Transmission and distribution (T&D) investments by investor-owned utilities, which collectively account for approximately two thirds of the electricity sales in the United States, have averaged about $26 billion annually over the past decade. This paper summarizes US experience to date of efforts to use geographically targeted efficiency programs to defer T&D system investments. It presents several case studies and summarizes lessons learned from those initiatives. Most importantly, it concludes that targeted efficiency programs – either alone or in combination with other demand resources – clearly can be a cost-effective alternative to T&D investments. However, their cost-effective potential as a T&D resource has been grossly under-utilized for a variety of policy and institutional reasons. The paper offers several policy recommendations to address those barriers.