As the White House and Congress grapple with negotiations to prevent yet another showdown over raising the country’s debt limit, hospitals across the nation are worried the so-called “fiscal cliff” will encourage lawmakers to strike a deficit-reduction deal that could cripple safety-net programs and hospitals.

Medicare and Medicaid, two of the budget’s largest entitlement expenditures, are ripe territory for potential cuts in a “grand bargain” on deficit-reduction. But health care advocates like Republican Senate Majority Leader Bill Frist — who is a former physician and an unabashed Obamacare supporter — warn that excessive additional cuts to Medicare- and Medicaid-servicing hospitals could be devastating:

“I don’t think hospitals understand how deep these cuts are going to be in the grand bargain,” Frist said at the World Healthcare Innovation and Technology Congress.

The possibility for more hospital spending cuts on top of those coming under the Patient Protection and Affordable Care Act was not a surprise to some.

“If you just take a look at where the money goes in terms of federal expenditures, healthcare is right there,” said Dr. Robert Laskowski, CEO of Christiana Care Health System, Wilmington, Del. “So the bull’s-eye is an accurate description of the risk.”

In response, his health system is focusing on implementing and expanding quality improvement and cost-savings initiatives. Laskowski said he did not know whether such initiatives by many hospitals would succeed in dissuading deficit negotiators from targeting them.

Safety net hospitals are already worried about the strain they will be under in the states that don’t participate in Obamacare’s Medicaid expansion. The health reform law cut funding to Medicaid disproportionate share hospitals, expecting the expanded Medicaid pool to offset the cost, but those cuts will deeply hurt safety-net hospitals if GOP governors keep refusing to expand their states’ programs.

The potential of looming spending cuts can help encourage doctors and providers to find innovative ways to cut health spending and improve their systems of care. The health law does include some cuts to hospitals’ reimbursements in order to reallocate those funds to reward the hospitals that provide higher quality, less expensive care. But if Congressional leaders shirk difficult budgetary decisions on taxes, defense, and discretionary spending and choose to instead slash funding for safety-net services in a way that spurs contraction instead of innovation, they will be balancing the budget on the backs of America’s sick, poor, elderly, and the hospitals that give them life-saving treatment.

President Obama’s re-election confirms his landmark health care reform isn’t going anywhere, but Republican lawmakers will likely continue their attempts to undermine Obamacare even if they no longer push for an full repeal of the law. In fact, uncompromising Republican governors will likely keep preventing Obamacare from taking effect in their states by standing firm in their resistance to setting up health exchanges and expanding Medicaid.

As Politico points out, whether or not the health reform law is able to operate as it was intended — and expand coverage to about 30 million previously uninsured Americans — largely depends on the extent that governors agree to cooperate in their states. But some Republican governors have already made it clear that they don’t plan on playing nice during Obama’s second term:

Bob McDonnell (R-VA)

McDonnell acknowledged that federal health reform is inevitable now that Obama has been re-elected — but that doesn’t mean he’s ready to cooperate. McDonnell confirmed that Virginia will not be setting up its own health exchange and will continue to refuse to participate in the expansion of the Medicaid program. “I don’t want to buy a pig in a poke for the taxpayers of Virginia,” he said on Wednesday.

Nathan Deal (R-GA)

On Thursday, Deal said his state still doesn’t want any part of Obamacare during the president’s second term and likely won’t work toward setting up its own health exchange. “We’ve pretty well indicated that we don’t like the way that the program has evolved,” he said. Unfortunately for his state’s low-income residents, Deal doesn’t plan to expand the Medicaid program in Georgia either.

Sam Brownback (R-KS)

Brownback chose to put off the decision about setting up a health exchange until after the election, in hopes that a Romney win would eliminate the need to implement Obamacare in his state. But now that the future of the health reform law is secure, Brownback noted on Thursday that he still won’t cooperate with the federal government. “My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could costs Kansas taxpayers millions of dollars,” Brownback said in a statement.

Rick Scott (R-FL)

Even before the election, Scott made it clear that he wouldn’t set up a health exchange or expand Medicaid in his state. And now that Obama has won a second term, he is holding firm in his opposition to heath care reform, even though Florida has some of the highest rates of uninsurance in the nation. On Wednesday, Scott confirmed that Obama’s re-election doesn’t change anything for him.

Nikki Haley (R-SC)

Like Scott, Haley announced her intention to opt out of both a state-run health exchange and the expansion of the Medicaid program during Obama’s first term. And her administration is showing no signs of changing course now that the election is over. On Thursday, South Carolina’s Department of Health and Human Services director Tony Keck reiterated that the state will not be pursuing its own exchange. “We’ve let them know we’re not going to set up a state-based exchange. It’s a federal program and it’s their responsibility to make it work,” Keck said.