"Do you think there's any place here for education/advocacy? For instance, everyone who makes web pages knows to provide alt text for images."
That's not a culture thing, this is by the mechanism of "If there was a standard package that everyone knew they had to include or else it breaks everything from ctrl-F to copy/paste to screen readers, presumably people would use it, right?"
Then it would still be nigh impossible because TeX commands, like all programming languages, compose rather poorly.
It would be a herculean effort to produce a kinda but not really TeX that is both accessible with a focus on semantics, yet still compatible with the billions of lines of LaTeX/TeX out there.
"I'm less interested in speculating what would have been if troff had "won", (though it is indeed fun to speculate), and more interested in how to fix the mess we're in now, so that 10 years in the future, blind people have better choices than OCR."
Boycott LaTeX/TeX and PDF everywhere you can.
Whenever you publish a paper, also publish it in markdown/html.
Publish in OpenAccess Journals like [PeerJ](https://peerj.com/) which convert all of their papers to html in addition to pdf.
Consider publishing papers in alternative forms like nextjournal.com .
We need to get our priorities straight in academia :/.
This entire "but latex produces such beautiful documents", "I'm working towards getting into the most prestigious journal" culture of snobbery and vanity needs to stop. We need to go back to caring about the content, not the presentation, something TeX ironically was meant to do.