Objectives: This study aims to compare arteriovenous (AV) access patency of hemodialysis (HD) patients according to health insurance type.   Methods: This retrospective observational study utilized the National Health Insurance Service claims database between January 2009 and December 2019. We identified maintenance HD patients who started HD during the study period. The primary, assisted primary, and secondary patency was investigated in the national health insurance and medical aid patients. The age and sex-adjusted hazard ratios of each patency were analyzed. Results: The number of incident HD patients was 151,382 (male 58.42%), and AV fistula (AVF) and AV graft (AVG) were created in 64,179 and 21,857 patients. Among the patients who underwent AV access placement, the health insurance and medical aid patients were 75,672 and 10,364, respectively. In both AVF and AVG, the incident rate for 100 person-year (95% CI) of endpoints for primary, assisted primary, and secondary patency in medical aid patients was significantly higher than those in health insurance patients (P < 0.001). In AVF, the hazard ratios (95% CI) adjusted by age and sex for the primary, assisted patency, and secondary patency of medical aid patients were 1.092 (1.056-1.129, P < 0.001), 1.203 (1.151-1.258, P < 0.001), and 1.239 (1.148-1.335, P < 0.001), respectively. The adjusted hazard ratios (95% CI) of primary, assisted patency, and secondary patency of medical aid patients in AVG were 1.503 (1.008-1.099, P = 0.019), 1.131 (1.076-1.190, P < 0.001), and 1.214 (1.135-1.297, P < 0.001), respectively. Conclusions: The patency of AV access was significantly poorer in medical aid than that of health insurance patients. The cause of the difference in patency according to the insurance type is necessary for further investigation.