U.S. lawmakers are starting negotiations this week on a potential next round of coronavirus aid to bolster the sagging economy and shore up the nation's healthcare infrastructure as COVID-19 cases skyrocket.

While another relief bill, likely the final before November's election, enjoys bipartisan backing in theory, Republicans back a far less expansive package than Democrats on top of the $3 trillion appropriated over the last four months.

The Democratic-led House passed a $3 trillion relief bill in May, though the so-called HEROES Act has languished on the desk of Senate Majority Leader Mitch McConnell, R-Ky., since then.McConnell halted progress on any additional relief following passage of the $2.2 trillion CARES Act in March.

Big question marks surround potential funding for schools to safely reopen in the fall, whether to continue weekly aid to the unemployed set to expire at the end of the month, and another round of direct payments to American citizens.

In the healthcare realm,the president's dislike of COVID-19 testing could stymie the push for funds in that arena, though states and public health agencies have clamored for additional aid. Hospitals want more grant dollars, protection from COVID-19 liability suits and a stronger safety net for the uninsured, citing continued need.

Almost 3.8 million people in the U.S.have been confirmed positive for the coronavirus and almost 141,000 have died to date, according to Johns Hopkins University's COVID-19 tracker:more than any other country. According to tracker COVID Act Now, as of Monday, only two states were on track to contain the virus.

Below are four of the biggest sticking points for the healthcare industry in a new COVID-19 bill.

Congress has earmarked $175 billion for a provider relief fund so far, though major hospital lobbies have warned it's not enough to cover the projected losses brought on by the pandemic's economic effects, including reduced revenues because of fewer elective procedures and rising expenses to increase capacity and combat the virus.

The American Hospital Association, along with other major hospital lobbies, recently ramped upefforts to secure additional relief money,armed with pollingtouting three-fourths of voters back release of another $100 billion for hospitals.

The House bill passed in May would deliver just that:an additional $100 billion for providers.

"That amount was greatly appreciated,"Lisa Kidder Hrobsky, AHA's group vice president and federal relations leader, said in a statement to Healthcare Dive, though the expensive bill has proved a nonstarter in the Senate.

Senate Republicans are likely to include funds for providers, but not nearly as much as they want given the ongoing economic crisis. AHA estimates U.S. hospitals could lose $323 billion over 2020.

Of the $175 billion Congress approved for providers so far, $125 billion has been allocated, but just $61 billion has been delivered and attested to by the providers that received it, according to a senior HHS official.

McConnell has said for weekshe won't support any deal without broad liability protections for business. The GOP's draft plan would shield businesses for five years, with The Hill reporting healthcare providers in draft legislation expected this week would only be legally responsible for "gross negligence and intentional misconduct."

Democrats are generally more critical of broad legal protections to businesses. House Speaker Nancy Pelosi, D-Calif., has said she opposes protecting employers from lawsuits from employees who may get sick on the job, citing the need to weigh consumer and worker protections with shielding businesses from meritless litigation.

According to a HuntonAndrews Kerthlaw firm database, litigation has not risenamid the pandemic,despite concerns. Provider groups support liability protection, however, citing worries they could be sued by patients or medical workers for providing inadequate protective gear, spreading the virus or delaying care down the line.

Public Citizen and major unions are among those slamming such a shield, arguing "giving businesses immunity from accountability would increase infection rates, make consumers and workers less safeand prolong the pandemic" in a Monday statement.

Patient advocates have clamored for a stronger safety net as millions of Americans lose their jobs and are booted off employer-sponsored insurance.

Despite gains in June, the U.S. unemployment rate is hovering around 11%, according to the Bureau of Labor Statistics. That's compared to just 3.5% in February. As a result,some 27 million Americansmay have lost their job-based insurance between March and May, according to the Kaiser Family Foundation.

And 90%think the government should step in and help the newly unemployed retain their insurance, according to a recent poll funded by the American Benefits Council and the Alliance to Fight for Health Care.

Assistance could take myriad shapes, from expanding federal subsidies for the COBRA program, which allows the newly unemployed to stay on their insurance, expand subsidies for individual market plans or more widely expand Medicaid safety net coverage.

Congress already increased the federal matching rate in Medicaid for states by 6.2 percentage points during the national emergency, though some public health experts called for more. HEROES proposes bumping up the match rate by 14 percentage points. The Senate bill will likely fall somewhere in between.

However, congressional Republicans and the Trump administration generally oppose broader Medicaid coverage and more lenient insurance options, including in the Affordable Care Act exchanges.

Though there's bipartisan support for subsidizing COBRA extensions, the chances of them making it to the final bill are less than 50%, according to Cowen analysts. If they are included, they'll likely be much lower than the 100% subsidy in the HEROES Act, the analysts wrote in a Monday note.

The current HHS relief fund includes dollars benchmarked for providers that care for uninsured COVID-19 patients.However, HHS has sent out $340 million so far, less than what they expected to deliver, a senior HHS official previously said.

The House HEROES bill builds on earlier legislation that allows states to use Medicaid dollars to pay for COVID-19 testing, treatment and vaccine coverage for the uninsured. Such funds could help providers, too, which face lower reimbursement rates when patients are kicked off job-based insurance.

Though the U.S. has ramped up its testing capacity, surging cases in the South and West have led to a major backlog in COVID-19 testing results. Some major labs are reporting it takes a week or more to get results out the door, hindering public health efforts to get an accurate picture of the disease and allocate resources appropriately.

The HEROES Act would provide $75 billion in additional funds for COVID-19 testing and contact tracing, on top of $25 billion already provided by the Families First Coronavirus Response Act and the Paycheck Protection Program and Health Care Enhancement Act.As of late June,HHS had only sent $8 billionof the existing trance out the door, despite acute need.

Diagnostic testing for the coronavirus could cost up to $25.1 billion annually, and antibody testing costs could reach up to $19.1 billion, according to a reportcommissioned by payer lobby America's Health Insurance Plans.

As a counter, Senate Republicans would allocate $25 billion to states for testing and contact tracing,along with roughly $10 billion for the Centers for Disease Control and Prevention and $15 billion for the National Institutes of Health, per the New York Timesand the Washington Post.

But the White House is reportedly trying to block any additional aid for testing and contact tracing, making the likelihood of comprehensive aid in the next package shaky at best.

President Donald Trump, who has consistently downplayed the severity of the pandemic,has said in a series of interviews and public appearances that he opposes broader testing. His oft-repeated claim that fewer tests equals fewer cases is untrue, as the number of new cases have outpaced the ramp-up in testing in recent weeks.

Public policy research group the Rockefeller Institute saysthe country should now be running 3 million tests a week and 30 million weekly by October to get a handle on the virus. The White House is aiming to conduct 50 million tests per month by the fall,mostly through point-of-care tests in hospitals and doctor's offices.

To date, the country has run more than 47 million tests, with a 9% positivity rate, per most recent CDC data. And the government is reportedly changing its testing strategy, leaning on pooled testing mixing patients samples and testing them together to try and get on top of rising outbreaks, though experts are skeptical of the effort.

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As Congress weighs next COVID-19 relief bill, 4 healthcare sticking points - Healthcare Dive