Academic papers demonstrate inaccessibility despite accessible writing resources made available by SIGACCESS and others. The move from accessibility guidance to accessibility implementation is challenging for authors. Our work focuses on understanding what challenges authors of academic papers face in creating content elements (e.g., tables, charts, images) to better understand how to improve accessibility. We classified 3866 content elements from 330 papers covering a 10-year sample of academic work from ASSETS to understand the variety used. We also reflected on the design choices that make the content elements inaccessible. We then conducted interviews with 13 academic authors from PhD student through to Professor Emeritus that publish within top-tier accessibility and HCI venues to understand the challenges faced in creating accessible content. We found critical issues in how academics understand and implement accessibility while also balancing the visual design of the paper. We provide recommendations for improving accessibility in the academic paper writing process and focus on steps that can be taken by authors, publishers, researchers, and universities.