential medical resources.

Wake’s injunction against the Arizona law has already been appealed.

Gov. Jan Brewer (R-AZ) is the third Republican governor to accept Obamacare’s optional expansion of the Medicaid program. The governor’s decision to expand Medicaid will extend health coverage to an additional 30,000 previously uninsured Arizonans.

In a speech on Monday, Brewer explained that expanding Medicaid is the right financial decision for Arizona because the federal government will reimburse states for the cost of expansion:

The governor said it makes no sense not to take the federal dollars. She said it’s not like opting out of what’s been called “Obama-care” will save federal dollars or go toward debt reduction.

On the other side of the equation, Brewer said not taking the money will continue to mean a high number of uninsured in Arizona, people who show up in emergency rooms to get care but are unable to pay. The governor said those costs amount to a “hidden tax’” of $2,000 per family.

Brewer could have a fight on her hands: While a few Democrat lawmakers stood to cheer, most Republicans not only stayed seated but refused to applaud.

Brewer joins New Mexico Gov. Sususan Martinez (R) and Nevada Gov. Brian Sandoval (R), who were the first GOP leaders to agree to expand Medicaid in their states. Seventeen Democratic governors have also accepted the expansion, but Republican politicians have been especially reluctant to cooperate with health reform.

About 19 percent of Arizona’s population doesn’t currently have health insurance, a statistic that spurred Brewer to expand the Medicaid program’s eligibility level. Nonetheless, GOP governors in some of the states with the highest rates of uninsurance are still resisting participating in any aspect of the health reform law, including its Medicaid expansion.